Matters_Summer_12_Matters!

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CONTINUING

Instructions For
Continuing Nursing
Education Contact Hours

CNE

NURSING
EDUCATION

Disseminated Intravascular
Coagulation and Implications
For Medical-Surgical Nurses

DIC and Implications for
Medical-Surgical Nurses
Deadline for Submission:
August 31, 2014
MSNN1204

To Obtain CNE Contact Hours
1. For those wishing to obtain CNE contact
hours, you must read the article and complete the evaluation through AMSN’s
Online Library. Complete your evaluation
online and print your CNE certificate
immediately, or later. Simply go to
www.amsn.org/library
2. Evaluations must be completed online by
August 31, 2014. Upon completion of the
evaluation, a certificate for 1.0 contact
hour(s) may be printed.

Fees
Member: FREE

Regular: $20

Objectives
The purpose of this continuing nursing education
article is to increase the awareness of disseminated
intravascular coagulation (DIC) in nurses and other
health care professionals. After studying the information presented in this article, you will be able to:
1. Define disseminated intravascular coagulation
(DIC).
2. Discuss symptoms and diagnosis of the patient
with DIC.
3. Identify the medical-surgical nurse’s role in the
care of the patient with DIC.

Note: The author, editor, and education director
reported no actual or potential conflict of interest in relation to this continuing nursing education article.
This educational activity has been co-provided by
AMSN and Anthony J. Jannetti, Inc.
Anthony J. Jannetti, Inc. is a provider approved by
the California Board of Registered Nursing, provider
number CEP 5387. Licensees in the state of CA must
retain this certificate for four years after the CNE
activity is completed.
Anthony J. Jannetti, Inc. is accredited as a
provider of continuing nursing education by the
American Nurses’ Credentialing Center’s Commission
on Accreditation.
This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC,
NE-BC, AMSN Education Director. Accreditation status
does not imply endorsement by the provider or ANCC
of any commercial product.

Tammeshin Frazier
The patient’s platelets are 50,000, and
we’re giving heparin. Something seems
amiss, and I do not understand what is
happening with this patient.
Although this scenario may sound
absurd, a logical and plausible explanation
exists. Disseminated intravascular coagulation (DIC) is the explanation, which
affects approximately 1% of hospitalized
patients and 30% to 50% of patients with
sepsis (Becker, Kumar, Shaaban, & Wira,
2009). DIC is not a new or rare phenomenon but a syndrome that has been
around for some time. At first discovery,
the pathophysiology was elusive and hard
to understand; however, with recent
advances in medicine and diagnostic technologies, hematologists are not only
understanding the condition, but they can
effectively diagnose and treat it.

What Is DIC?
DIC, also known as consumptive
coagulopathy and defibrination syndrome, is an acquired syndrome secondary to tissue damage, vessel damage, or
infections (LeMone, Burke, & Bauldoff,
2010). Table I lists common conditions
that precipitate the development of DIC.

Table 1.
Conditions that Trigger the DIC Process

Physiological Results
of Conditions
Tissue damage

Conditions
Trauma: Burns, gunshot wounds, motor vehicle
accidents, head injuries
Obstetric complications: HELLP, abruption placenta,
amniotic fluid embolus
Cancer: Acute leukemia, adenocarcinoma
Fat emboli

Vessel damage

Aortic aneurysm, acute glomerulonephritis, hemolytic
uremic syndrome

Infections

Severe bacterial, viral, parasite, or rickettsial infection
Sepsis

Source: Adapted from LeMone et al., 2010.

8

Present in the syndrome is an inappropriate activation of the clotting cascade, leading to hypercoagulation and then bleeding
once the clotting factors are consumed.
Unless the disorder is detected early and
the initiating cause is corrected, multiple
system organ failure due to microembolie
will result (Becker et al., 2009).
DIC is classifiable as either overt or
non-overt. Overt DIC is a noncompensatory syndrome with a high rate
of mortality and organ failure. Overt DIC
is associated with sepsis, severe infections,
HELLP (hemolysis, increased liver
enzymes, and decreased platelet count),
liver failure, and obstetrical complications.
The overt form of DIC is recognizable by
obvious bleeding and a symptomatic
patient. Non-overt DIC is compensatory
or chronic and is associated with blood
dyscrasias, such as anemias, leukemias, and
malignancies (Somashekhar, Kadamba, &
Wakodkar, 2008). In compensatory (nonovert) DIC, the patient’s hematological
system is continously or intermittently
exposed to small amounts of tissue factors. The patient may be asymptomatic,
and the syndrome may only be noticeable
in laboratory studies (Becker et al., 2009).

greater than 6 seconds = 2 points Fibrinogen level: Greater than 1 g/L = 0 points. and repeat assessment of coagulation factors. the process is impaired due to high levels of the principle inhibitor of the fibrinolytic system: plasminogenactivator inhibitor type 1 (PAI-1). In essence. causing an increase in fibrin clot formation within the intravascular system (Wei. & Spek. fibrinogen measurement. Normally. PT and aPTT are prolonged in approximately half of Figure 1. 2009. strong increase = 3 points Prolonged PT: Less than 3 seconds = 0 points. bleeding starts (Levi & Schmaier. platelet count. 2009. Pathophysiology of Sepsis-Induced DIC Accumulation of micro thrombi • Hemorrhage • Platelet aggregation Vascular Occlusion Apoptosis (regulated cell death) – varies in degree Microvasculature necrosis • Fibrinolysis inhibited • Accumulation of neutrophils • Endothelial injury Source: Adapted from Slofstra. Carrell. Yan. 2009). less than 100 = 1 point. suppressed fibrinolysis. Figure 1 shows the Generalized Schwartzman Reaction (GSR) progression of sepsis-induced DIC. less than 50 = 2 points Elevated fibrin marker: No elevation = 0 points. As deposits of fibrin in the intravascular system continue to occur. or condition triggers inflammation in the intravascular system. 2006. and fibrin D-dimer (FDP). diagnosis is made after careful analysis of laboratory studies. 2009). The tool provides an objective measurement with 91% sensitivity and 97% specificity of diagnosing DIC. leading to a global deficiency of clotting factors and predisposing the body to bleeding. such as the kidneys. less than 1 g/L = 1 point Calculate score Greater than or equal to 5 = compatible with overt DIC. the body’s coagulation system is overworked in response to a triggering factor that has activated the clotting cascade (LeMone et al. & Watson. and when clotting factors are consumed. thus acti- sels. leading to decreased blood flow to vital organs. Specific laboratory assays to diagnose DIC include prothrombin time (PT). obstetric emergency) compatible with DIC? Laboratory Platelet count coagulation tests D-dimer and Fibrin degradation products (FDPs) Fibrinogen PT and aPTT Scoring Platelet count: Greater than 100 = 0 points. 2010). trauma. Diagnosis and Treatment A definitive test for DIC does not exist. The occurrence of either oozing or frank bleeding is often the first sign that DIC has developed. Cate. objective scoring. ISTH Diagnostic Scoring System for DIC Risk assessment Does the patient have an underlying disorder (sepsis. activated partial thromboplastin time (aPTT). The ISTH system should be used throughout the care of the patient (see Table 2). As a result. infection. Somashekhar et al. interleukin-6 (IL-6). Toh. greater than 3 but less than 6 seconds = 1 point. 9 . 2008). and tumor necrosis factor-α (TNF-α). Thachil. a serine protease inhibitor. The inflammation reduces the plasma levels of antithrombin III.Matters_Summer_12_Matters! newsletter 6/21/12 12:02 PM Page 9 866-877-2676 Volume 21 – Number 3/4 Table 2. clotting is stimulated. repeat scoring daily Less than 5 = suggestive of non-overt DIC Source: Levi et al.. moderate increase = 2 points. the body is able to break down fibrin clots by a process known as fibrinolysis. The International Society for Thrombosis and Haemostasis (ISTH) developed a DIC scoring system to aid in the diagnosing and confirmation of the syndrome (Levi.. which overwhelms the anticoagulant mechanisms.. and inflammation that occur prior to the onset of manifestations. In essence. The systemic response to an injury. The Pathogenesis of DIC vating the clotting cascade. The process of thrombosis occurrence is mediated by key proinflammatory cytokines. fibrin continues to be deposited in the intravascular system and thrombosis form within small and midsize blood ves- The pathogenesis of DIC can be easily stated as impaired coagulation. & Zhou. The defining pathophysiological process is the amplification of procoagulation factors. platelets and coagulation factors are consumed. but in DIC.

Heparin or low molecular heparin is ordered when thrombosis is apparent and dominating. whether it is acute (overt) or chronic (non-overt) DIC. Nursing interventions are directed at the primary illness and DIC collectively.Matters_Summer_12_Matters! newsletter 6/21/12 12:02 PM Page 10 Academy of Medical-Surgical Nurses www.. A transfer to a critical care unit is needed for a critical. how the risk factors trigger DIC. if count is less than 50. Hinkle. Treatment Approaches Basic Treatment Advanced Treatment • Monitor vital signs • Monitor lab work and anticoagulation factors • Determine presence of risk factors and patient’s DIC score per ISTH • Assess for signs of bleeding or possible thrombi formation • Correct hypovolemia if present • Identify primary factor and ensure proper treatment is in place • Advocate for patient care. 2009.amsn. FDP measures the breakdown and lysis of fibrinogen. not treating the primary condition leads to increased mortality. Bare. The patient’s plan of care is individualized depending on the initiating factor that caused the DIC. Platelets may or may not be given depending on the clinical condition and laboratory results of the patient. it is important not to focus on curing or alleviating DIC. and medical-surgical nurses need to assess patients at risk for this lifethreatening condition and be prepared to advocate for the appropriate level of care. Diagnosis and treatment of DIC occur with the collaboration of clinical and laboratory information.. In developing the plan of care for the patient. unstable patient with overt DIC. and venipuncture sites) Bleeding ranges from minimal to severe hemorrhaging Source: Adapted from Smeltzer. no single course of action exists (see Table 3). Medical-Surgical Nurses’ Response to DIC DIC is a dynamic condition that changes rapidly and contributes to increased patient mortality and morbidity. 2009. urinary. knowledgeable of the risk factors. Medical-surgical nurses should be vigilant about identifying manifestations in patients at risk for DIC (see Table 4) and should also monitor laboratory values. 2009). Prolonged coagulation factors reflect the consumption and depletion of various coagulation agents.000 and active bleeding noted. mucous membranes. Conclusion DIC is relevant to the medicalsurgical specialty because it is the one specialty outside of critical care that cares for patients with multiple diagnoses. The medical-surgical nurse must be 10 Table 4. Most cases of DIC syndrome resolve spontaneously once the underlying condition is managed (Levi & Schmaier. and co-morbidities.org Table 3. Medical-surgical nurses must practice aseptic care and advocate for patients and themselves. and platelets. ISTH consistently states that the key to DIC treatment is specific and vigorous treatment of the underlying disorder. Levi et al. susceptibilities. 2009). such as a complete blood count (CBC) for decreases in red blood cells. therefore. Laboratory assays are done frequently in the attempt to capture and understand the dynamic environment of the DIC. and the pathophysiological processes involved in DIC. but eliminating the underlying causative factor. 2009. hemoglobin. or prior to an invasive procedure • Recombinant activated human protein C • Continue treatment of the primary disorder • Severe bleeding – can be treated with lysine analogues (such as tranexamic acid) Source: Adapted from Becker et al. which lead to the measurement of Factors V and VII. & Cheever. . Successful treatment or management of the initiating factor will eradicate or control DIC syndrome. DIC cases. Clinical Manifestations of DIC Spontaneous bruising Petechiae Decline in organ function Low blood pressure Bleeding from more than one site (gastrointestinal. hematology should be consulted and possible transfer to ICU if patient is critical (overt DIC) • Antibiotics for infections and sepsis • Routine platelet and coagulation factor replacement is not indicated in acute DIC • Administration of unfractionated heparin (UFH) weightbased • Lovenox (Enoxaparin) or other low molecular weight heparin • Fresh frozen plasma if the PT or aPTT is prolonged and clinically relevant • Platelet transfusion. A patient can present with and/or develop DIC at any time. The medical-surgical nurse responds first by identifying patients at risk and then being alert for the subtle changes in the patient’s condition that could signal the development of DIC (Levi & Schmaier. hematocrit.

& Wira. B. J.G. Nursing2008. and personnel issues. (2010). Inserted in this copy of MedSurg Matters! is a removable poster explaining the characteristics of a healthy work environment. you’d have an extra $201 in your pocket.The work of nurses and physicians overlaps more and more. H. A Culture of Concern for Patients One Value of Membership: Contact Hours Membership in AMSN is $84 per year. & Zhou. (2006). Bare.Y. in your break room.44767 Wei.1182/blood-2009-04-210021 Additional Reading Levi. Thrombosis Journal. Adequacy of Staffing Kramer and colleagues (2008) reported that the perception of adequate staffing is the measurable factor in creating a HWE. or in your cafeteria. C.S. Because of this.).. Crystal structure of protein Z–dependent inhibitor complex shows how protein Z functions as a cofactor in the membrane inhibition of factor X.07600.03891.2010. 38(1). K. J. Shaaban.Yan. A comparison between a single dose endotoxemia model and a double hit endotoxin induced Shwartzman reaction. (2009). 2008). (2009). This does cause one problem – what are you going to do with all your savings? Just another way AMSN is supporting you! Shared values and beliefs must be reflected in behaviors. 13(4).H. rest room. 11 .medscape. & Wakodkar. Journal of Thrombosis and Haemostasis. She is a member of the MedSurg Matters! Editorial Committee. When a nurse lacks competent co-workers. H..). Lippincott Williams & Wilkins. 114(17). P. A. and more. doi:10. (2009). RN. viable. 144-146.H.. M..H.15387836.. Journal of the American Hematological Society: Blood. Pitman. & Schmaier.. P. G.x Tammeshin Frazier.W. C. Volume 21 – Number 3/4 Defining a Healthy Work Environment continued from page 1 Working with Clinically Competent Nurses Clinically competent nurses will have degrees..4103/0971-9261. Contact hours often total over 20 per year. Medical-surgical nursing: Critical thinking in patient care (5th ed.. Kumar.1111/j. & Watson. it hurts both quality patient care and job satisfaction. A. Essentials of a magnetic work environment.com/article/779097-overview LeMone. policies. H. Please use it to engage conversation in your workplace by displaying it on your unit. M. You have the support of AMSN with you! Reference Kramer. M. Inherent in this is the need for the nurse to be knowledgeable – to know what best practice is through evidence-based practice and continuing education. and peer reinforcement. working with budgets. Thus administration should confer with nurses on staffing standards. Positive Nurse/Physician Relationships A good relationship between nurses and physicians is essential for improving patient care. (2009). S. British Journal of Haemotology. Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed. Academy of Medical-Surgical Nurses (AMSN). The enabling structure must be visible. doi:10. 1475-1476. Low dose endotoxin priming is accountable for coagulation abnormalities and organ damage observed in the Shwartzman reaction. doi:10. MD.A. (2008). Philadelphia. Retrieved from http://emedicine. Burke. P. BSN. Levi. M. placing patients.Thachil.. Cate. is a Travel Nurse. CMSRN. C. & Cheever.U.. Hinkle.. 24-33. they are asked for and provide feedback and input in decision-making. R. Disseminated intravascularcoagulation in emergency medicine.13652141.R. Nurses must perceive that they have the support of adequate staffing to help them better perform their duties. To receive all the contact hours provided in 2011 without an AMSN membership.org/HWE to learn more about how you can help create a healthy work environment in your workplace. Disseminated intravascular coagulation or extended intravascular coagulation in massive pulmonary embolism. Supportive Nurse Managers Nurse-managers are very involved in many levels. (2009).S. national specialty certifications.1186/14779560-4-13 Smeltzer. J. & Maguire. and these professionals must recognize the other is bringing an important facet of care to the table.Toh. 3662-3667.G. NJ.C. Schmalenberg. Melissa Patterson is Customer Service Coordinator. If you have an AMSN membership... M...1111/j. NJ: Pearson. A. Baltimore. K.2009. Randstad HealthCare.medscape.x Slofstra.amsn.L. you would spend approximately $285. Guidelines for the diagnosis and management of disseminated intravascular coagulation. Each employee plays a role in communicating and reinforcing the culture. their role is pivotal in creating (or hindering) a HWE through each of these essentials. 8(7)... Disseminated intravascular coagulation. doi:10.. & Bauldoff. & Spek. Carrell. C. M. Autonomous Nursing Practice A nurse must have the freedom to act on what he or she knows to provide the best patient care. Retrieved from http://emedicine. 1-7.Matters_Summer_12_Matters! newsletter 6/21/12 12:02 PM Page 11 866-877-2676 References Becker. 4(13). Somashekhar. AMSN members get free contact hours from journal and newsletter articles. Chronic disseminated intravascular coagulation presenting as a renal mass.. (2008)...M. 145(1). Control Over Nursing Practice When nurses have control over their practice. The nurse-manager must support his or her nurses. S.. Z. Journal of Indian Association of Pediatric Surgeons. 23-27. managing staff.The concern is for both the patients and the nurses who care for them. Kadamba. (2010).com/article/199627 Levi. and supported (Kramer et al. doi:10. Be sure to visit www. Upper Saddle River.

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