Disseminated Intravascular Coagulation

- sometimes referred to as defibrination syndrome - it is not a disease but a sign or manifestation of an underlying disorder. - is a rare condition distinguishable by extreme blood coagulation that oddly enough results in bleeding that cannot be controlled. - it is a condition in which small blood clots develop throughout the bloodstream, blocking the small vessels - may be localized to one specific organ or generalized, involving multiple organs. TYPES OF DISSEMINATED INTRAVASCULAR COAGULATION A. ACUTE DIC also known as consumptive coagulopathy may develop primarily (e.g. caused by sepsis) develops quickly (over hours or days) and must be treated right away it begins with excessive blood clotting in the small blood vessels and quickly advances to serious bleeding is a serious physiological condition which, if left untreated, can lead to hemorrhage and ultimately death. B. CHRONIC DIC also known as compensated disseminated intravascular coagulation results from a persistent weak or intermittent activating stimulus involves formation of blood clots in blood vessels (thromboembolism) develops slowly (over weeks or months). It lasts longer and usually isn't recognized as quickly as acute DIC is more frequently observed in solid tumors and in large aortic aneurysms.

RISK FACTORS: ACUTE DIC: Gram-negative (endotoxin) Gram-positive (mucopolyaccharides) Cytomegalovirus (CMV) Transfusion reactions Burns Traumatic crash injuries and tissue necrosis Acute liver failure Arterial hypotension secondary to shock Prosthetic devices

CHRONIC DIC: Retained products of conception (eg. dead fetus, post miscarriage). Leukemia Rheumatoid Arthritis Ulcerative colitis Crohns Disease Solid Tumors Metastatic carcinoma

CLINICAL MANIFESTATIONS: ACUTE DIC: Multiple bleeding sites Bruising of skin, mucous membranes Internal bleeding Lack of blood supply to tissues (ischemia)

 Sudden onset of high fever, severe general malaise, and extensive purpura of the extremities Petechiae, purpuric papules, blood-filled blisters and bluish fingers and toes CHRONIC DIC: Deep vein or arterial thrombosis or embolism (clots) Superficial venous thrombosis, especially without varicose veins Multiple thrombotic sites at the same time Serial thrombotic episodes ASSESSMENT & DIAGNOSTIC FINDINGS: Diagnosis of clinically significant DIC is based on the presence of clinical and/or laboratory abnormalities of coagulation or thrombocytopenia. Laboratory diagnosis of DIC should prompt a search for the underlying disease if it is not already apparent. No single test establishes the diagnosis of DIC. Laboratory investigation should include: Coagulation tests (activated partial thromboplastin time [aPTT], prothrombin time [PT], and thrombin time [TT]) Markers of FDP Platelet and red cell count
These tests should be repeated over a period of 68 hours because an initially

mild abnormality can change dramatically in patients with severe DIC. Laboratory results: Decreased platelet count Increased prothrombin time (PT) Increased partial thromboplastin time (activated) (aPTT) Increased thrombin time

 Decreased fibrinogen Increased D-dimer Increased fibrin degradation products (FDPs) most sensitive test for DIC

MANAGEMENT: (MEDICAL AND PHARMACOTHERAPY) ACUTE DIC Without bleeding or evidence of ischemia With bleeding No treatment required, observe Blood components: With ischemia Fresh frozen plasma Cryoprecipitate Platelet transfusions

Anticoagulants such as heparin or low molecular weight heparin (LMWH) after bleeding is corrected with blood products

CHRONIC DIC Without thromboembolism No specific therapy but prophylactic anticoagulants (e.g. low-dose heparin, LMWH) may be used for patients at high risk of thrombosis

With thromboembolism

Anticoagulant therapy with heparin or LMWH Trial of warfarin (variable response between patients)

Nursing Management:
Avoid procedure/activities that can increase intracranial pressure (eg. coughing, straining to have a bowel movement) Avoid medications that interfere with platelet function if possible (eg. ASA, NSAIDS, beta-lactam antibiotics) Carefully assess skin particularly to bony prominences and skin folds Reposition carefully, use pressure-reducing mattress Monitor extent of edema Assess extent of bleeding Monitor volume of IVs, blood products; decrease volume of IV medications if indicated. Administer diuretics as prescribed Identify previous coping mechanism, if possible; encourage patient to use them as appropriate Explain all the procedures and rationale for these in terms patient and family can understand

References:
http://emedicine.medscape.com/article/199627-overview http://dermnetnz.org/vascular/dic.html http://www.nhlbi.nih.gov/health/health-topics/topics/dic/ Brunner & Suddarths textbook of Medical-Surgical Nursing