Disseminated intravascular coagulation



Disseminated intravascular coagulation, also known as consumptive coagulopathy, defibrinogenation syndrome, or DIC, is an acute disorder that accelerates the activation of the intrinsic and/or extrinsic cascade clotting mechanism and depletes both clotting factors and platelets. DIC is usually a complication of another disease process in which excessive thrombin is produced, converting fibrinogen to fibrin, and the fibrin creates damaging thrombi in the microcirculation. Fibrin blocks the capillary flow to the organs and results in ischemic tissue damage, and as the clotting factors, platelets, and fibrin split products (FSP) are consumed, hemorrhage and shock results. As the fibrin and FSP repolymerize, a secondary fibrin mesh forms in the microcirculation and when blood travels through this, the red blood cells become damaged and a hemolytic anemia can occur.

Some of the precipitating factors include sepsis, neoplasm necrosis, eclampsia, abruptio placentae, saline-induced abortions, retained dead fetus, amniotic fluid embolus, hemolysis, giant hemangiomas, systemic lupus erythematosus, transfusions, trauma, shock, burns, head injuries, transplant rejection, snake bite, fractures, anoxia, heat stroke, surgery utilizing cardiopulmonary bypass, and necrotizing enterocolitis.

Bleeding in a patient with no other previous history of bleeding or coagulopathy problems should raise questions as to the possibility of the presence of DIC. DIC may be acute or chronic (usually seen with neoplasms) and can vary in severity from mild oozing to exsanguination from all orifices. Treatment is aimed at correction of the underlying problem, correction of shock, acidosis, and sepsis, supportive care to restore circulatory volume and adequate oxygenation of tissues, and to replace blood loss due to hemorrhage.

Laboratory     : prothrombin time (PT) to measure activity level and patency of the extrinsic and final pathways, increased in DIC; partial thromboplastin time (PTT) to measure activity level and patency of the intrinsic and final pathways, increased in DIC; thromboplastin time increased, platelet count decreased, fibrinogen usually decreased showing increased hypercoagulability and decreased bleeding tendency, FSP elevated, usually >10; clotting factor analysis used to identify factors being depleted; CBC used to evaluate anemia and RBC fragmentation; BUN and creatinine used to assess renal involvement from thrombosis; guaiacs on all body fluids to identify occult bleeding; cultures of sputum, blood, urine, CSF and other drainage used to identify causative organism of infection and to ascertain appropriate antimicrobial for therapy

Blood components: used as replacement therapy for significant blood loss; RBCs given to increase the oxygen-carrying capability; whole blood, plasma, plasmanate and albumin used to expand volume; fresh frozen plasma (FFP) and albumin used to replace proteins; FFP, cryoprecipitate, and fresh whole blood used to replace coagulation fac- tors; platelet concentrate used to replace platelets

IV fluids          : used to treat hypovolemia and shock

Antibiotics    : used to treat infection that may cause DIC

Heparin         : use is controversial; heparin inhibits micro thrombi formation by neutralizing free circulating thrombin; shouldn’t be used unless bleeding is unmanageable by replacement therapy of FFP and platelets

NURSING CARE PLANS

Risk for impaired gas exchange

[See GI Bleeding] Related to: bleeding, disease
Defining characteristics: decreased Pa02 below 80 mmHg, dyspnea, tachypnea, increased work of breathing, restlessness, irritability, mental status changes, changes in blood pressure and pulse, decreased hemoglobin and hematocrit

Risk for fluid volume deficit

[See GI Bleeding] Related to: blood loss, altered coagulability
Defining characteristics: weight loss, oliguria, abnormal electrolytes, hypotension, tachycardia, decreased central venous pressures, decreased filling pressures, altered coagulation studies, lethargy, mental status changes

Risk for injury

Related to: hemorrhage, blood loss, altered coagulability
Defining characteristics: bleeding, exsanguination, decreased hemoglobin and hematocrit levels, increased fibrin split products, increased prothrombin time, decreased platelet count, increased partial thromboplastin time, decreased fibrinogen

Outcome Criteria

Patient will be free of unexplained bleeding and will have stable vital signs and hemodynamic pressures.

INTERVENTIONS
RATIONALES
Identify and treat underlying disorder.
Treatment of cause and correction of coagulation problem is major goal of treatment. DIC is most often seen as the complication of an underlying infection, malignant disease, trauma, or shock state.
Administer IV fluids as ordered.
Large volumes may be required
to maintain circulating volume due to bleeding, and to maintain
hemodynamic status.
Administer blood and blood by products, such as cryoprecipitate, fresh frozen plasma, etc. as
ordered.
May be required to replace circulating blood volume and to help correct thrombocytopenia or
hypofibrinogenemia.
Administer supplemental oxygen
as warranted.
Decreased blood volume impairs
oxygen carrying capability and supplemental oxygen may be required to maintain oxygenation.
Observe patient for petechiae, bruising, overt and occult bleeding.
May be present with impending
DIC.
Monitor for dyspnea, hemoptysis, and decreased saturation; auscultate lung fields for adventitious breath sounds.
Crackles may be present and patient may exhibit these signs if
microemboli in the pulmonary circulation are present.
Monitor intake and output.
Microemboli or deposits of fibrin within the renal system may pre-
sent as renal insufficiency or
failure.
Administer heparin therapy as
ordered.
Controversial treatment may be
given to disperse clumped clot- ting factors, but is rarely used today.
Monitor lab work for coagulation studies and CBC.
Provides identification of effectiveness of therapy or worsening of condition.

Discharge or Maintenance Evaluation

·         Patient will have stable vital signs and hemodynamic pressures.
·         Patient will exhibit no bleeding tendencies or active hemorrhage.
·         Patient will exhibit no complications from other disease processes.
·         Patient will achieve and maintain adequate blood volume.
·         Patient will have underlying disease process corrected.


EmoticonEmoticon