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DIC

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Kristi Perham

on 30 April 2013

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Transcript of DIC

Group 3 Disseminated Intravascular
Coagulation (DIC) PATHOPHYSIOLOGY COMPLICATIONS PHYSICAL ASSESSMENT LAB, RADIOLOGY & OTHER TESTS: MEDICATIONS & DOSES MEDICATIONS & DOSES The body's natural ability to regulate blood clotting does not function properly. This causes the platelets to clump together and clog small blood vessels throughout the body. The excessive clotting damages organs, destroys blood cells, and depletes the supply of platelets and other clotting factors so that the blood can no longer clot normally. This can cause excessive clotting (thrombosis) or hemorrhage throughout the body and lead to shock, organ failure, and death.

DIC is rare and life-threatening.

(WebMD, 2010) Bleeding, characterized by multiple ecchymoses and mucosal bleeding. Concurrent widespread microvascular thrombosis may lead to tissue ischemia and multiorgan failure

In chronic DIC --a hypercoagulatable state which may result in venous or arterial thrombosis

Treatment: mainly that of underlying disorder, with circulatory blood product support as necessary. Anticoagulation may be indicated.

The removal of the cause does not necessarily alleviate the process in all cases. This is relevant in patients with sepsis, where clinical deterioration may continue despite antibiotic treatment.


(Clinical Key, 2012) Health History:

recent abortion (spontaneous or therapeutic) or current pregnancy

history of abnormal bleeding episodes or a hematologic disorder

presence of known malignant tumor

Physical Examination:

bleeding from puncture wounds (eg. injections), IV sites, incisions

hematuria, obvious or occult blood in emesis or stool, epistaxis, other abnormal bleeding

vital signs

heart and breath sounds

abdominal assessment including girth, contour, bowel sounds, tenderness or guarding to palpation

color, temperature, skin condition of hands, feet, and digits

petechiae or purpura of skin, mucous membranes


(Lemone, Burke & Bauldoff, 2011 p.1113) Diagnostic tests are used to confirm diagnosis and evaluate risk for hemorrhage.

CBC and platelet count: evaluate hemoglobin, hct, and number of circulating platelets.

Coagulation Studies: Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and Thrombin Time are prolonged, Fibrinogen Level is low

Fibrin Degradation Products (FDPs) or Fibrin Split Products (FSPs): increased due to fibrinolysis


(Lemone, et al., 2011 p1113) Heparin

Trade name: Heparin

Generic name: Heparin Sodium

Dosage: Dosing is based on severity of DIC but usually 10,000-20,000 units IV / day.

(Medscape, 2013)
(Pepid, 2013) Antithrombin III

Trade: Thrombate

Generic: Antithrombin

Dosing: Dosage is determined based on a pre-therapy plasma antithrombin III Level (AT-III) Calculate dosage using the following equation:Unit required(IU) = {[desired baseline AT-III level ] x weight (kg)} / 1.4

(Pepid, 2013) TREATMENTS Before treatment can begin the cause of DIC must be identified.

Treatment consists of transfusion and/or anticoagulant antithrombotic therapy.

Ultimate goal is to stabilize hemodynamically. This can be done by giving IV NS, fresh frozen plasma (FFP), cryoprecipitate, platelets.

**Fresh frozen plasma and platelet concentrates are given to restore clotting factors and circulating platelets.

**Heparin therapy interferes with the clotting cascade and may prevent further clotting factor consumption due to uncontrolled thrombosis.

**Antithrombin III concentrates (which inhibits coagulation and inactivates thrombin) are also given alone or in conjugation with Heparin

(Lemone, et al., 2011 p1113)
(Pepid, 2013) SIDE/ADVERSE EFFECTS Antithrombin III: Dizziness, bowel fullness, chest pain/tightness, chills, cramps, dyspnea, hives, fever, film over eye, lightheadedness, nausea, and hematoma.

Heparin: Hemorrhage, thrombocytopenia, local irritation, and osteoporosis with long term use.

(Pepid, 2013)

(RxLIst, n.d.) COMPLEMENTARY THERAPIES

Complementary therapies not recommended due to severity of disease and necessity for immediate interventions

Herbal supplements available in place of blood thinners as prevention: garlic, tumeric, bromelain, ginger

Garlic relaxes blood vessel walls promoting vascular health

(Budritz, 2011)
(Challem, 2012) NURSING DIAGNOSES Ineffective Tissue Perfusion

Thrombi and emboli forming throughout microcirculation affect perfusion of many organs and tissues. The bleeding due to clotting factor consumption affects cardiac output and blood flow to these tissues.

Impaired Gas Exchange

Microclots in the pulmonary vasculature are likely to interfere with gas exchange.

Pain

The underlying cause of DIC and tissue ischemia from microvascular clots can cause pain.

Fluid Volume Deficit

Fluid deficit is common from immense blood loss causing low blood pressure, Hct, Hgb and RBC's.

(LeMone, et al., p1113-1114) NURSING CARE Anxiety

Increased bleeding and uncertain prognosis is often accompanied with anxiety.

Fear

The underlying serious illness and a complication such as DIC results in an uncertain prognosis, often accompanied by fear.

Further Nursing Care

Take a thorough history especially regarding previous bleeding disorders, turn patient every two hours, assess skin thoroughly and keep clean and moisturized, safety devices should be padded. THERAPEUTIC EFFECTS Antithrombin III

Therapeutic Effects: Antithrombin is used to treat moderately severe to severe DIC. It is an alpha 2 globulin that inactivates thrombin, plasmin, and other components responsible for coagulation.

Heparin

Therapeutic effects: Heparin augments the activity of antithrombin and prevents the conversion of fibrinogen to fibrin. It does not destroy current clots but prevents further clotting.

(Medscape, 2013) DISCHARGE CRITERIA AND COMMUNITY BASED CARE Discharge Criteria

Health care team must determine appropriate discharge setting taking into account:

Cognitive status, functional status, availability of family or companion support, ability to obtain medications, and services, transportation, availability of services in the community to assist the patient with ongoing care.

Community Based Care

Acute DIC

Teach the patient and family about specific care needs, such as foot care or dressing changes.

Provide instruction about continuing medications and follow-up care.

Chronic DIC

May require continuing heparin therapy (intermittent subcut injections or portable infusion pump)

Teach patient and family how to administer the injection or manage pump.

Provide referral to home health care or a home IV management service for assistance.

Discuss manifestations of excessive bleeding or recurrent clotting that needs to be reported to a healthcare provider.


(LeMone, et al., p1115) FLOW CHART TEST YOUR KNOWLEDGE! http://www.classtools.net/mob/quiz_11/Disseminated_Intravascular_Coagulation_wK8b8.htm APPLICATION QUESTION When comparing her 0700 assessment of a patient with chronic DIC to the 0300 assessment done on night shift, the nurse notes increased abdominal girth and hypotension. The nurse should first...

A) Hold the patient's 0900 dose of LMW heparin
B) Notify the physician *
C) Document findings in chart and continue to monitor the patient
D) Make the patient NPO
REFERENCES Budnitz, Daniel S., MD, MPH, Marybeth C. Lovegrove, MPH, Nadine Shehab, MPH, PharmD, and Chesley
L.Richards, MD,

MPH. "The New England Journal of Medicine." Emergency Hospitalizations for Adverse Drug Events in Older
Americans NEJM. N.p., 24 Nov. 2011. Web. 17 Apr. 2013.
<http://www.nejm.org/doi/full/10.1056/NEJMsa1103053>.

Challem, J. (2012). THE STINKING ROSE. Better Nutrition, 74(11), 44-46.

Dressler, D. (2004), DIC: coping with a coagulation crisis. Nursing,34(5), 58-63

Dressler, D.K. (2012). Coagulation in the Intensive Care Unit. Critical Care Nurse. 32(5), 48-60.

http://ehis.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=f76a0297-f28c-404c-bafd-
bafa681f0258%40sessionmgr114&v

id=8&hid=105

Medscape Reference. (2013). Retrieved April 16, 2013, from http://emedicine.medscape.com/article/199627
-medication#2

P, LeMone, Burke, K., & Bauldoff, G. (New Jersey). The Patient with Disseminated Intravascular Coagulation.
Medical-Surgical

Nursing Critical Thinking in Patient Care (5th ed., pp. 1112-1115). Upper Saddle River: Pearson

RxList - The Internet Drug Index for prescription drugs, medications and pill identifier. (2013). Retrieved April
16, 2013, from http://www.rxlist.com/script/main/srchcont_rxlist.asp?src=heparin&x=0&y=0

RxList - The Internet Drug Index for prescription drugs, medications and pill identifier. (2013). Retrieved April
16, 2013, from http://www.rxlist.com/thrombate-drug.htm

(2010, 17). WebMD-Better information. Better health. Disseminated Intravascular Coagulation (DIC)-Topic
Overview. Retrieved

April 15, 2013, from http://www.webmd.com/a-to-z-guides/disseminated-intravascular-coagulation-dic
-topic-overview

(2012, ). ClinicalKey. Disseminated Intravascular Coagulation . Retrieved April 16,2013, from
http://www.clinicalkey.com/topics/hematology/disseminatedintravascular-coagulation.html DIC Video Screenshot http://www.merckmanuals.com/home/blood_disorders/bleeding_and_clotting_disorders/disseminated_intravascular_coagulation_dic.html Diffuse bleeding Consumption of platelets and coagulation factors; decreased BP, bleeding, decreased Hct, Hgb, RBC’s Secondary Fibrinolysis Ischemic tissue damage Fibrin deposits in the microcirculation Systemic activation of coagulation What Causes DIC? What Causes DIC? Systemic activation of coagulation Fibrin deposits in the microcirculation Ischemic tissue damage Secondary Fibrinolysis Consumption of platelets and coagulation factors; decreased BP, bleeding, decreased Hct, Hgb, RBC’s Diffuse bleeding Treat underlying cause. Heparin, antithrombin (Dressler, 2004) HighImpactGraphics (2011). YouTube. Disseminated Intravascular Coagulation (DIC). Retrieved April 12, 2013, from (live link embeds video).
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