This is Part II of a 2-part lecture on TTP, DIC, and thrombocytopenia in the critically ill patient. It was given by Tom Deloughery at the EEMCrit Conference. The Essentials folks have a video package of the whole day at their site.
See Part I for Diagnosis
TTP
Never Give Platelets Never Give Platelets Never Give Platelets
Plasma Exchange is the treatment of Choice
Temporize with 2 units of Plasma, then 1 unit q6 hrs until plasma exchange
These patients will not bleed regardless of PLTs when you place the HD Cath–just do it (but not the intern)
Give Steroids (i.e. 125 mg solumedrol or similar)
Send ADAMSTS13 find out how long it takes and make sure it is sent before plasma exchange
Goals
- PLT target >150,000 on 2 draws
- normalizing LDH
- neuro sx fixed
after this, 2 more days; then cold turkey or wean
DIC
Treat underlying cause (duh_
Transfuse to
- Fibrinogen > 150 (200 in OB disasters) — Give 10-pack of cryo and recheck (even in places that have fibrinogen conc.)
- PLT > 50
- HCT > 21
- PTT < 1.5 x control
- INR < 2-3
Heparin and AT III have not panned out. Only use heparin if there is macro-thrombosis (i.e. PE)
Additional New Information
More on EMCrit
- EMCrit Podcast 223 – TTP & DIC with Tom DeLoughery – Part I – Diagnosis(Opens in a new browser tab)
- Thrombotic microangiopathies (including TTP, ST-HUS, and C-HUS)(Opens in a new browser tab)
- Acute Disseminated Intravascular Coagulation (DIC)(Opens in a new browser tab)
- Thrombocytopenia(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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amazing stuff
Thanks for the post. I have some disagreement with the recommendation to give FFP for high INR or PTT in a non-bleeding DIC patient.. This will predispose many patients to thrombosis and volume overload among other things. I recently read with interest Josh Farkas’ DIC post and he brings up the concept that many DIC patients are procoagulable, especially if they have elevated fibrinogen. How do you reconcile this with Dr. DeLoughery’s FFP recommendation?