N240 Olol - Test 1 - Disseminated Intravascular Coagulopathy (Dic)

Front 1

Disseminated Intravascular Coagulopathy (DIC)
Definition

Back 1

-A disorder or imbalance in the coagulation system characterized by generalized clotting in the microcirculation followed by clot lysis.
-Clot formation causes peripheral and organ ischemia.
-Clot lysis produces anticoagulants that cause uncontrolled bleeding in a system that has used up many of its clotting factors.

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Causes of DIC

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-Always a result of a primary condition that triggers the clotting cascade.
-Sepsis, shock of any kind, trauma, crush injury, acidosis, obstetrical complications, eclampsia, retained placenta, incomplete abortion, amniotic fluid embolism, malignancies.

Front 3

Pathophysiology of DIC

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-Presenting condition damages the endothelial lining of the blood vessel. Endothelial cells release tissue thromboplastin. Factor VII (extrinsic pathway) or factor XII (intrinsic pathway) is activated in the clotting cascade.
-Platelets become activated and become sticky. As they aggregate they release mediators that are powerful vasoconstrictors (serotonin, histamine, adenosine diphosphate, and thromboxane-A).
-This vasoconstriction reduces blood loss.

Front 4

Pathophysiology of DIC (con't)

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-Clotting cascade continues with prothrombin being converted to thrombin.
-Thrombin converts fibrinogen to fibrin (at last the clot).
-Endothelial cells now release prostoclyclin a vasodilator and platelet inhibitor to counter the prior effects.
-Mediators called antithrombins (protein S, protein C) along with t-PA keep clot formation in check, not allowing the clotting cascade to go overboard.
-In DIC thrombin formation beats clot lysing

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Pathophysiology of DIC (con't)

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-Massive clotting uses up clotting factors.
-Clots obstruct arterioles and capillaries causing tissue hypoperfusion.
-Hemorrhage occurs because clots can’t form at sites of endothelial injury.

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Signs and Symptoms

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-Bleeding from multiple sites that are unrelated.
-Ischemia in peripheral tissues fingers, nose, toes.
-Acute renal failure from thrombosis in the glomerulus's.

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Laboratory Findings

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-4 basic components to diagnose
-Evidence of coagulation
-Evidence of clot lysis
-Evidence of consumption of clotting factors
-Organ damage

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Front 10

Evidence of Coagulation

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-Platelet count drops as a sign of rapid clot formation.
-A decrease to 50,000 per ml, or 50% drop from baseline raises the suspicion of DIC.
-Caution heparin, hypothermia, and infection can suppress platelet levels.
-Fibrinogen is rapidly used up in clot formation, but can be made quickly so the drop in fibrinogen can be mild to moderate in DIC.

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-

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Front 12

Evidence of clot lysis

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-As clots are lysed fibrin degradation products are produced and rise dramatically.
- Normal < 10
-FDP are powerful anticoagulants.
-D-Dimer produced when clots are lysed and more indicative of DIC. The higher the level the more severe the DIC.
-Caution D-Dimer can elevate from dissolving DVT or other clot.

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Front 14

Evidence of consumption of clotting factors

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PT and PTT prolonged as clotting factors are used up

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Lab normal values

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Platelet count: 150,000-400,000/mm3
Fibrinogen: 150-400 mg/dl
FDP: <10 mcg/ml
D-Dimer: <200 mg/ml
PT: 12 sec (INR 1.0)
APTT: <33 sec

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Front 18

Treatment

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-ABC first
-Correct the underlying condition.
-Administer volume and blood products as needed.
-Consider vasopressors if needed.
-Fresh Frozen plasma for clotting factors.
-Platelets if needed.
-Cryoprecipitate for fibrinogen
-Heparin drip or low molecular weight heparin.
-Activated Protein C (Xigris).

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Front 20

Nursing Care

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-Assess vital signs, urine output every hour for hemodynamic stability.
-Assess oxygenation with SAO2 every hour.
-Assess neuro status every hour.
-Assess peripheral ischemia.
-Clotting profile every four hours.
-Avoid needle sticks.
-Use arterial line and venous lines that are in place.
-Avoid cuff pressures which can increase bruising.
-Handle patient gently to avoid bruising.
-Suction only when necessary and with low suction.
-Consider low pressure bed to prevent skin breakdown.
-Explain all procedures, answer all questions, provide emotional support.