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Disseminated Intravascular Coagulation WangXin Department of Emergency Medicine Tianjin Medical University General Hospital
 
General Considerations DIC is not a kind of independent disease, but a middle process or complication of some diseases . It is essentially an imbalance between the coagulation process and anticoagulation process. It is a syndrome characterized by massive activation and consumption of coagulation proteins, fibrinolytic proteins and platelets.
Coagulation is usually confined to a localized area by the combination of blood flow and circulating inhibitors of coagulation, especially antithrombin Ⅲ . If the stimulus to coagulation is too great, these control mechanisms can be overwhelmed, leading to the syndrome of DIC.
Classification Acute DIC :It happened rapidly, the coagulopathy is dominant and major symptoms are bleeding and shock, mainly seen in severe infection, amniotic fluid embolism.  Chronic DIC: it happened slowly and last several weeks, thrombosis and clotting may predominate mainly seen in cancer.
Etiology DIC is not a primary disease, but a disorder secondary to numerous triggering events such as serious illnesses.
infectious disease  31%~43% cancer  24%~34% obstetric complications  4%~12% severe tissue injury  1%~5% systemic disease
● infectious disease  31%~43% (bacterial, viral, rickettsial, parasitic diseases and so on) Bacterial infection, in particular septicemia, is commonly associated with DIC. However, systemic infections with other microorganisms, such as viruses and parasites, also may lead to DIC.
● cancer  24%~34% (Acute promyelocytic leukemia, acute myelomonocytic or monocytic leukemia, disseminated prostatic carcinoma Lung, breast, gastrointestinal malignancy)
● obstetric complications  4%~12% (amniotic fluid embolus, septic  abortion, retained fetus and so on)
● severe tissue injury  1%~5% (burn, heart shock,  fracture and so on) Head trauma in particular is strongly associated with DIC; both local and systemic activation of coagulation may be detected after such an event. The increased risk of DIC after head trauma is understandable in view of the relatively large amount of tissue factor in the cerebral compartment.
● systemic disease (malignant hypertension , Acute  respiratory distress syndrome<ARDS>, hemolytic transfusion reaction)
Pathophysiology DIC occurs when monocytes and endothelial cells are activated or injured by toxic substances elaborated in the course of certain diseases. The response of monocytes and endothelial cells to injury is to generate tissue factor on the cell surface, activating the coagulation cascade .
In acute DIC, an explosive generation of thrombin depletes clotting factors and platelets and activates the fibrinolytic system. Bleeding into the subcutaneous tissues, skin, and mucous membranes occurs, along with occlusion of blood vessels caused by fibrin in the microcirculation.
In chronic DIC, the process is the same, but it is less explosive. Usually there is time for compensatory responses to take place, which diminish the likelihood of bleeding but give rise to a hypercoagulable state.
These changes in the blood can be detected by testing the coagulation system. Thromboembolism occurs in this setting, and when oral anticoagulants are given following heparin therapy, there is a tendency for it to recur.
Long-term therapy with low-molecular-weight heparin may be a solution to this problem until the underlying cause can be brought under control.
Stimulation of Coagulation Intravascular thrombosis Consumption  of coagulation factors Secondary  activation of  thrombolysis Hypoperfusion to tissues and organs Inability to  form a  stable clot Release of  anticoagulants Ischemic  damage Bleeding Bleeding
Diagnosis ●Symptoms and Signs ●Laboratory Findings ●Different Diagnosis
Symptoms and Signs Bleeding Thrombosis Hypotension or shock Organ dysfunction
●   Bleeding :84%~95%  It may occur at any site, but spontaneous bleeding and oozing at venipuncture sites or wounds are important clues to the diagnosis.
Meningococcemia on the Calves
Meningococcemia on the Leg
Meningococcemia Associated Purpura
Thrombosis: It is most commonly manifested by digital ischemia and gangrene, renal cortical necrosis and hemorrhagic adrenal infarction may occur.
Necrosis of the toes
Acute DIC Clinical findings  Multiple bleeding sites  Ecchymoses of skin, mucous membranes  Visceral hemorrhage  Ischemic tissue
Chronic DIC   Clinical findings  Signs of deep venous or arterial thrombosis or embolism  Superficial venous thrombosis, especially without varicose veins  Multiple thrombotic sites at the same time  Serial thrombotic episodes
Purpura fulminans
Purpura fulminans of a child's leg
Necrosis - of a child's toes
Laboratory Findings
Markedly decreased  Protein C  Markedly decreased  Antithrombin III (AT III) Normal or decreased  Fibrinogen  Markedly increased  Fibrin degradation products (FDP) Increased  Activated partial thromboplastin time (APTT)  Increased  Prothrombin time (PT)  Markedly decreased  Platelet count  Result   Test
Different Diagnosis Liver disease Vitamin K deficiency Sepsis TTP ( Thrombotic  thrombocytopenic  purpura  )
Liver disease Liver disease may prolong both the PT and PTT, but fibrinogen levels are usually normal, and the platelet count is usually normal or only slightly reduced. Severe liver disease may be difficult to distinguish from DIC.
Vitamin K deficiency Vitamin K deficiency will not affect the fibrinogen level or platelet count and will be completely corrected by vitamin K replacement.
Sepsis Sepsis may produce thrombo-cytopenia, and coagulopathy may be present because of vitamin K deficiency. However, in these cases, the fibrinogen level should be normal.
TTP  (Thrombotic thrombocytopenic  purpura ) TTP may produce fever and MAHA ( microangiopathic hemolytic anemia ). However, fibrinogen levels and other coagulation studies should be normal.
Treatment Treatment of the underlying disorder  Replacement therapy Heparin therapy Other Treatment
Treatment of the underlying disorder The primary focus should be the diagnosis and treatment of the underlying disorder that has given rise to DIC.
Treatment of the underlying disease is the mainstay of management of either acute or chronic DIC. Avoid delay treat vigorously (eg, shock, sepsis, obstetrical problems).
Replacement therapy Coagulation factor deficiency require replacement with FFP (fresh frozen plasma). Platelet transfusion should be used to maintain a platelet count greater than 30000/μl, and 50000/μl.
Fibrinogen is replaced with cryoprecipitate. One unit of cryoprecipitate usually raises the fibrinogen level by 6~8mg/dl,so that 15 units of cryoprecipitate will raise the level from 50 to 150mg/dl.
Heparin therapy In some cases heparin therapy is contraindicated, but when DIC is producing serious clinical consequences and the underlying cause is not rapidly reversible, heparin may be necessary. Dose:500~750u/h is necessary.
Attention: Heparin therapy must be used in combination with replacement therapy, it can lead to severe  bleeding .
It cannot be effective if AT Ⅲ  levels are markedly depleted. ATⅢ levels should be measured, and FFP used to raise levels to greater than 50%.FDP will decline over 1~2d.Improvement in the platelet count may lag as much as 1 week behind control of the coagulopathy.
Other Treatment Aminocaproic acid, 1g/h  iv  Tranexamic acid, 10mg/kg, iv,q8h,
Those two drugs should be added to decrease the rate of fibrinolysis, raise the fibrinogen level, and control bleeding. Attention  : Aminocaproic acid can never be used without heparin in DIC because of the risk of thrombosis.
Acute DIC    Without bleeding or evidence of ischemia No treatment With bleeding Blood components as needed Fresh frozen plasma Cryoprecipitate Platelet transfusions   With ischemia Anticoagulants after bleeding risk is corrected  with blood products
Chronic DIC Without thromboembolism No specific therapy needed but prophylactic drugs (eg, low-dose heparin, low-molecular-weight heparin) may be used for patients at high risk of thrombosis
With thromboembolism Heparin or low-molecular-weight heparin, trial of warfarin sodium (Coumadin). (If warfarin is unsuccessful, long-term use of low-molecular-weight heparin may be helpful.)
Complications Severe bleeding Stroke Ischemia of extremities or organs
Prognosis Since DIC is a result of an acute medical illness, prognoses depends almost entirely upon the speed of the intensivist in handing the bleeding emergency, as well as the ability to treat the underling disorder The underlying disease that causes the disorder will usually predict the probable outcome.
Summary An awareness of the clinical settings in which DIC can occur and the diagnostic features that warn of its presence should enable the physician to diagnose and treat DIC appropriately.  New treatments that are more effective and less hazardous are clearly needed, and a number of such agents are now undergoing clinical trial.
Thank You

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Disseminated Intravascular Coagulation

  • 1. Disseminated Intravascular Coagulation WangXin Department of Emergency Medicine Tianjin Medical University General Hospital
  • 2.  
  • 3. General Considerations DIC is not a kind of independent disease, but a middle process or complication of some diseases . It is essentially an imbalance between the coagulation process and anticoagulation process. It is a syndrome characterized by massive activation and consumption of coagulation proteins, fibrinolytic proteins and platelets.
  • 4. Coagulation is usually confined to a localized area by the combination of blood flow and circulating inhibitors of coagulation, especially antithrombin Ⅲ . If the stimulus to coagulation is too great, these control mechanisms can be overwhelmed, leading to the syndrome of DIC.
  • 5. Classification Acute DIC :It happened rapidly, the coagulopathy is dominant and major symptoms are bleeding and shock, mainly seen in severe infection, amniotic fluid embolism. Chronic DIC: it happened slowly and last several weeks, thrombosis and clotting may predominate mainly seen in cancer.
  • 6. Etiology DIC is not a primary disease, but a disorder secondary to numerous triggering events such as serious illnesses.
  • 7. infectious disease 31%~43% cancer 24%~34% obstetric complications 4%~12% severe tissue injury 1%~5% systemic disease
  • 8. ● infectious disease 31%~43% (bacterial, viral, rickettsial, parasitic diseases and so on) Bacterial infection, in particular septicemia, is commonly associated with DIC. However, systemic infections with other microorganisms, such as viruses and parasites, also may lead to DIC.
  • 9. ● cancer 24%~34% (Acute promyelocytic leukemia, acute myelomonocytic or monocytic leukemia, disseminated prostatic carcinoma Lung, breast, gastrointestinal malignancy)
  • 10. ● obstetric complications 4%~12% (amniotic fluid embolus, septic abortion, retained fetus and so on)
  • 11. ● severe tissue injury 1%~5% (burn, heart shock, fracture and so on) Head trauma in particular is strongly associated with DIC; both local and systemic activation of coagulation may be detected after such an event. The increased risk of DIC after head trauma is understandable in view of the relatively large amount of tissue factor in the cerebral compartment.
  • 12. ● systemic disease (malignant hypertension , Acute respiratory distress syndrome<ARDS>, hemolytic transfusion reaction)
  • 13. Pathophysiology DIC occurs when monocytes and endothelial cells are activated or injured by toxic substances elaborated in the course of certain diseases. The response of monocytes and endothelial cells to injury is to generate tissue factor on the cell surface, activating the coagulation cascade .
  • 14. In acute DIC, an explosive generation of thrombin depletes clotting factors and platelets and activates the fibrinolytic system. Bleeding into the subcutaneous tissues, skin, and mucous membranes occurs, along with occlusion of blood vessels caused by fibrin in the microcirculation.
  • 15. In chronic DIC, the process is the same, but it is less explosive. Usually there is time for compensatory responses to take place, which diminish the likelihood of bleeding but give rise to a hypercoagulable state.
  • 16. These changes in the blood can be detected by testing the coagulation system. Thromboembolism occurs in this setting, and when oral anticoagulants are given following heparin therapy, there is a tendency for it to recur.
  • 17. Long-term therapy with low-molecular-weight heparin may be a solution to this problem until the underlying cause can be brought under control.
  • 18. Stimulation of Coagulation Intravascular thrombosis Consumption of coagulation factors Secondary activation of thrombolysis Hypoperfusion to tissues and organs Inability to form a stable clot Release of anticoagulants Ischemic damage Bleeding Bleeding
  • 19. Diagnosis ●Symptoms and Signs ●Laboratory Findings ●Different Diagnosis
  • 20. Symptoms and Signs Bleeding Thrombosis Hypotension or shock Organ dysfunction
  • 21. Bleeding :84%~95% It may occur at any site, but spontaneous bleeding and oozing at venipuncture sites or wounds are important clues to the diagnosis.
  • 25. Thrombosis: It is most commonly manifested by digital ischemia and gangrene, renal cortical necrosis and hemorrhagic adrenal infarction may occur.
  • 27. Acute DIC Clinical findings Multiple bleeding sites Ecchymoses of skin, mucous membranes Visceral hemorrhage Ischemic tissue
  • 28. Chronic DIC Clinical findings Signs of deep venous or arterial thrombosis or embolism Superficial venous thrombosis, especially without varicose veins Multiple thrombotic sites at the same time Serial thrombotic episodes
  • 30. Purpura fulminans of a child's leg
  • 31. Necrosis - of a child's toes
  • 33. Markedly decreased Protein C Markedly decreased Antithrombin III (AT III) Normal or decreased Fibrinogen Markedly increased Fibrin degradation products (FDP) Increased Activated partial thromboplastin time (APTT) Increased Prothrombin time (PT) Markedly decreased Platelet count Result Test
  • 34. Different Diagnosis Liver disease Vitamin K deficiency Sepsis TTP ( Thrombotic thrombocytopenic purpura )
  • 35. Liver disease Liver disease may prolong both the PT and PTT, but fibrinogen levels are usually normal, and the platelet count is usually normal or only slightly reduced. Severe liver disease may be difficult to distinguish from DIC.
  • 36. Vitamin K deficiency Vitamin K deficiency will not affect the fibrinogen level or platelet count and will be completely corrected by vitamin K replacement.
  • 37. Sepsis Sepsis may produce thrombo-cytopenia, and coagulopathy may be present because of vitamin K deficiency. However, in these cases, the fibrinogen level should be normal.
  • 38. TTP (Thrombotic thrombocytopenic purpura ) TTP may produce fever and MAHA ( microangiopathic hemolytic anemia ). However, fibrinogen levels and other coagulation studies should be normal.
  • 39. Treatment Treatment of the underlying disorder Replacement therapy Heparin therapy Other Treatment
  • 40. Treatment of the underlying disorder The primary focus should be the diagnosis and treatment of the underlying disorder that has given rise to DIC.
  • 41. Treatment of the underlying disease is the mainstay of management of either acute or chronic DIC. Avoid delay treat vigorously (eg, shock, sepsis, obstetrical problems).
  • 42. Replacement therapy Coagulation factor deficiency require replacement with FFP (fresh frozen plasma). Platelet transfusion should be used to maintain a platelet count greater than 30000/μl, and 50000/μl.
  • 43. Fibrinogen is replaced with cryoprecipitate. One unit of cryoprecipitate usually raises the fibrinogen level by 6~8mg/dl,so that 15 units of cryoprecipitate will raise the level from 50 to 150mg/dl.
  • 44. Heparin therapy In some cases heparin therapy is contraindicated, but when DIC is producing serious clinical consequences and the underlying cause is not rapidly reversible, heparin may be necessary. Dose:500~750u/h is necessary.
  • 45. Attention: Heparin therapy must be used in combination with replacement therapy, it can lead to severe bleeding .
  • 46. It cannot be effective if AT Ⅲ levels are markedly depleted. ATⅢ levels should be measured, and FFP used to raise levels to greater than 50%.FDP will decline over 1~2d.Improvement in the platelet count may lag as much as 1 week behind control of the coagulopathy.
  • 47. Other Treatment Aminocaproic acid, 1g/h iv Tranexamic acid, 10mg/kg, iv,q8h,
  • 48. Those two drugs should be added to decrease the rate of fibrinolysis, raise the fibrinogen level, and control bleeding. Attention : Aminocaproic acid can never be used without heparin in DIC because of the risk of thrombosis.
  • 49. Acute DIC    Without bleeding or evidence of ischemia No treatment With bleeding Blood components as needed Fresh frozen plasma Cryoprecipitate Platelet transfusions   With ischemia Anticoagulants after bleeding risk is corrected with blood products
  • 50. Chronic DIC Without thromboembolism No specific therapy needed but prophylactic drugs (eg, low-dose heparin, low-molecular-weight heparin) may be used for patients at high risk of thrombosis
  • 51. With thromboembolism Heparin or low-molecular-weight heparin, trial of warfarin sodium (Coumadin). (If warfarin is unsuccessful, long-term use of low-molecular-weight heparin may be helpful.)
  • 52. Complications Severe bleeding Stroke Ischemia of extremities or organs
  • 53. Prognosis Since DIC is a result of an acute medical illness, prognoses depends almost entirely upon the speed of the intensivist in handing the bleeding emergency, as well as the ability to treat the underling disorder The underlying disease that causes the disorder will usually predict the probable outcome.
  • 54. Summary An awareness of the clinical settings in which DIC can occur and the diagnostic features that warn of its presence should enable the physician to diagnose and treat DIC appropriately. New treatments that are more effective and less hazardous are clearly needed, and a number of such agents are now undergoing clinical trial.