DIC

Pathophysiology of Disseminated Intravascular Coagulation (DIC)

  • DIC is also referred to as consumptive coagulopathy.

  • Characterized by an imbalance between coagulation and bleeding.

  • Tissue factor released from vascular endothelial damage activates coagulation factors VII to VIIa, initiating the coagulation cascade.

  • This leads to the formation of fibrin and thrombin, resulting in clot formation within the general circulation.

  • The excessive clotting disrupts the coagulation process, creating a vicious cycle.

  • Continuous consumption of clotting factors results in excessive bleeding.

  • Platelet depletion occurs as they are engaged in forming clots.

  • Increase in plasma activator inhibitor reduces fibrinolysis, further complicating the condition.

Epidemiological and Etiological Risk Factors

Etiology

  • Primary causes of DIC include:

    • Trauma

    • Pregnancy-related complications

    • Cardiac disease

    • Sepsis or serious infections

    • Cancer

  • Difficult to reverse the effects of DIC, leading to high mortality rates.

Risk Factors/Incidence

  • Significant risk factors include:

    • Pregnancy complications, such as placental abruption.

    • Bloodstream infections (sepsis).

    • Hematological malignancies, including leukemia and lymphoma.

    • Severe trauma or injury.

    • Blood transfusion reactions.

  • Comorbidities associated with DIC:

    • Aneurysms

    • Various types of cancer

    • Pancreatic disorders

    • Liver disorders

  • In obstetric populations, associated conditions are postpartum hemorrhage, placental abruption, and sepsis.

  • Epidemiology statistics:

    • DIC occurs in 30%-50% of clients suffering from sepsis.

    • Roughly 1% of all hospitalized clients are affected by DIC.

    • No racial or sex predisposition noted.

    • Higher mortality rate of 34.7% is observed in DIC compared to trauma patients.

Impact on Overall Health

Physiological/Psychosocial Context

  • Clients with DIC often start from a critical state, complicating overall care due to simultaneous presenting conditions.

  • Potential complications of DIC include:

    • Changes in mental status

    • Respiratory dysfunction

    • Acute renal failure

    • Extensive systemic bleeding

  • Greater challenges during hospitalization for older adults, particularly those aged 65 and above due to higher comorbidity rates and reduced physiological reserve.

Common Causes of DIC in Older Adults

  • Increased risks in this demographic due to:

    • Heat illnesses

    • Infections like sepsis, COVID-19

    • Various cancers, particularly acute myeloid leukemia.

  • Underlying conditions leading to increased risk include:

    • Kidney injury

    • Hepatic dysfunction

    • Cardiac tamponade

    • Gangrene

    • Hemothorax

    • Intracerebral hematoma

    • Overall increased mortality.

Clinical Presentation of DIC

  • Initial manifestations include:

    • Bleeding from wounds, surgical sites, and phlebotomy sites.

    • Possible bleeding from gingiva, rectum, vagina, and through catheters.

  • Signs of internal bleeding include:

    • Ecchymosis, hematomas, petechiae.

    • Oliguria, anuria, or hematuria indicative of renal failure.

    • Respiratory issues such as dyspnea, cyanosis, and hemoptysis due to pulmonary hemorrhage or embolism.

    • Neurological changes related to thrombi or hemorrhages in the brain.

    • Chest pain due to coronary artery occlusions.

    • Jaundice resulting from liver failure.

Coagulation Lab Testing and Diagnostic Studies

  • D-dimer Test:

    • Common laboratory test for identifying thrombosis.

    • Level not specific to DIC but correlated with clot activity.

  • Prothrombin Time (PT) and Partial Thromboplastin Time (PTT):

    • Measured levels are often prolonged in DIC due to decreased availability of clotting factors.

  • Fibrinogen Levels:

    • Usually low initially, but can improve in chronic DIC cases.

  • ISTH DIC Scoring System:

    • Clients can be classified as “nonovert DIC” in earlier stages when tests may show inconclusive results.

Role of the Nurse

  • Assessment and History Taking:

    • Comprehensive assessment including objective (physical) and subjective (reported) findings.

    • Identification of hemorrhage sites and possible thrombosis locations.

  • Laboratory Evaluations:

    • Monitoring test results and promptly notifying medical providers about abnormalities.

  • Vital Signs Monitoring:

    • Routine checks to detect any significant changes.

  • Intervention Planning and Implementation:

    • Timely treatment of the underlying causes assists in managing DIC efficiently.

    • Administer prescribed IV fluids, platelets, factor replacements, and heparin as indicated.

Safety Considerations

  • The nurse must ensure that all laboratory tests are conducted and results are available in a timely manner to prevent errors that can compromise client safety.

  • DIC Scoring Criteria: (points assigned based on results):

    • INR or PT prolongation:

    • 0 Points: INR < 1.3

    • 1 Point: INR 1.3 - 1.7

    • 2 Points: INR > 1.7 but ≤ 3

    • 3 Points: INR > 3

    • Fibrinogen Levels:

    • 0 Points: > 100 mg/dL

    • 1 Point: < 100 mg/dL

    • D-dimer Levels:

    • 0 Points: No increase

    • 1 Point: Moderate increase

    • 2 Points: Severe increase

    • Platelet Count:

    • 0 Points: > 100,000/μL

    • 1 Point: 50,000 - 100,000/μL

    • 2 Points: < 50,000/μL.

    • Scoring Interpretation:

    • Score ≥ 5 = Positive for DIC.

    • Score < 5 = Negative, however, “nonovert” DIC may still exist.

Ongoing Monitoring and Assessments

  • Frequent monitoring for any signs of bleeding.

  • Assess abdominal girth and inspect for rectal bleeding and blood presence in urine.

Client Education

  • Medication Guidance:

    • Educate clients regarding new medications prescribed.

    • Instruct clients to monitor for bleeding manifestations.

    • Encourage the use of soft-bristle toothbrushes and electric razors to minimize injury risk.

Nursing Process Steps

Recognize Cues (Assessment)

  • Monitor for changes in consciousness (e.g., restlessness, confusion).

  • Assess respiratory parameters and obtain arterial blood gases (ABGs).

  • Conduct skin assessments for bruising and any external bleeding.

Analyze Cues (Analysis)

  • Review ABG results to determine acid-base imbalances.

  • Monitor vital signs for any concerning changes in hemodynamics and oxygen saturation.

  • Address anxiety with comfort measures and medications, recognizing anxiety can worsen respiratory distress.

Prioritize Hypotheses (Analysis)

  • Primary care priorities in DIC include:

    • Maintaining respiratory status.

    • Monitoring and managing bleeding manifestations.

    • Changes in hemodynamic status related to DIC.

Generate Solutions (Planning)

  • Collaborate on a care plan based on assessments, clinical priorities, and the pathophysiology of DIC.

Take Actions (Implementation)

  • Prioritize treating the underlying cause to mitigate DIC, as its existence persists until the initial problem is addressed.

Evaluate Outcomes (Evaluation)

  • Continuous evaluation of client responses to interventions is crucial for care effectiveness.

  • Close monitoring of IV sites for complications (e.g., bleeding, pain, tenderness, redness).

Treatments and Therapies for DIC

  • Initial treatment includes the administration of blood products such as:

    • Fresh Frozen Plasma (FFP): A crucial plasma product containing necessary clotting factors, fibrinogen, proteins, and electrolytes.

    • Splitting whole blood into components (red blood cells, plasma, platelets).

  • Anticoagulants such as heparin and low molecular weight heparins are administered through IV.

  • IV fluids, like normal saline or Lactated Ringer’s, are used to increase cardiac output (CO).

  • It is critical to routinely assess laboratory findings (e.g., PTT) during heparin administration to adjust dosage effectively, usually every 6 hours.