Seminars in Oncology Nursing 37 (2021) 151135

Contents lists available at ScienceDirect

Seminars in Oncology Nursing

journal homepage: https://www.journals.elsevier.com/seminars-in-oncology-nursing

Disseminated Intravascular Coagulation

Leslie Smith, MSN, RN, AOCNSÓ, APRN-CNS*
National Institutes of Health, Bethesda, MD

A R T I C L E I N F O A B S T R A C T

Key Words: Objectives: This article describes the pathophysiology and causes of disseminated intravascular coagulation
Disseminated intravascular coagulation (DIC). Implications for nurses are also reviewed.
Pathophysiology Data Sources: Pee-reviewed articles and up-to-date references were used to check accuracy of the informa-
Interventions tion and provide information for current management of this syndrome.
Oncology
Conclusion: DIC is an oncologic emergency in which bleeding and clotting occur simultaneously. In the cancer
Nurses
population, the syndrome is frequently associated with certain malignancies or sepsis. If not recognized and
treated early, mortality can be high. This article describes the risk factors that contribute to DIC, clinical man-
ifestations of DIC, and its treatment.
Implications for Nursing Practice: Nurses need to consider the presenting diagnosis of the patient and under-
stand laboratory abnormalities that signify DIC. The nurse plays a key role in early recognition of this syn-
drome as prompt treatment can reduce fatality.
Published by Elsevier Inc.

Introduction is caused by a substance in the body, a “procoagulant factor.” The

Normal hemostasis is a tightly regulated process in which a clot is
formed and then dissolved (fibrinolysis). With tissue injury, a platelet
plug is initially formed over the site of the injury.1 The injured tissue
releases tissue factor that interacts with activated Factor VII circulat-
ing in the blood.2 The activation of Factor VII leads to the initiation of
the clotting cascade and a small amount of thrombin formation.2 The
clotting cascade is usually thought of in terms of the intrinsic and
extrinsic pathways. Both pathways lead to Factor X activation which
ultimately causes more thrombin to be formed. Multiple clotting fac-
tors and proteins are involved in both pathways,3 but the final result
is that thrombin formation leads to the conversion of fibrinogen into
fibrin.4 Fibrin forms a mesh over the platelet clot to stabilize it (Fig. 1).
Clotting stops when antithrombin, tissue factor pathway inhibitor,
and the protein C pathway stop the formation of the clot.6 8 Eventu-
ally, another complicated cascade involving plasminogen and tissue
plasminogen activator (tPA) dissolve the clot9,10 and helps with tissue
healing. This description of clotting and fibrinolysis is a brief over-
view because a detailed description is complex and beyond the scope
of this article. Any disruption in the system, such as deficient clotting
factors or proteins (eg, protein C) or overstimulation of the clotting
cascade, can cause abnormal bleeding or clotting. Disseminated intra-
vascular coagulation (DIC) is an example of hemostasis gone awry.
DIC is a disorder in which both clotting and bleeding occur simul-
taneously. The syndrome starts with excessive clotting.11 The clotting
* Corresponding author.
E-mail address: leslie.smith2@nih.gov
clotting continues without stopping due to continued stimulation
from the procoagulant factor. As a result, platelets and clotting factors
are depleted as more clots are formed. This continual process results
in bleeding when the platelets and clotting factors are consumed.
DIC is a condition that is always driven by an underlying disease
process.12 DIC can occur acutely or develop as a chronic condition. In
acute situations, DIC is life-threatening. In the oncology population,
malignancy or sepsis is the most common reason for the develop-
ment of DIC. DIC can also result from inflammatory states from treat-
ment of cancer, such as chimeric antigen receptor T-cell (CAR-T cell)
therapy,13 which can cause cytokine release syndrome, a type of
hyperinflammatory state. The incidence of DIC in the oncology popu-
lation has been estimated to range from 6.8% in those with solid
tumors14 to 83% in a patient with sepsis.15 Treatment of the underly-
ing cause is critical to managing this oncologic emergency in oncol-
ogy nursing.
Risk Factors and Etiology
In DIC, the coagulation cascade is abnormally activated, leading to
coagulation and fibrinolysis. Blood is exposed to a procoagulant fac-
tor, which activates clotting. The procoagulant factor can come from
different sources. Examples include blood vessel injury, such as in
trauma, which can release procoagulant enzymes or phospholipids,
“cancer procoagulant” with malignancy that activates factor X,16 or
bacterial products that cause inflammation activating coagulation.
Coagulation leads to extensive clotting in the vasculature. The body
responds to this clotting by activating fibrinolysis to break up the

https://doi.org/10.1016/j.soncn.2021.151135
0749-2081/Published by Elsevier Inc.
2 L. Smith / Seminars in Oncology Nursing 37 (2021) 151135
Fig. 1. Coagulation Cascade Overview.5
clots. Fibrin degradation products (FDPs) break up the clots; FDPs in
turn interfere with platelet aggregation and further clotting. This pro-
cess can lead to bleeding. End-organ damage occurs from decreased
perfusion due to the clotting or bleeding.
As stated previously, DIC does not occur by itself. In the oncology
population, the most common causes of DIC are sepsis and certain
types of tumors. Acute promyelocytic leukemia (APML) is the most
common cancer associated with DIC.17 Mucin-producing tumors,
such as gastric, ovarian, and pancreatic cancers, can also be a source
of DIC because the cancer releases enzymes or necrotic tissue that
can stimulate the clotting cascade.18 The development of cytokine
release syndrome after CAR-T cells has also been associated with
DIC.12 Procoagulant factors released from the vascular endothelium
as part of inflammation are thought to be the reason behind the
development of DIC in this population.19 The higher the grade of CRS,
the more likely the patient will develop DIC.
Clinical Manifestations
Nurses may see bleeding as one of the first clues that the patient
has DIC. Constant oozing of blood from central venous catheters,
drains, and sites of minor trauma, such as a small cut or peripheral
intravenous catheter, will be present. Petechiae and bruising may be
present. It is important for the oncology nurse to consider the diagno-
sis or condition of the patient. For instance, if the patient presents
with a new diagnosis of APML or sepsis, DIC is likely to be the reason
for the bleeding. Although not common in acute DIC, venous throm-
boembolism may also be present.
Assessment
DIC may be the presenting symptom of an underlying diagnosis.18
Nurses should make a detailed review of the clinical history of the
patient and any differential diagnoses, particularly a possible new
cancer diagnosis or recurrence of malignancy. As sepsis is also a cause
for DIC, quickly determining if the patient is septic is time-critical.
Interviewing the patient and caregivers on recent symptoms and a
thorough physical examination focusing on bleeding that does not
resolve, bruising, swelling of extremities, or any signs of end-organ
damage (anuria, jaundice, neurologic changes such as confusion, and
hemoptysis to name a few) can lead to a presumptive finding of DIC
and to early intervention.
Diagnostic Evaluation
No one laboratory (lab) test is diagnostic of DIC. Lab tests that
assist in the diagnosis of DIC are thrombocytopenia, prolonged pro-
thrombin time (PT) and activated partial thromboplastin time (aPTT),
decreased fibrinogen, and increased D-dimer (Table 1). DIC is diag-
nosed by both the clinical presentation and abnormal lab results.18 It
is important for the nurse to advocate for orders if DIC is suspected to
trend lab results.
Treatment Including Nursing Management and Patient/Family
Education
Timely delivery of treatment of the underlying condition manages
DIC.18 For cancer diagnoses, starting chemotherapy or treatment as
soon as diagnosis is confirmed is imperative. In sepsis, antibiotic ther-
apy with broad-spectrum antibiotics is urgent. However, the coagula-
tion abnormality can take several days to be corrected, despite
treatment of the problem.18 For this reason, supportive care is neces-
sary.
In patients who are bleeding, transfusions of platelets when the
platelet count is less than 50,000 is recommended.18 With a pro-
longed PT or aPTT, or a fibrinogen <50 mg/dL, fresh frozen plasma
(FFP) and cryoprecipitate is transfused. Cryoprecipitate is a good
source of fibrinogen and is dispensed with less volume than FFP. Red
blood cell transfusion may also be necessary if the patient is anemic
and bleeding or at risk for bleeding. Management of the patient is
individualized based on clinical presentation. Some institutions may
have institutionalized guidelines for DIC management. Prophylactic
anticoagulation therapy, such as heparin infusions, have not been
shown to prevent thrombosis in this population.15 Anticoagulants
may be used if the patient develops venous thromboembolism.
Close hemodynamic monitoring of the patient with DIC is critical.
Depending on the level of bleeding or degree of coagulopathy, these
patients may require transfer to the intensive care unit. Frequent vital
signs and physical assessment is required. Nurses should also closely
monitor for end-organ dysfunction, including renal failure, hepatic
failure, and neurologic changes. The manifestations of DIC and the
condition causing it can be frightening to patients and caregivers.
Therefore, ongoing communication is essential. Mortality among
patients affected by DIC can be as high as 80%.12 It is imperative to
educate and involve caregivers as they often are the first to notice
subtle changes in the patient. Encourage both the patient and care-
giver to alert the nurse to any new symptom or change. Early identifi-
cation and intervention is time-critical to mediate this life-
threatening condition.
Future Perspectives
Early recognition of DIC is warranted to increase life-saving strat-
egies. Risk-stratification algorithms leading to early patient diagnosis
are being researched for early DIC management.21 There are several
scoring systems to assist with the diagnosis of DIC including the
International Society on Thrombosis and Haemostasis (ISTH), which
Table 1
Laboratory Results in Disseminated Intravascular Coagulation.
Platelets Decreased
Prothrombin time (PT) Increased
Activated partial thromboplastin time (aPTT) Increased
Fibrinogen Decreased
D-dimer Increased
 L. Smith / Seminars in Oncology Nursing 37 (2021) 151135
uses lab results plus the presence of an underlying condition to deter-
mine if the patient has DIC.21 This scoring system has been widely
implemented in practice by multidisciplinary team and labs.20
The clinical management of DIC has not changed in oncology for
many years. Although heparin is not currently used in the manage-
ment of DIC, some researchers are now stating that this therapy is
worthy for further research to inform clinical practice guidelines.22
DIC management is largely supportive and resolution depends on
successful treatment of the underlying cause(s). Treatment options
are needed that quickly reverse DIC without waiting days for correc-
tion of coagulation factors.22 Further research directions also include
exploring genetic variants that may cause some individuals to be
more prone to developing DIC and a greater degree of coagulop-
athy.23 Understanding these variants could assist oncology nurses in
determining who may have a greater propensity toward DIC as well
as identifying targeted timely assessment and management.
Fast Facts
 DIC is an oncologic emergency. If not recognized early, mortality
is high.
 Because DIC is not a condition that occurs by itself, successful
treatment of the underlying cause should correct the DIC. APML
and sepsis are the most common causes of DIC in patients with
cancer.
 In addition to looking at the platelet count, which is often the
reason for bleeding in oncology patients, it is important review
the coagulation labs as well. Ongoing hemodynamic monitoring
is essential.
 DIC can take several days to resolve once treatment of the under-
lying cause is started. Supportive care with transfusions is still
the standard of care for DIC management.
 Informing patients and caregivers of what DIC is, the cause, treat-
ment, and the time to resolution is an important part of nursing
care in developing partnership with patients.
Case Study
Mrs. Samson is a 56-year-old woman admitted with a differential
diagnosis of APML. While assessing her, the nurse notes large bilat-
eral retroperitoneal hematomas. She also assesses petechiae on her
legs. Mrs. Samson reports that the retroperitoneal hematomas “just
appeared” over the last couple days; she did not fall or injure herself.
The hematomas are slightly sore but not painful. The remainder of
her physical assessment was unremarkable.
Mrs. Samson’s vitals are temperature 37.2°C (99.1°F); pulse 102;
respiratory rate 20; blood pressure 143/52 mm Hg; and oxygen satu-
ration 95% on room air.
Because the patient has a tentative diagnosis of APML, the nurse is
concerned about DIC. This may be one reason for the large hemato-
mas and petechiae that the nurse saw on assessment. On evaluation
of Mrs. Samson’s labs results, the nurse reviews the following:
Labs Patient results Normal values
White blood count 65,000 5000-10,000
Hemoglobin 6.2 g/dL 12-16 g/dL
Platelets 25,000 150,000-450,000
Absolute neutrophil count 1300 2500-6000
Blasts (leukemia cells) 25% 0 Lecture. Thromb Haemost. 1980;43:77.
aPTT 45.1 s 25.3-37.3s
PT 26 s 11.6-15.2 s
Fibrinogen 82 177-466
D-dimer 0.9 (or 900 mg/mL) 0.0-0.5
3
Based on the tentative diagnosis of APML, the prolonged aPTT and
PT, the decreased fibrinogen, and increased D-dimer, the nurse sus-
pects DIC. The nurse calls the physician to report the retroperitoneal
hematomas and relay the lab results. The physician orders a com-
puted tomography (CT) scan to evaluate if the retroperitoneal hema-
tomas are compressing any major organs.
To correct the coagulopathies, the physician orders FFP and cryo-
precipitate. Two units of red blood cells are also ordered. Because
Mrs. Samson has bilateral retroperitoneal hematomas that may be
continuing to bleed and is in DIC, the physician also orders platelets
with the goal of achieving a platelet count greater than 30,000. Due
to the hyperleukocytosis, hydroxyurea is started immediately to
decrease the total white blood count. Ongoing monitoring of labs is
ordered twice a day. The nurse quickly begins the transfusions to cor-
rect the coagulopathies and elevate the platelet count. The hydroxy-
urea is also started immediately to decrease the blast count.
Once the diagnosis of APML is confirmed by the pathologist, treat-
ment with trans-retinoic acid and chemotherapy is immediately
started. Lab work is monitored twice per day until the DIC is resolved.
The retroperitoneal hematomas were not compressing any major
organs and the bruises slowly resolved with time. Thorough physical
assessment and an understanding of APML’s association with DIC
gave the nurse the knowledge to quickly act to prevent further bleed-
ing, coordinate care with the physician and other nursing staff, and
provide supportive care while Mrs. Samson began treatment for
APML. Based on the nurse’s quick suspicion of DIC and timely nursing
interventions, the patient’s bleeding was controlled. Mrs. Samson
remained hemodynamically stable and a transfer to the intensive
care unit was prevented. With control of her APML achieved, the DIC
resolved.
Implications for Oncology Nurses
Nurses play a key role in the identification and management of
DIC. Oncology nurses require a high level of knowledge and clinical
expertise to be able to identify the types of diagnoses that are fre-
quently associated with DIC and accurately interpret the lab results
that point to this life-threatening condition. Collaborating with the
medical team and other members of the multidisciplinary team to
advocate for appropriate orders will assist with obtaining time and
proactive clinical interventions. Educating the patient and caregiver
will help prepare them for treatment. Patients who present with DIC
will be acutely ill and need knowledgeable nursing care.
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