Disseminated Intravascular Coagulation

From Anvita Health Wiki

Contents 1 Introduction 2 Etiology 3 Pathology 4 Clinical-manifestations 5 Laboratory 6 Differential-diagnosis 7 Management 8 More General Terms 9 Additional Terms 10 References

Introduction

• DIC results from activation of the coagulation & fibrinolytic systems. It occurs in conditions which promote tissue factor release. DIC may be acute or chronic. Patients with chronic DIC present with bleeding such as epistaxis or gingival bleeding; the condition is problematic, but not life threatening as is acute DIC.

Etiology

• obstetric

• amniotic fluid embolism
• abruptio placentae
• eclampsia
• uterine rupture
• retained dead fetus
• septic or missed abortion

• tissue injury

• trauma (head or crush injury)
• burns
• surgery
• hypothermia
• hyperthermia
• anoxia or asphyxia
• ischemia or infarction

• immunologic

• anaphylaxis
• hemolytic transfusion reaction
• drug reaction
• autoimmune vasculitis

• pulmonary

• adult respiratory distress syndrome ( ARDS)
• pulmonary embolism
• pulmonary infarction

• infection

• bacterial: Gm-, Gm+, anaerobes
• Mycobacteria
• viral: CMV, Varicella zoster, hepatitis
• Rickettsia
• fungus: Aspergillus, Candida, Histoplasmosis
• protozoa: malaria

• malignancy

• leukemia, especially promyelocytic leukemia
• solid tumors, especially adenocarcinomas

• pancreatic carcinoma
• prostate carcinoma

• chronic DIC is generally associated with malignancy

• Trousseau's syndrome

• cardiovascular

• acute myocardial infarction
• vascular surgery
• peripheral vascular disease
• shock

• miscellaneous

• liver disease, acute & chronic
• evenomation
• embolism
• amyloidosis

Pathology

• initiation

• release of tissue factor or generation of tissue factor on the surface of endothelial cells & monocytes
• release of tumor necrosis factor
• IL-1 release
• endotoxin release
• placental tissue substances

• activation of extrinsic pathway of coagulation

• excessive formation of thrombin & plasmin
• formation & breakdown of fibrin
• clot formation & breakdown
• depletion of coagulation factors & platelets
• microvascular fibrin deposition
• microangiopathic hemolysis

Clinical-manifestations

• bleeding

• bleeding at site of wound
• gingival bleeding
• vascular access site oozing
• epistaxis

• petechiae
• echymosis
• hemorrhagic bullae
• gangrene
• purpura: purpura fulminans
• acral cyanosis
• hematuria
• thromboses (chronic), venous or arterial
• skin infarction

Laboratory

• thrombocytopenia ( platelets < 60,000/ mm3)
• PT & aPTT may be prolonged or normal
• increased fibrin/ fibrinogen degradation products

• elevated D-dimer
• diminished fibrinogen* level

• microangiopathic anemia

• schistocytosis in peripheral smear

• * may be elevated with inflammatory process

Differential-diagnosis

• vitamin K deficiency
• renal failure
• dysfibrinogenemia
• systemic lupus erythematosus
• thrombotic thrombocytopenic purpura ( TTP)
• liver disease
• sickle cell crisis
• sepsis

Management

• acute DIC

• treatment of underlying pathology
• fresh frozen plasma

• 10-15 mL/kg
• aim for PT within 2-3 seconds of control

• cryoprecipitate:

• indicated for hypofibrinogenemia
• 0.2 bags/kg, 1-12 bags for 70 kg person

• platelet transfusion

• platelets < 10,000-20,000/ mm3
• platelets < 50,000/ mm3 with major bleeding

• heparin

• indications:

• amniotic fluid embolism
• aortic aneurysm
• evidence of thrombosis
• transfusion reaction
• neoplasm

• contraindications

• CNS injury
• fulminant liver failure
• obstetric accidents

• administration

• 80-100 units/kg SC every 4-6 hours
• 5-10 units/kg/hour IV drip

• chronic DIC

• treatment of underlying pathology
• low dose subcutaneous heparin
• combination antiplatelet agents

• aspirin 600 mg BID with 30 mL of liquid antacid plus dipyridamole 50 mg QID
• sulfinpyrazone 200 mg BID with 30 mL of liquid antacid plus dipyridamole 50 mg QID

More General Terms

• coagulation disorder
• sign/symptom
• intravascular coagulation

Additional Terms

• localized intravascular coagulation
• Trousseau's syndrome

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 617-618
2. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
3. Schiller G, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
4. National Guideline Clearinghouse Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology ngc-guideline: [1]

disseminated intravascular coagulation (DIC)