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COAGULATION
(DIC)
DEFINITION
DIC is an acquired syndrome characterized by the intravascular activation of coagulation with loss of localization arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction
ISTHs Scientific Subcommittee on DIC, July 2001
INCIDENCE / ETIOLOGY
DIC is reported to occur in 1% of hospitalized patients. Of those patients, the underlying cause was:
Generalized infection in ~30% of cases Malignancy in ~15% Surgery or trauma in ~20% Hepatic disease in ~10% Miscellaneous in ~25%
INFECTION
There are some mechanisms specific to infection in animals, there is evidence that Protein C is downregulated, as well as thrombomodulin. When shock develops, blood flow is reduced, which diminishes not only hemodilution, but to stasis as well. Tissue damage then occurs, which in itself causes thombin formation.
MALIGNANCY
Malignancy is a coagulopathic state. The features of malignancy most closely associated with DIC include: High levels of tissue factor expressed by tumor cells The expression by tumor cells of cancer procoagulant, a calcium-dependent cysteine protease which is not found in normal tissue (but is found in fetal tissue). It activates factor X directly.
TRAUMA
Trauma causes the release of tissue enzymes and phospholipids into the circulation in turn, these trigger the activation of cytokines and the coagulation system. The brain seems to have a higher proclivity to cause DIC than other body parts. Head trauma is associated with coagulopathy in twice as many patients with CT evidence of injury (41%) as in those without this evidence the coagulopathy was consistent with DIC by labs (more on labs later).
OBSTETRICAL
DIC occurs in a variety of obstetrical complications, including: Amniotic fluid embolization Abruptio placentae Eclampsia & severe pre-eclampsia Blah blah blah
Bleeding
PROGRESSION OF SEPSIS
Non-adhesive Adhesive adhesive surface surface
Platelets
Monocytes
Cytokines Tissue factor
Endothelial cells
Leukocytes
Accelerates coagulation
VII
CLINICAL
MANIFESTATIONS OF
DIC
SYMPTOMS OF DIC
Dysfunction of multiple organs
The pulmonary microembolism syndrome
Acute: vascular and bronchial constriction Late: ARDS
Cerebral dysfunction
Confusion, blurred consciousness, coma
DIAGNOSTIC
CRITERIA OF
DIC
D fragments E fragments
Fibrinogen
THROMBIN Antithrombin
Fibrinopeptide A+B
Fibrin
Plasmin
FXIII
FXIIIa
Cross-linked fibrin
D dimer E fragments
CONSIDERATIONS
IN PRACTICAL DIAGNOSTIC APPROACH TO DIC Presence of an underlying disorder The severity of haemostatic changes
Decompensated haemostatic system: Overt DIC Compensated haemostatic system: Non-overt DIC
Laboratory tests
Global tests / Molecular markers Diagnostic value / Prognostic value
YES
continue
NO
stop
Soluble fibrin/D-dimer
(normal=0, =2, =3) .............................
Prolongation of PT
(<3s=0, 3-6s=1, >6s=2) ................................
Fibrinogen
(>1g/l=0, <1g/l=1) ..........................................
TAT complexes
5: compatible with overt DIC repeat scoring daily <5: suggestive (not affirmative) for non-overt DIC repeat next 1-2 days.
TREATMENT OF DIC
TREATMENT OF DIC
DIRECTED AGAINST ETIOLOGICAL FACTORS
Infections Trauma
Antibiotics
ASSESMENT
abnormal bleeding from any or all body orifices bleeding into the skin (petechiae, ecchymoses, hematomas) bleeding from surgical or invasive procedure sites (incisions, venipuncture sites) mental status changes confusion dyspnea and tachycardia potential nausea, vomiting potential severe muscle, back and abdominal pain chest pain hemoptysis epistaxis seizures oliguria possible GI bleeding hematuria complicationsrenal failure hepatic damage, stroke, ischemic bowel,
LAB
Fibrinogen << Degradation fibrin product >> Platelet << PT, PTT prolonged
NX DIAGNOSE
Defisit fluid volume Ineffective tissue perfusion Impaired gas exchange: infant Anxiety
INTERVENTION
IV fluid with 16 0r 18 gauge cannula Folley catheter Intake out put monitoring Transfusion with red blood cell, fresh frozen plasmato replace fibrinogen and clothing factor Monitoring of transfusion reaction Asses client for abnormal bleeding: injection site, mucosa, etc
Posisi client of left side and monitori fetus well being Monitor laboratory values as obtained for improvement or worsening condition