DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

• Also known as consumption coagulopathy and defibrination syndrome.
• Disseminated intravascular coagulation (DIC) is an acquired thrombotic and haemorrhagic syndrome characterized by diffuse activation of the clotting cascade and accelerated fibrinolysis that results in depletion of clotting factors in the blood (widespread clotting in small vessels with consumption of clotting factors and platelets) that can provoke severe haemorrhage. So that the bleeding and thrombosis occur simultaneously.
• DIC is occurs when the blood clotting mechanisms are activated all over the body instead of being localized to an area of injury.

ETIOLOGY

A syndrome arising secondary to an underlying disorder or event.

• Overwhelming infections: gram-negative or gram-positive septicaemia; viral, fungal, or rickettsial infection; and protozoal infection
• Obstetric complications: abruptio placentae, eclampsia, amniotic fluid embolism, retention of dead fetus, septic abortion, and postpartum haemorrhage.
• Massive tissue injury: extensive burns and trauma, brain tissue destruction, transplant rejection, fractures, major surgery, fat embolism, organ destruction like severe pancreatitis, hepatic failure).
• Neoplastic disease: lung, colon, stomach, pancreatic malignancy; acute leukemia, metastatic carcinoma, and lymphomas.
• Vascular and circulatory collapse, heatstroke, shock.
• Severe toxic or immunologic reactions: haemolytic transfusion reaction, drug reactions, poisonous snakebites, recreational drugs.
• Other conditions - cardiac arrest, surgery necessitating cardiopulmonary bypass, giant hemangioma, severe venous thrombosis, purpura fulminans, adrenal disease, adult respiratory distress syndrome, diabetic ketoacidosis, pulmonary embolism, and sickle cell anaemia.

CLINICAL MANIFESTATIONS

• Signs of abnormal clotting:
  • Coolness and mottling of extremities.
  • Acrocyanosis (cold, mottled extremities with clear demarcation from normal tissue).
  • Dyspnea, adventitious breath sounds.
  • Altered mental status.
  • Acute renal failure.
  • Pain (eg, related to bowel infarction).
• Signs of abnormal bleeding:
  • Oozing, bleeding from sites of procedures, IV catheter insertion sites, suture lines, mucous membranes, orifices.
  • Internal bleeding leading to changes in vital organ function, altered vital signs.

DIAGNOSTIC EVALUATION

• Decreased platelet count—less than 100,000/mm³
• Reduced fibrinogen levels—less than 150 mg/dl
• Prolonged prothrombin time—more than 15 seconds
• Prolonged partial thromboplastin time—more than 80 seconds
• Fibrinogen—decreased level.
• Increased FDP(fibrin degradation product)—often greater than 45μg/ml, or positive at less than 1:100 dilution
• Positive D-dimer test (specific fibrinogen test for DIC) — positive at less than 1:8 dilution.
• Decreased haemoglobin levels - less than 10 g/dl
• Decreased urine output - less than 30 ml/hr.
• Elevated blood urea nitrogen - greater than 25 mg/ dl
• Elevated serum creatinine - greater than 1.3 mg/dl
• The FDP and D-dimer tests are considered specific and diagnostic of DIC.

COMPLICATIONS

• Thromboembolic:
  • Pulmonary embolism;
  • Cerebral, myocardial, splenic, or bowel infarction;
  • Acute renal failure;
  • Tissue necrosis or gangrene.
  • Respiratory distress.
  • Shock and coma
• Haemorrhagic:
  • Cerebral haemorrhage is most common cause of death in DIC.

MEDICAL MANAGEMENT

• Successful management of DIC requires prompt recognition and adequate treatment of the underlying disorder.
• Treatment may be supportive or highly specific
• If the patient is not actively bleeding, supportive care alone may reverse DIC.
• Active bleeding may require administration of:
  • Fresh-frozen plasma replaces clotting factors.
  • Platelet transfusions.
  • Cryoprecipitate replaces clotting factors and fibrinogen.
• Supportive measures including fluid replacement, oxygenation, maintenance of BP and renal perfusion.
• Heparin or other anticoagulant therapy (controversial) inhibits clotting component of dic.

NURSING MANAGEMENT

Nursing diagnoses

• Risk for bleeding due to thrombocytopenia.
• Ineffective peripheral tissue perfusion related to small vessel occlusion
• Risk for deficient fluid volume related to blood loss.
• Fatigue related to decreased haemoglobin secondary to bleeding.

Nursing Interventions

• Keep patient warm.
• Avoid vasoconstrictive agents (systemic or topical).
• Change patient's position frequently, perform range-of motion exercises, and provide meticulous skin care to prevent skin breakdown.
• Administer oxygen therapy as ordered.
• Administer prescribed analgesics for pain as necessary.
• If bleeding occurs, use pressure, cold compresses, and topical hemostatic agents to control it; effective agents may include an absorbable gelatin sponge, a microfibrillar collagen hemostat, or thrombin.
• Maintain bed rest during bleeding episode. Provide frequent rest periods if the patient can't tolerate activity because of blood loss.
• After giving an injection or removing an I.V. catheter or needle, apply pressure to the injection site for at least 10 minutes. Alert all members of the health care team to the patient's tendency to hemorrhage. Provide Heplock, avoid IM, SQ and any venipunctures
• Avoid vigorous rubbing of affected area when washing to prevent clots from dislodging and causing fresh bleeding.
• Use a 1:1 solution of hydrogen peroxide and water to help remove crusted blood.
• Protect the patient from injury. Enforce complete bed rest during bleeding episodes. If the patient is very agitated, pad the bed rails.
• Perform bladder irrigations as ordered for genitourinary (GU) bleeding.
• If internal bleeding is suspected, assess bowel sounds and abdominal girth.
• Inform the family of the patient's progress. Prepare them for his appearance (I.V. lines, nasogastric tubes, bruises, and dried blood). Provide emotional support and encouragement, and listen to the patient's and family's concerns.
• Evaluate fluid status and bleeding by frequent measurement of vital signs, central venous pressure, intake and output.
• Monitor pad count and amount of saturation during menses; administer or teach self-administration of hormones to suppress menstruation, as prescribed.
• Monitor electrocardiogram and laboratory tests for dysfunction of vital organs caused by ischemia—arrhythmias.