Understanding DisseminatedUnderstanding Disseminated
Intravascular Coagulation (DIC)Intravascular Coagulation (DIC)
“An On...
WelcomeWelcome
This tutorial is self guided by using buttons to move about screens.This tutorial is self guided by using b...
Understanding Disseminated IntravascularUnderstanding Disseminated Intravascular
Coagulation (DIC) “An Oncologic Emergency...
ObjectivesObjectives
Understand the pathophysiology ofUnderstand the pathophysiology of
Disseminated Intravascular Coagula...
What is DIC?What is DIC?
Is considered an “acquired bleeding disorder”Is considered an “acquired bleeding disorder”
Is not...
PathophysiologyPathophysiology
In DIC, a systemic activation of theIn DIC, a systemic activation of the
coagulation system...
PathophysiologyPathophysiology
ThrombosisThrombosis-brief period of-brief period of
hypercoagulabilityhypercoagulability
1...
PathophysiologyPathophysiology
(Porth, 2004)(Porth, 2004)
Risk Factors and EtiologyRisk Factors and Etiology
Almost always a secondary event fromAlmost always a secondary event fro...
Pathologic PathwaysPathologic Pathways
ExtrinsicExtrinsic (endothelial)(endothelial)
– Shock or traumaShock or trauma
– In...
Oncology Related DICOncology Related DIC
Usually related to:Usually related to:
– Disease processDisease process
-APML( ac...
Clinical FeaturesClinical Features
Onset maybe Acute or ChronicOnset maybe Acute or Chronic
– Acute DICAcute DIC
Develops ...
Signs and SymptomsSigns and Symptoms
Most common sign of DIC is bleedingMost common sign of DIC is bleeding
-manifested by...
Genetic ComponentGenetic Component
None associated with DICNone associated with DIC
BUT-------BUT-------
Genetic mutations...
Inflammation and DICInflammation and DIC
Sepsis is usually underlying process forSepsis is usually underlying process for
...
Diagnosis/Lab FindingsDiagnosis/Lab Findings
TestTest
Platelet countPlatelet count
Fibrin degradation productFibrin degrad...
Treatment ModalitiesTreatment Modalities
Treat the underlying causeTreat the underlying cause
Provide supportive managemen...
Case Study/Post TestCase Study/Post Test
D.G.,a 48-year-old, is 30 days post matched unrelatedD.G.,a 48-year-old, is 30 da...
Case Study cont.Case Study cont.
D.G. is started on Vanco and Primaxin and givenD.G. is started on Vanco and Primaxin and ...
Case Study cont.Case Study cont.
MD orders 2 units of PRBC to be infused over 4 hours.MD orders 2 units of PRBC to be infu...
Case Study cont.Case Study cont.
O2 sats on RA measure 84% and lung sounds are coarseO2 sats on RA measure 84% and lung so...
Case Study Cont.Case Study Cont.
MD orders CBC and coagulation screen. The results areMD orders CBC and coagulation screen...
Case Study Cont.Case Study Cont.
D.G. Continues to be hypotensive. Lung soundsD.G. Continues to be hypotensive. Lung sound...
Case Study cont.Case Study cont.
D.G. status continues to deteriorate andD.G. status continues to deteriorate and
needed t...
Answers for Case StudyAnswers for Case Study
(a)Risk for infection, renal insufficiency,(a)Risk for infection, renal insuf...
Answers for Case StudyAnswers for Case Study
(b)(b) Possible septic shock as a result of anPossible septic shock as a resu...
Answers for Case StudyAnswers for Case Study
(a)(a) D.G.’s labs cont to show anemia,D.G.’s labs cont to show anemia,
neutr...
Answers for Case StudyAnswers for Case Study
(a)(a) Pt possibly developing hypoxemia as aPt possibly developing hypoxemia ...
Answers for Case StudyAnswers for Case Study
(c)(c) Patient maybe developing pneumoniaPatient maybe developing pneumonia
a...
Answers for Case StudyAnswers for Case Study
(a) The clinical presentation leads to the(a) The clinical presentation leads...
Answer for Case StudyAnswer for Case Study
(b)(b) A DIC panel results would be helpful atA DIC panel results would be help...
Answers for Case StudyAnswers for Case Study
(a)(a) Based on the lab values, DIC is confirmed forBased on the lab values, ...
Answers for Case StudyAnswers for Case Study
(b)(b) The immediate goal for the overallThe immediate goal for the overall
m...
Answers for Case StudyAnswers for Case Study
(a)(a) Based on the lab values, DG showsBased on the lab values, DG shows
sli...
ReferencesReferences
Otto, Shirley E. (2001). OncologyOtto, Shirley E. (2001). Oncology
Nursing. Mosby: St. Louis.Nursing....
GlossaryGlossary
Complement-Complement-a heat-labile cascade system of at least 20a heat-labile cascade system of at least...
GlossaryGlossary
FibrinFibrin- an insoluble protein that is essential to clotting of blood,- an insoluble protein that is ...
GlossaryGlossary
Activated PTTActivated PTT- aPTT tests the intrinsic and- aPTT tests the intrinsic and
common pathwayscom...
GlossaryGlossary
Blood Components:Blood Components: used to correct abnormalused to correct abnormal
homeostasis. Used to ...
GlossaryGlossary
Blood Components cont’d:Blood Components cont’d:
Packed Red Blood Cells (PRBC’s)Packed Red Blood Cells (P...
Thank youThank you
This completes the DIC tutorial. Any and allThis completes the DIC tutorial. Any and all
comments regar...
Upcoming SlideShare
Loading in …5
×

Read More...

343
-1

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
343
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
10
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Read More...

  1. 1. Understanding DisseminatedUnderstanding Disseminated Intravascular Coagulation (DIC)Intravascular Coagulation (DIC) “An Oncologic Emergency”“An Oncologic Emergency” Deborah Kwasneske RN, BSN, OCNDeborah Kwasneske RN, BSN, OCN MSN 621, Spring 2006MSN 621, Spring 2006 Alverno CollegeAlverno College Email: debbiern@wi.rr.comEmail: debbiern@wi.rr.com
  2. 2. WelcomeWelcome This tutorial is self guided by using buttons to move about screens.This tutorial is self guided by using buttons to move about screens. You can return to the main screen at anytime by using the homeYou can return to the main screen at anytime by using the home button. The arrow buttons allow you to move forward or back.button. The arrow buttons allow you to move forward or back. To return to previous spot you may use the return buttonTo return to previous spot you may use the return button To navigate through different topics of this tutorial, use theTo navigate through different topics of this tutorial, use the button.button. There are multiple hyperlinks to outside learning sources to help withThere are multiple hyperlinks to outside learning sources to help with the understanding of DIC . To get back to DIC tutorial use backthe understanding of DIC . To get back to DIC tutorial use back button on links.button on links. For the case study answers, just click on the question for answers toFor the case study answers, just click on the question for answers to appear. You can return to the case study using the return key.appear. You can return to the case study using the return key.
  3. 3. Understanding Disseminated IntravascularUnderstanding Disseminated Intravascular Coagulation (DIC) “An Oncologic Emergency”Coagulation (DIC) “An Oncologic Emergency” Introduction Pathophysiology Treatments GlossaryCase Study References Genetics DIC What isDIC Inflammation
  4. 4. ObjectivesObjectives Understand the pathophysiology ofUnderstand the pathophysiology of Disseminated Intravascular CoagulationDisseminated Intravascular Coagulation (DIC)(DIC) Identify risk factors and etiology of DICIdentify risk factors and etiology of DIC Describe the signs and symptoms of DICDescribe the signs and symptoms of DIC Identify treatment modalities for DICIdentify treatment modalities for DIC Define, identify and understand Acute vsDefine, identify and understand Acute vs Chronic DICChronic DIC Develop understanding of diagnosing DICDevelop understanding of diagnosing DIC (lab interpretations)(lab interpretations)
  5. 5. What is DIC?What is DIC? Is considered an “acquired bleeding disorder”Is considered an “acquired bleeding disorder” Is not a disease entity but an event that canIs not a disease entity but an event that can accompany various disease processesaccompany various disease processes Is an alteration in the blood clottingIs an alteration in the blood clotting mechanism:abnormal acceleration of themechanism:abnormal acceleration of the coagulation cascadecoagulation cascade, resulting in thrombosis, resulting in thrombosis As a result of the depletion of clotting factors,As a result of the depletion of clotting factors, hemorrhage occurs simultaneouslyhemorrhage occurs simultaneously Is aIs a Paradoxical Clinical PresentationParadoxical Clinical Presentation “clotting“clotting and hemorrhage”and hemorrhage” ((Porth, C.M. (2004) Essentials of Pathophysiology) & (Otto, S. (2001).Porth, C.M. (2004) Essentials of Pathophysiology) & (Otto, S. (2001). Oncology Nursing)Oncology Nursing)
  6. 6. PathophysiologyPathophysiology In DIC, a systemic activation of theIn DIC, a systemic activation of the coagulation system simultaneously leadscoagulation system simultaneously leads to thrombus formation (compromisingto thrombus formation (compromising blood supply to various organs) andblood supply to various organs) and exhaustion of platelets and coagulationexhaustion of platelets and coagulation factors (results in hemorrhage). This is afactors (results in hemorrhage). This is a disruption of body homeostasis.disruption of body homeostasis. (Porth, 2001)(Porth, 2001)
  7. 7. PathophysiologyPathophysiology ThrombosisThrombosis-brief period of-brief period of hypercoagulabilityhypercoagulability 1)1) Coagulation cascade isCoagulation cascade is initiated, causinginitiated, causing widespread fibrinwidespread fibrin formationformation 2)2) Microthrombi areMicrothrombi are deposited throughout hedeposited throughout he microcirculatorymicrocirculatory 3)3) Fibrin deposits result inFibrin deposits result in tissue ischemia, hypoxia,tissue ischemia, hypoxia, necrosisnecrosis 4)4) Leads to multi organLeads to multi organ dysfunctiondysfunction (Porth, 2004) & (Otto, 2001)(Porth, 2004) & (Otto, 2001) FibrinolysisFibrinolysis-period of-period of hypocoagulability (thehypocoagulability (the hemorrhagic phase)hemorrhagic phase) 1)1) Activates theActivates the complementcomplement systemsystem 2)2) Byproducts of fibrinolysisByproducts of fibrinolysis (fibrin/fibrin degradation(fibrin/fibrin degradation products(FDP)) furtherproducts(FDP)) further enhance bleeding byenhance bleeding by interfering with plateletinterfering with platelet aggregation, fibrinaggregation, fibrin polymerization, &polymerization, & thrombin activitythrombin activity 3)3) Leads to HemorrhageLeads to Hemorrhage
  8. 8. PathophysiologyPathophysiology (Porth, 2004)(Porth, 2004)
  9. 9. Risk Factors and EtiologyRisk Factors and Etiology Almost always a secondary event fromAlmost always a secondary event from activation of one of the coagulationactivation of one of the coagulation pathwayspathways Underlying pathology creates a triggeringUnderlying pathology creates a triggering event: Either-event: Either- – endothelial tissue injury (Extrinsic)endothelial tissue injury (Extrinsic) – blood vessel injury (Intrinsic)blood vessel injury (Intrinsic) (Porth, 2004)(Porth, 2004)
  10. 10. Pathologic PathwaysPathologic Pathways ExtrinsicExtrinsic (endothelial)(endothelial) – Shock or traumaShock or trauma – Infections ( gram positiveInfections ( gram positive and gram negative sepsis,and gram negative sepsis, aspergillosis)aspergillosis) – Obstetric complicationsObstetric complications (eclampsia, placenta(eclampsia, placenta abruptio, fetal deathabruptio, fetal death syndrome)syndrome) – Malignancies: APML, AML,Malignancies: APML, AML, cancers of the lung, colon,cancers of the lung, colon, breast, prostate)breast, prostate) (Porth, 2004) & (Otto, 2001)(Porth, 2004) & (Otto, 2001) IntrinsicIntrinsic (blood vessel)(blood vessel) – Infectious vasculitis (certainInfectious vasculitis (certain viral infections, rockyviral infections, rocky mountain spotted fever)mountain spotted fever) – Vascular disordersVascular disorders – Intravascular hemolysisIntravascular hemolysis (hemolytic transfusion(hemolytic transfusion reactions)reactions) – Miscellaneous: snakebite,Miscellaneous: snakebite, pancreatitis, liver diseasepancreatitis, liver disease
  11. 11. Oncology Related DICOncology Related DIC Usually related to:Usually related to: – Disease processDisease process -APML( acute promyelocytic leukemia)-APML( acute promyelocytic leukemia) -mucin-secreting adenocarcinomas-mucin-secreting adenocarcinomas – Treatment of cancerTreatment of cancer -chemotherapy-chemotherapy -radiation-radiation – Concomitantly with sepsisConcomitantly with sepsis -10-20% with gram-negative-10-20% with gram-negative (Otto, S. (2001). Oncology Nursing)(Otto, S. (2001). Oncology Nursing)
  12. 12. Clinical FeaturesClinical Features Onset maybe Acute or ChronicOnset maybe Acute or Chronic – Acute DICAcute DIC Develops rapidly over a period of hoursDevelops rapidly over a period of hours Presents with sudden bleeding from multiple sitesPresents with sudden bleeding from multiple sites Treated as a medical emergencyTreated as a medical emergency – Chronic DICChronic DIC Develops over a period of monthsDevelops over a period of months Maybe subclinicalMaybe subclinical Eventually evolves into an acute DIC patternEventually evolves into an acute DIC pattern (Otto, 2001)(Otto, 2001)
  13. 13. Signs and SymptomsSigns and Symptoms Most common sign of DIC is bleedingMost common sign of DIC is bleeding -manifested by ecchymosis, petechiae,and-manifested by ecchymosis, petechiae,and purpurapurpura -bleeding from multiple sites either oozing or-bleeding from multiple sites either oozing or frank bleedingfrank bleeding -cool and or mottled extremities may be noted-cool and or mottled extremities may be noted -dyspnea and chest pain if pleura and-dyspnea and chest pain if pleura and pericardium involvementpericardium involvement -hematuria-hematuria (Porth, 2004) & (Otto, 2001)(Porth, 2004) & (Otto, 2001)
  14. 14. Genetic ComponentGenetic Component None associated with DICNone associated with DIC BUT-------BUT------- Genetic mutations to the clotting cascadeGenetic mutations to the clotting cascade can lead to coagulation disorders:can lead to coagulation disorders: Hemophilla A and BHemophilla A and B von Willebrand Factorvon Willebrand Factor Impaired Synthesis of CoagulationImpaired Synthesis of Coagulation FactorsFactors tutorial on homeostasistutorial on homeostasis http://alverno.edu.bownephttp://alverno.edu.bownep
  15. 15. Inflammation and DICInflammation and DIC Sepsis is usually underlying process forSepsis is usually underlying process for developmentdevelopment Endotoxins associated with sepsis activateEndotoxins associated with sepsis activate factors and initiate coagulation.factors and initiate coagulation. Bacteria, virus also trigger the clotting cascade.Bacteria, virus also trigger the clotting cascade. Sepsis activatesSepsis activates complement cascadecomplement cascade.. http://http://tutorial on inflammationtutorial on inflammation P.Bowne, Alverno CollegeP.Bowne, Alverno College
  16. 16. Diagnosis/Lab FindingsDiagnosis/Lab Findings TestTest Platelet countPlatelet count Fibrin degradation productFibrin degradation product (FDP)(FDP) Factor assayFactor assay Prothrombin time (PT)Prothrombin time (PT) Activated PTTActivated PTT Throbimn timeThrobimn time FibrinogenFibrinogen D-dimerD-dimer AntithrombinAntithrombin AbnormalityAbnormality DecreasedDecreased IncreasedIncreased DecreasedDecreased ProlongedProlonged ProlongedProlonged ProlongedProlonged DecreasedDecreased IncreasedIncreased DecreasedDecreased (Otto,2001)(Otto,2001)
  17. 17. Treatment ModalitiesTreatment Modalities Treat the underlying causeTreat the underlying cause Provide supportive management ofProvide supportive management of complicationscomplications Support organ functionSupport organ function Stop abnormal coagulation and control bleedingStop abnormal coagulation and control bleeding by replacement of depleted blood and clottingby replacement of depleted blood and clotting componentscomponents (FFP,Platelets,PRBC)(FFP,Platelets,PRBC) Medications can be used and choice dependsMedications can be used and choice depends on the patient’s condition (Heparin, Antithrombinon the patient’s condition (Heparin, Antithrombin III (ATIII), Fibrinolytic inhibitors)III (ATIII), Fibrinolytic inhibitors) (Porth, C.M. (2004) Essentials of Pathophysiology) & (Otto, S. (2001). Oncology(Porth, C.M. (2004) Essentials of Pathophysiology) & (Otto, S. (2001). Oncology Nursing)Nursing)
  18. 18. Case Study/Post TestCase Study/Post Test D.G.,a 48-year-old, is 30 days post matched unrelatedD.G.,a 48-year-old, is 30 days post matched unrelated allogenic stem cell transplant for Acute Myelegenousallogenic stem cell transplant for Acute Myelegenous Leukemia. His Lab work is as follows:Leukemia. His Lab work is as follows: WBC 480WBC 480 SodiumSodium 130130 ANC 120ANC 120 PotassiumPotassium 3.73.7 PltsPlts 3535 BUNBUN 1616 HctHct 2727 CreatinineCreatinine 1.41.4 Hgb 10Hgb 10 (( a) Based on the above lab values, what risk factors does D.Ga) Based on the above lab values, what risk factors does D.G The next morning after labs are drawn, D.G. developed aThe next morning after labs are drawn, D.G. developed a fever of 101.2 and BP fell to 98/60 (normally 130/76).fever of 101.2 and BP fell to 98/60 (normally 130/76). ((b)What may be the cause of the fever and low BP?b)What may be the cause of the fever and low BP? (c)What interventions should you as primary RN take at this time(c)What interventions should you as primary RN take at this time
  19. 19. Case Study cont.Case Study cont. D.G. is started on Vanco and Primaxin and givenD.G. is started on Vanco and Primaxin and given 1 liter fluid bolus over 2 hours. Blood cultures1 liter fluid bolus over 2 hours. Blood cultures were drawn prior to antibiotic RX. His feverwere drawn prior to antibiotic RX. His fever decreased to 99.8 and BP increased to 108/70.decreased to 99.8 and BP increased to 108/70. Overnight D.G. again became febrile to 102.4Overnight D.G. again became febrile to 102.4 with drop in BP to 70’s/50’s. Labs were drawnwith drop in BP to 70’s/50’s. Labs were drawn and fluids started at 500cc/hr. Labs valuesand fluids started at 500cc/hr. Labs values were significant:were significant: ANCANC 100100 PltsPlts 2020 HctHct 99 BUN 35BUN 35 HgbHgb 2424 Creat 2.8Creat 2.8 (a)What do the above lab values say about D.G. status(a)What do the above lab values say about D.G. status
  20. 20. Case Study cont.Case Study cont. MD orders 2 units of PRBC to be infused over 4 hours.MD orders 2 units of PRBC to be infused over 4 hours. During infusion BP increased to 90/48 and he continuesDuring infusion BP increased to 90/48 and he continues to be febrile at 101.0.to be febrile at 101.0. D.G. is becoming more confused, complaining of GI painD.G. is becoming more confused, complaining of GI pain and cramping, developing a moist cough with rapidand cramping, developing a moist cough with rapid respiratory rate.respiratory rate. ((a)What maybe causing the new symptoms?a)What maybe causing the new symptoms? (b)What interventions do you take at this time?(b)What interventions do you take at this time? (c)What maybe the underlying process? What else is he at risk fo(c)What maybe the underlying process? What else is he at risk fo
  21. 21. Case Study cont.Case Study cont. O2 sats on RA measure 84% and lung sounds are coarseO2 sats on RA measure 84% and lung sounds are coarse throughout. STAT ABG’s and CXR are done. X-raythroughout. STAT ABG’s and CXR are done. X-ray results show diffuse consolidation and the ABGsresults show diffuse consolidation and the ABGs demonstrate respiratory acidosis with hypoxemia. D.G.demonstrate respiratory acidosis with hypoxemia. D.G. is placed on oxygen, O2 sats improve to 91%. Urine andis placed on oxygen, O2 sats improve to 91%. Urine and stool output at this time test heme positive. You alsostool output at this time test heme positive. You also note he has small lower extremity bruising and scatterednote he has small lower extremity bruising and scattered petechia. A bronchoscophy is ordered and performed.petechia. A bronchoscophy is ordered and performed. Results show diffuse alveolar hemorrhage.Results show diffuse alveolar hemorrhage. (( a) Based on D.G. history and the current clinical picture, whata) Based on D.G. history and the current clinical picture, what (b) What information would be useful at this time for diagnosis?(b) What information would be useful at this time for diagnosis?
  22. 22. Case Study Cont.Case Study Cont. MD orders CBC and coagulation screen. The results areMD orders CBC and coagulation screen. The results are as follows:as follows: WBCWBC <100<100 PT 34 secPT 34 sec ANCANC 00 PTT 72PTT 72 PltsPlts 1212 Fibrinogen <100Fibrinogen <100 Hct 23Hct 23 FSP >1000FSP >1000 HgbHgb 99 D-dimer >500D-dimer >500 (( c)What secondary process is possibly occurring based on aboc)What secondary process is possibly occurring based on abo (( d)What interventions are appropriate? What should be the fod)What interventions are appropriate? What should be the foc
  23. 23. Case Study Cont.Case Study Cont. D.G. Continues to be hypotensive. Lung soundsD.G. Continues to be hypotensive. Lung sounds remain course, hemoptysis develops and CXRremain course, hemoptysis develops and CXR continues with diffuse consolidation. Urine andcontinues with diffuse consolidation. Urine and stool remain heme positive. After transfusion,stool remain heme positive. After transfusion, labs redrawn. Values as follows:labs redrawn. Values as follows: PltsPlts 2222 Pt 28Pt 28 Hct 26Hct 26 PTT 54PTT 54 Hgb 10Hgb 10 Fibrin <100Fibrin <100 FSP >1000FSP >1000 (( a)What is the results of treatment based on above vaa)What is the results of treatment based on above va (b)What interventions should be done?(b)What interventions should be done?
  24. 24. Case Study cont.Case Study cont. D.G. status continues to deteriorate andD.G. status continues to deteriorate and needed to be intubated 2 days afterneeded to be intubated 2 days after developing DIC. The sepsis remaineddeveloping DIC. The sepsis remained unresolved and he went into acute renalunresolved and he went into acute renal failure. Family decided not to dialyze duefailure. Family decided not to dialyze due to the multi-organ involvement. D.G.to the multi-organ involvement. D.G. expired 2 days later from the gram negexpired 2 days later from the gram neg sepsis and secondary DIC.sepsis and secondary DIC.
  25. 25. Answers for Case StudyAnswers for Case Study (a)Risk for infection, renal insufficiency,(a)Risk for infection, renal insufficiency, neutropenia, bleeding based on labneutropenia, bleeding based on lab values. WBC low along with the ANCvalues. WBC low along with the ANC makes patient more susceptible tomakes patient more susceptible to infection. The BUN and creatinine areinfection. The BUN and creatinine are elevated leading to possible renalelevated leading to possible renal problemsproblems
  26. 26. Answers for Case StudyAnswers for Case Study (b)(b) Possible septic shock as a result of anPossible septic shock as a result of an underlying infection. Neutropenic patientsunderlying infection. Neutropenic patients are at high risk for development ofare at high risk for development of infections.infections. (c) Patient will need blood cultures and labs(c) Patient will need blood cultures and labs drawn, a fluid challenge is needed to helpdrawn, a fluid challenge is needed to help with low BP’s. Will need to be started onwith low BP’s. Will need to be started on antibiotics. Patient will need to beantibiotics. Patient will need to be monitored closely, VS, I&O’s …monitored closely, VS, I&O’s …
  27. 27. Answers for Case StudyAnswers for Case Study (a)(a) D.G.’s labs cont to show anemia,D.G.’s labs cont to show anemia, neutropenia, renal insuffiency/failure.neutropenia, renal insuffiency/failure. BUN and creatinine have increased andBUN and creatinine have increased and the H&H has falling since previous draw.the H&H has falling since previous draw. The ANC conts to drop.The ANC conts to drop. (b)(b) Fluids, PRBC transfusion, monitoring ofFluids, PRBC transfusion, monitoring of urine output and VS are needed at thisurine output and VS are needed at this time. The transfusion and fluids will helptime. The transfusion and fluids will help with hypotension and anemia.with hypotension and anemia.
  28. 28. Answers for Case StudyAnswers for Case Study (a)(a) Pt possibly developing hypoxemia as aPt possibly developing hypoxemia as a result of the infection process,result of the infection process, hypotension.hypotension. (b)(b) Need to monitor O2 sats and applyNeed to monitor O2 sats and apply oxygen. Need to get orders for CXR andoxygen. Need to get orders for CXR and cont to monitor Vital signs closely.cont to monitor Vital signs closely.
  29. 29. Answers for Case StudyAnswers for Case Study (c)(c) Patient maybe developing pneumoniaPatient maybe developing pneumonia and is at an increased risk for ARDSand is at an increased risk for ARDS (acute respiratory distress syndrome).(acute respiratory distress syndrome). The moist cough with rapid resp. rate isThe moist cough with rapid resp. rate is good indication of pulmonarygood indication of pulmonary involvement.involvement. The patient also has increased risk ofThe patient also has increased risk of developing DIC based on the clinicaldeveloping DIC based on the clinical presentation and risk factors presented.presentation and risk factors presented.
  30. 30. Answers for Case StudyAnswers for Case Study (a) The clinical presentation leads to the(a) The clinical presentation leads to the diagnosis of DIC (effects every system ofdiagnosis of DIC (effects every system of the body);the body); Lungs-Lungs- hypoxemia,hypoxemia, hemorrhage, tachypneahemorrhage, tachypnea Cardiac-Cardiac- acidosis, tachycardiaacidosis, tachycardia GI-GI- cramping,cramping, abdominal painabdominal pain Renal-Renal- hematuriahematuria Integument-Integument- bruising, petechiaebruising, petechiae MentalMental status changes-status changes- confusionconfusion
  31. 31. Answer for Case StudyAnswer for Case Study (b)(b) A DIC panel results would be helpful atA DIC panel results would be helpful at this time. Lab abnormalities along withthis time. Lab abnormalities along with clinical presentation is used to confirm aclinical presentation is used to confirm a diagnosis of DIC. If abnormal results arediagnosis of DIC. If abnormal results are obtained for PT, PTT, platelets, andobtained for PT, PTT, platelets, and fibrinogen, then the D-dimer and FDPsfibrinogen, then the D-dimer and FDPs levels are used to confirm DIC...FDPslevels are used to confirm DIC...FDPs abnormal in 75% and D-dimer in 95%.abnormal in 75% and D-dimer in 95%. (Otto, 2001)(Otto, 2001)
  32. 32. Answers for Case StudyAnswers for Case Study (a)(a) Based on the lab values, DIC is confirmed forBased on the lab values, DIC is confirmed for the patient. The Platelet count is decreased,the patient. The Platelet count is decreased, the fibrinogen level is decreased, PT and PTTthe fibrinogen level is decreased, PT and PTT levels increased and prolonged, FDPs level islevels increased and prolonged, FDPs level is increased and the D-dimer is increasedincreased and the D-dimer is increased (usually together, levels are 100% specificity(usually together, levels are 100% specificity and sensitive). If a factor assay was done oneand sensitive). If a factor assay was done one would expect the levels to show a decrease inwould expect the levels to show a decrease in factors VI, VIII, and IXfactors VI, VIII, and IX (Otto, 2001)(Otto, 2001)
  33. 33. Answers for Case StudyAnswers for Case Study (b)(b) The immediate goal for the overallThe immediate goal for the overall management of DIC is the treat the underlyingmanagement of DIC is the treat the underlying disorder and to stop the patient from activelydisorder and to stop the patient from actively bleeding and clotting with the need to givebleeding and clotting with the need to give transfusions and anticoagulation therapy iftransfusions and anticoagulation therapy if needed.* Focus of assessments is to monitorneeded.* Focus of assessments is to monitor for more bleeding and changes.for more bleeding and changes. *Heparin therapy has met with controversy for the*Heparin therapy has met with controversy for the treatment of DICtreatment of DIC (Porth, 2004) & (Otto, 2001)(Porth, 2004) & (Otto, 2001)
  34. 34. Answers for Case StudyAnswers for Case Study (a)(a) Based on the lab values, DG showsBased on the lab values, DG shows slight improvement. The PT and PTTslight improvement. The PT and PTT numbers are better, platelet level hasnumbers are better, platelet level has increased.increased. (b)(b) The patient will cont to need to beThe patient will cont to need to be monitored very closely. Will need to contmonitored very closely. Will need to cont with treatment, monitor lab valueswith treatment, monitor lab values frequently. Patient remains critically ill.frequently. Patient remains critically ill.
  35. 35. ReferencesReferences Otto, Shirley E. (2001). OncologyOtto, Shirley E. (2001). Oncology Nursing. Mosby: St. Louis.Nursing. Mosby: St. Louis. Porth, Carol M. (2004). Essentials ofPorth, Carol M. (2004). Essentials of Pathophysiology: Concepts of AlteredPathophysiology: Concepts of Altered Health States. Lippncott Williams &Health States. Lippncott Williams & Wilkins: Philadelphia.Wilkins: Philadelphia. Web Sites:Web Sites: Pat Bowne, faculty Alverno College Milwaukee Wis.Pat Bowne, faculty Alverno College Milwaukee Wis.
  36. 36. GlossaryGlossary Complement-Complement-a heat-labile cascade system of at least 20a heat-labile cascade system of at least 20 glycoproteins in normal serum that interacts to provideglycoproteins in normal serum that interacts to provide manu of the effector functions of humoral immunity andmanu of the effector functions of humoral immunity and inflammation, including vasodilation and increases ofinflammation, including vasodilation and increases of vascular permeability, facilitation of phagocyte activityvascular permeability, facilitation of phagocyte activity and lysis of certain foreign cells.and lysis of certain foreign cells. F’s (factors) of Coagulation:F’s (factors) of Coagulation:factors essential to normalfactors essential to normal blood-clotting, whose absence, diminution, or excessblood-clotting, whose absence, diminution, or excess may lead to abnormality of clotting mechanisms. Theremay lead to abnormality of clotting mechanisms. There are 12 Factors-designated by Roman Numerals.are 12 Factors-designated by Roman Numerals. (Porth, 2004) & (Otto, 2001)(Porth, 2004) & (Otto, 2001)
  37. 37. GlossaryGlossary FibrinFibrin- an insoluble protein that is essential to clotting of blood,- an insoluble protein that is essential to clotting of blood, formed from fibrinogen by action of thrombinformed from fibrinogen by action of thrombin FibrinogenFibrinogen- a coagulation factor I, a glycoprotein; administered to- a coagulation factor I, a glycoprotein; administered to increase the coagulability of the bloodincrease the coagulability of the blood FibrinolysinFibrinolysin- plasmin, a preparation of proteolytic enzyme formed- plasmin, a preparation of proteolytic enzyme formed from profibrinolysin(plasminogen); to promote dissolution offrom profibrinolysin(plasminogen); to promote dissolution of thrombithrombi HemostasisHemostasis-the condition in which the external and internal-the condition in which the external and internal environment of a cell remains relatively constantenvironment of a cell remains relatively constant ThrombinThrombin- an enzyme resulting from activation of prothrombin,- an enzyme resulting from activation of prothrombin, which catalyzes the conversion of fibrinogen to fibrin.which catalyzes the conversion of fibrinogen to fibrin. ThrombosisThrombosis-formation,development or presences of a thrombus-formation,development or presences of a thrombus Thrombus-Thrombus-an aggregation of blood factors, primarily platlets andan aggregation of blood factors, primarily platlets and fibrin with entrapment of cellular elements, frequently causingfibrin with entrapment of cellular elements, frequently causing vascular obstruction at the point of formation.vascular obstruction at the point of formation. (Porth, 2004) & (Otto, 2001)(Porth, 2004) & (Otto, 2001)
  38. 38. GlossaryGlossary Activated PTTActivated PTT- aPTT tests the intrinsic and- aPTT tests the intrinsic and common pathwayscommon pathways D-dimerD-dimer- an antigen formed as a result of plasmin- an antigen formed as a result of plasmin lysis of cross-linked fibrin clots, documents thelysis of cross-linked fibrin clots, documents the presence of thrombinpresence of thrombin Fibrin degradation product(FDP)Fibrin degradation product(FDP)- degradation- degradation products increase as plasmin biodegradesproducts increase as plasmin biodegrades fibrinogen and fibrin,levels are elevated in 85-fibrinogen and fibrin,levels are elevated in 85- 100% of patients with DIC100% of patients with DIC Prothrombin Time(PT)Prothrombin Time(PT)- tests the extrinsic and- tests the extrinsic and common pathwayscommon pathways (Porth, 2004) & (Otto, 2001)(Porth, 2004) & (Otto, 2001)
  39. 39. GlossaryGlossary Blood Components:Blood Components: used to correct abnormalused to correct abnormal homeostasis. Used to correct the clottinghomeostasis. Used to correct the clotting deficiencies caused by the consumption ofdeficiencies caused by the consumption of blood components during the DIC process.blood components during the DIC process. --PlateletsPlatelets: contain platelet factor III, which: contain platelet factor III, which functions as a mechanical plugfunctions as a mechanical plug --Fresh frozen plasma (FFPs):Fresh frozen plasma (FFPs): used for volumeused for volume expansion and contains clotting factorsexpansion and contains clotting factors V,VIII,XIII and antithrombinIII.V,VIII,XIII and antithrombinIII. (Otto, S. (2001) Oncology Nursing.)(Otto, S. (2001) Oncology Nursing.)
  40. 40. GlossaryGlossary Blood Components cont’d:Blood Components cont’d: Packed Red Blood Cells (PRBC’s)Packed Red Blood Cells (PRBC’s): used: used to increase RBC’s and clotting factors.to increase RBC’s and clotting factors. Used instead of whole blood to help withUsed instead of whole blood to help with fluid overload and reduce development offluid overload and reduce development of antibodies.antibodies. Cryoprecpitate:Cryoprecpitate: contains fibrinogen andcontains fibrinogen and factor VIII.factor VIII. (Otto, S. (2001). Oncology Nursing)(Otto, S. (2001). Oncology Nursing)
  41. 41. Thank youThank you This completes the DIC tutorial. Any and allThis completes the DIC tutorial. Any and all comments regarding your learningcomments regarding your learning experience are greatly appreciated.experience are greatly appreciated. Please send any correspondence to myPlease send any correspondence to my email address listed below:email address listed below: debbiern@wi.rr.comdebbiern@wi.rr.com
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×