8/12/2019 DIC [Compatibility Mode]

1/30

DISSEMINATED INTRAVASCULAR

COAGULATION

(DIC)

Clinic Departement of Nursing FacultyUNPAD

8/12/2019 DIC [Compatibility Mode]

2/30

DEFINITION OF DISSEMINATEDINTRAVASCULAR COAGULATION

DIC is an acquired syndromecharacterized by the intravascular

ISTHs Scientific Subcommittee on DIC, July 2001

localization arising from different causes.It can originate from and cause damage to

the microvasculature, which if sufficientlysevere, can produce organ dysfunction

8/12/2019 DIC [Compatibility Mode]

3/30

INCIDENCE / ETIOLOGY

DIC is reported to occur in 1% of hospitalized

patients. Of those patients, the underlying cause was:

enera ze n ect on n ~ o casesMalignancy in ~15%

Surgery or trauma in ~20%

Hepatic disease in ~10%

Miscellaneous in ~25%

8/12/2019 DIC [Compatibility Mode]

4/30

INFECTION

There are some mechanisms specific to infection in

animals, there is evidence that Protein C is downregulated, as

well as thrombomodulin.

diminishes not only hemodilution, but to stasis as well.

Tissue damage then occurs, which in itself causes

thombin formation.

8/12/2019 DIC [Compatibility Mode]

5/30

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

T e express on y tumor ce s o cancer procoagu ant, acalcium-dependent cysteine protease which is not found in

normal tissue (but is found in fetal tissue). It activates factor

X directly.

8/12/2019 DIC [Compatibility Mode]

6/30

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.

DIC than other body parts. Head trauma is associated withcoagulopathy 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 labslater).

8/12/2019 DIC [Compatibility Mode]

7/30

OBSTETRICAL

DIC occurs in a variety of obstetrical complications,

including:

Amniotic fluid embolization

Abruptio placentae

Eclampsia & severe pre-eclampsia

Blah blah blah

8/12/2019 DIC [Compatibility Mode]

8/30

DISSEMINATED INTRAVASCULAR COAGULATION

(DIC)MECHANISM

Systemic activation

of coagulation

Intravasculardeposition of fibrin

Depletion of plateletsand coagulation factors

BleedingThrombosis of small

and midsize vessels

with organ failure

8/12/2019 DIC [Compatibility Mode]

9/30

PPROGRESSIONROGRESSION OFOFSEPSISSEPSIS

MonocytesEndothelial

cells

Endothelial

cells

Platelets

Leuko-

Non-adhesivesur

Adhesivesurfa

Cytokines

Tissue

factor

Activation of coagulation Thrombin Fibrin

cy es

f

ace

ce

Accelerates

coagulation

8/12/2019 DIC [Compatibility Mode]

10/30

THE CLASSIC COAGULATION SYSTEM

Surface contact Tissue factor

XII XIIa

XI XIa

APTT Prothrombin time

IX IXa

X Xa X

II IIa

I Ia (fibrin)

Phospholipid, Ca++, VIII

Phospholipid, Ca++, V

VIIa VII

Ca++

8/12/2019 DIC [Compatibility Mode]

11/30

CLINICAL

OF DIC

8/12/2019 DIC [Compatibility Mode]

12/30

SYMPTOMS OF DIC

Dysfunction of multiple organs The pulmonary microembolism syndrome

Acute: vascular and bronchial constriction Late: ARDS

Acute renal failure Oli uria increasin serum creatinine haematuria

Cerebral dysfunction Confusion, blurred consciousness, coma

Cutane haemorrhagic Failure of liver.

8/12/2019 DIC [Compatibility Mode]

13/30

DIAGNOSTIC

DIC

8/12/2019 DIC [Compatibility Mode]

14/30

BLOOD TESTS WHEN DIC IS SUSPECTED

Simple screening

Extended screening

Platelet count

Activated partial thromboplastin time (APTT)

Prothrombin time (PT)

Fibrin D-dimer fragment

Antithrombin

Supplementary testsFibrinogen

Further evidence for activation of coagulation

and fibrinolysis

8/12/2019 DIC [Compatibility Mode]

15/30

Activation of coagulation

Prothrombin

THROMBIN

Antithrombin

Fibrinogen

Fibrin

D fragmentsE fragments

Fragment 1+2

Fibrino-peptideA + B

Thrombin-Antithrombin

complex

(TAT)

FXIII FXIIIa

D dimerE fragments

Cross-linkedfibrin

8/12/2019 DIC [Compatibility Mode]

16/30

PREDICTOR FORDIC IN

NEONATAL SEPSIS

Healthy neonates: 24,5 6,09 mg/l Sepsis, no DIC: 33,7 11,9 mg/l

Sepsis + DIC*: 73,2 31,6 mg/l

Critical level: 48,5 mg/l

Sensitivity: 100%

Specificity: 93%

Overall accuracy: 97,5% Selim et al. Haematologica 2005;90:419-20

*ISTH DIC score 5

8/12/2019 DIC [Compatibility Mode]

17/30

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

The duration of activation Temporary: e.g. Abruptio placentae, transfusion reaction Prolonged: e.g. Sepsis, malignancy, polytrauma

Laboratory tests Global tests / Molecular markers

Diagnostic value / Prognostic value Use of scoring systems

DIC scoring system Other scoring systems

ISTHs Scientific Subcommittee on DIC, July 2001

8/12/2019 DIC [Compatibility Mode]

18/30

SCORING SYSTEM FOR OVERTDIC

Platelet count (>100=0,

8/12/2019 DIC [Compatibility Mode]

19/30

SCORING SYSTEM FOR OVERTDIC

Platelet count (>100=0,

8/12/2019 DIC [Compatibility Mode]

20/30

SCORING SYSTEM FOR NON-OVERTDI

Presence of underlying disorder (no=0, yes=2) ..........................................................

Platelet count + changes (100=0, 3s=1) + ( =-1, stable=0,

=1) ........... Antithrombin (normal=-1, low=1) .................................................

Protein C (normal=-1, low=1) .................................................

TAT complexes (normal=-1, high=1)

.................................................

Calculate sum ................................................ISTHs Scientific Subcommittee on DIC, July 2001

8/12/2019 DIC [Compatibility Mode]

21/30

SCORING SYSTEM FOR OVERTDIC

If the calculated score is 5: compatible with

overt DIC

repea scor ng a y

8/12/2019 DIC [Compatibility Mode]

22/30

OFDIC

8/12/2019 DIC [Compatibility Mode]

23/30

DICTREATMENT APPROACHES

Treatment of underlying disorder

Anticoagulation with heparin

Platelet transfusion

Fresh frozen plasma

8/12/2019 DIC [Compatibility Mode]

24/30

TREATMENT OFDICDIRECTED AGAINST ETIOLOGICAL FACTORS

Infections

Trauma

Antibiotics

Removal of damaged tissue

Obstetriccomplications

stabilisation of fractures

Evacuation of the uterus

8/12/2019 DIC [Compatibility Mode]

25/30

ASSESMENT

abnormal bleeding

from any or all body

orifices bleeding into

the skin (petechiae,

ecch moses

confusion dyspnea and

tachycardia potential

nausea, vomiting

potential severe

hematomas) bleeding from surgical

or invasive procedure

sites (incisions,

venipuncture sites)

mental status changes

muscle, back andabdominal pain chest

pain hemoptysis

epistaxis seizures

oliguria possible GIbleeding hematuria

complicationsrenal

failure

hepatic damage, stroke,

8/12/2019 DIC [Compatibility Mode]

26/30

LAB

Fibrinogen > Platelet

8/12/2019 DIC [Compatibility Mode]

27/30

NX DIAGNOSE

Defisit fluid volume

Ineffective tissue perfusion Impaired gas exchange: infant

Anxiety

8/12/2019 DIC [Compatibility Mode]

28/30

INTERVENTION

IV fluid with 16 0r 18 gauge cannula

Folley catheter Intake out put monitoring

,

frozen plasmato replace fibrinogen andclothing factor

Monitoring of transfusion reaction

Asses client for abnormal bleeding:

injection site, mucosa, etc

8/12/2019 DIC [Compatibility Mode]

29/30

Posisi client of left side and monitori fetus well

being

Monitor laboratory values as obtained for

improvement or worsening condition

8/12/2019 DIC [Compatibility Mode]

30/30

THE FACE OF SEPSIS