CASE

A 70-year-old man was admitted to the

hospital because of generalized ecchymoses. He had been diagnosed with prostate cancer metastatic to bone 5 years earlier. Subsequently, he had slowly progressive disease He also received radiation therapy to his left shoulder and to epidural disease in the lower thoracic spine Three months before this admission, he underwent posterolateral decompression and

Within 24 hours of surgery, his platelet count

dropped from 230,000/µL to 69,000/µL, and his prothrombin time increased to 19.1 seconds (International Normalized Ratio [INR] = 1.56). He was given packed red cells, platelets, and fresh frozen plasma, and he showed improvement in all hematologic parameters. Five weeks before this admission, his platelet count was 149,000/µL. The most striking physical finding on this admission was multiple large confluent ecchymoses primarily involving the flanks and lower extremities

His platelet count was 62,000/µL, and his

prothrombin time was 14.8 seconds (INR = 1.21). The activated partial thromboplastin time was 32.6 seconds, the serum fibrinogen was 87 mg/dL. Shortly after admission, the fibrinogen dropped to 55 mg/dL.

Overview
Disseminated Intravascular Coagulation

- clinicopathologic syndrome that is not a specific disease but a manifestation of an underlying disorder. - loss of balance between procoagulant and fibrinolytic capacities.

Types of DIC
1. Acute 2. Chronic

Diagnostic exams 2.Prothrombin Time (11-16 seconds) 3.Prothrombin / International normalized ratio (1.2 – 2.5 seconds) 3. Activated partial thromboplastin time (25-38 seconds) 4. Fibrinogen (200 – 400 g/dL)

Manifestations
1. Thrombosis - petechiae or ecchymoses 2. Hemorrhage

Causes

1. 2. 3. 4. 5.

Obstetric conditions Cancers Infections Trauma or surgery Shock

Anatomy and Physiology

Platelets
Platelets (see fig. 18.1) are not cells but small fragments of megakaryocyte cytoplasm. They are 2 to 4 m in diameter and possess lysosomes, endoplasmic reticulum, a Golgi complex, and Golgi vesicles, or “granules,” that contain a variety of factors involved in platelet function.

Events in Hemostasis
1. Vascular constriction 2. Formation of a platelet plug 3. Formation of a blood clot as a result of blood

coagulation 4. Eventual growth of fibrous tissue into the blood clot to close the hole in the blood vessel permanently

Lysis of Blood Clots
Plasmin
- Digest fibrin fibers

t-PA Plasminoge n Plasmin

Pathophysiology

Stimulus Tissue destruction Extrinsic pathways Endothelial Injury

Tissue factor Thrombin generation

Factor XII activation (intrinsic pathway)

Intravascular fibrin deposition

Plasminogen activation Plasmin generation Fibrinolysis

Platelet consumption Thrombocytopenia Clotting factor degradation Bleeding dec circulating blood dec O2 transportation Tissue hypoxia

Thrombosis RBCs damaged Hemolytic anemia Tissue ischemia

Fibrin degradation products (inhibit thrombin and platelet aggregation) Organ Failure

Nursing Problems
1. High Risk for Altered Tissue Perfusion 2. High Risk for Fluid Volume Deficit 3. Impaired Tissue Integrity

Bibliography
Ximelagatran

A promising new oral anticoagulant
by Lee P. Skrupky and Karen Kopacek , RPh

References Hematology 9  Wintrobe’s Clinical
     

th

ed. by

Lee Internal Medicine by Jay Stein Kelley’s Internal Medicine by H. David Humes Anatomy and Physiology 6th ed. By Thibodeau & Patton Pathophysiology: The Biological Principles of Disease by Smith & Thier Textbook of Medical Physiology by Guyton & Hall Pathophysiology for the Health Professions 3rd ed. by Gould

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