Delayed Rewarming Thrombocytopenia Not Disseminated Intravascular Coagulation, is the Cause of Rewarming Deaths in Neonatal Cold Injury

Disseminated intravascular coagulation (DIC) was suspected of being the cause of fatal rewarming deaths in neonatal cold injury (NCI) in the absence of any other known explanation for this complication. It was associated with thrombocytopenia, bleeding, and abnormal clotting studies. Subsequently, this suspicion was questioned because of the reversibility of thrombocytopenia and more recently because of the delineation of a new entity DRT (delayed rewarming thrombocytopenia) that better explained the clinical and laboratory features of this condition. The sudden bleeding that occurs after 24 hours of hypothermia is explained by the reappearance, on rewarming, of the second stage of (irreversible) platelet aggregation that does not occur below 32°C, and the presence of high levels of ADP that leak from erythrocytes. It is recommended that DRT should be treated by rapid rewarming, blocking of the second phase of platelet aggregation or platelet transfusions rather than replacement therapy with several clotting factors that would be appropriate in DIC.