Rahmawati Minhajat Tutik Harjianti

Div. of Hematology & Medical Oncology Dept. of Internal Medicine, Medical Faculty Hasanuddin University

Sub Topics
Introduction of DIC. Trigger Mechanism of DIC. Etiology of DIC. Clinical pictures of DIC. Diagnosis of DIC. Management of DIC. Prognosis of DIC.

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

I. Introduction

D.I.C :
Disseminated : widespread Intravascular : inside the bloodline Coagulation : blood clot production

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Physiology of Blood Circulation Blood always in a liquid form Vascular disruption initiate coagulation (as a part of normal homeostasis ) Coagulation is limited in area of lesion by the effect of : - blood streaming / blood flow - coagulation inhibitor inside the circulalationtion (esp. Anti Thrombin III/ATIII / AT III)

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Physiology of Coagulation Vasculature rupture/ lesion

Vasoconstriction
Primary homeostasis reaction

Coagulation

homeostasis mechanism

Fibrinolysis

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Why DIC can be occured? Overstimulation of coagulation

suppression of control mechanism

DIC
Division of Hematology & Medical Oncology - Dept. of Internal Medicine

DIC
A clinicopathologic syndrome in which widespread intravascular coagulation is induced by procoagulants that are introduced into or produced in the blood secondary to 1 or more underlying condition(s)

A syndrome associated with many underlying conditions & manifested as microvascular thrombosis, tissue hypoxia,& organ damage

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Important Clue The presence of thrombin circulating in bloodline. Normally : thrombin can only be found in area of lesion (where the coagulation process is still running)

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Pathophysiology of DIC
1 1 1 2

Activation of Blood Coagulation Suppression of Anticoag Pathway Impaired Fibrinolysis Cytokines release & activation

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Result of excess of thrombin

1 1 2 3 4

Decreased of fibrinogen

Decreased of platelet

Decreased of coagulation factors

Exaggerated of fibrinolysis

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

II. Trigger Mechanism of DIC

TUMOR Tissue TRAUMA Tissue NECROSIS ENDOTOXIN GRAM NEGATIVE BACT. RELEASE OF TISSUE FACTOR INTO CIRCULATION ACTIVATION of COAG. CASCADE (F.XII)

DIC DIC

EXPRESSION of TISSUE FACTOR in MONOCYTE & ENDOTHELIAL cells

ACCELERATION of COAG RX

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

III. Etiology of DIC

DIC is not a stand alone disease entity, as a result of severe disease or condition: Sepsis: gram +, gram -, & fungal infection Tissue necrosis: trauma & combustio/ burn Obstetric: abortus, emboli of liquor amnion, Malignancy: leukemia, Ca

fetal death

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Other cause of DIC Major hemolytic reaction as a result of blood transfusion error!.

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Clinical Features

1. Acute DIC
Develops rapidly over a period of hours Presents w/ sudden bleeding from multiple sites Treated as a medical emergency

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Clinical Features

2. Chronic DIC
Develops over a period of months May be subclinical Eventually evolves into an acute DIC pattern

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

IV. Clinical Pictures of DIC

1. Abnormal coagulation 2. Bleeding (more often) - can be found at any place - spontaneous bleeding - at the site of wound, etc.

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Coagulation disorders in DIC Thrombosis can be occurred if the abnormality of coagulation more prominent than fibrinolysis - digital ischemia - gangrene (necrosis) - Necrosis of cortex of kidney - Adrenal gland necrosis & bleeding

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Trousseau Syndrome Sub-acute DIC Often found in cancer patients Thrombosis in superficial & profundal veins (DVT), commonly recurrent

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

V. Diagnosis of DIC
1. 2. Clinical pictures (severe disease, bleeding, thrombosis) Laboratory : - Fibrinogen < - FDP > - Platelet < - Prothrombin Time > - activated Partial Thromboplastin Time (aPTT) >

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Scoring system for overt DIC

Underlying disorder known to be associated with overt DIC YES NO

continue

stop

Platelet count

Soluble fibrin/D-dimer Prolongation of PT Fibrinogen

(>100=0, <100=1, <50=2) .............................. (normal=0, =2, =3) ............................. (<3s=0, 3-6s=1, >6s=2) ................................

(>1g/l=0, <1g/l=1) ..........................................

Calculate sum ........................................

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Scoring system for overt DIC

- Example Underlying disorder known to be associated with overt DIC Polytrauma YES NO

continue
85
8

stop

Platelet count

Soluble fibrin/D-dimer Prolongation of PT Fibrinogen

(>100=0, <100=1, <50=2) .............................. (normal=0, =2, =3) ................................. (<3s=0, 3-6s=1, >6s=2) .................................
+3

1
3 1 0

(>1g/l=0, <1g/l=1) .............................................

2,2

Calculate sum ............................................

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Scoring system for overt DIC

5 : compatible with overt DIC repeat scoring daily <5: suggestive (not affirmative) for non-overt DIC repeat next 1-2 days.

If the calculated score is

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Differential Diagnosis of DIC Liver Diseases (normal fibrinogen ) Vit K defc (normal fibrinogen & platelet)

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

VI. Management of DIC

Treat the underlying disease/condition. Replacement Tx:
Platelet concentrate transfusion
(maintain the platelet > 50.000 / mm3)
Dose: 1 unit/ 10kgBW. 5 7 units PC may increase 5000 10.000/uL PLT in adult with BW 70kg.

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Management

Cryoprecipitate transfusion
(maintain the fibrinogen > 150.000 mg/dL) dose: 10 units for adult with BW 70 kg. may increase fibrinogen 60 - 100 mg/dl

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Management

Fresh Frozen Plasma transfusion (to increase coagulation factors)

Dose: 10 15ml/ kgBW or 3 4 units for adult with BW 70kg.

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

Management
Heparin : still controversial Should be given with Replacement Tx Dose : 500 750 u/ hour

Division of Hematology & Medical Oncology - Dept. of Internal Medicine

VII. Prognosis of DIC

Depends on : 1. Severity of coagulation reaction 2. Amount of bleeding 3. Etiology of DIC (malignancy etc)

Division of Hematology & Medical Oncology - Dept. of Internal Medicine