DIC as a topic in critical care nursing 1 DIC as a topic in critical care nursing Jennifer Fiorica NURS 320 National University School of Nursing DIC as a topic in critical care nursing 2 Disseminated Intravascular Coagulation DIC or disseminated intravascular coagulation is a life-threatening bleeding and thrombolytic disorder. It is always a complication of another condition, such as massive trauma, bacterial sepsis, an obstetric emergency, or metastatic cancer. DIC consists of several components including activation of intravascular coagulation, depletion of clotting factors, and end-organ damage. (Wada & Hatada, 2008). In the normal individual who has an injury or becomes ill, specific proteins in the blood become activated and travel to the injury/illness site to help stop bleeding. In the patient with DIC, these proteins become hyperactive. The blood vessels become lined with small clots of blood. These clots can eventually clog major organs such as the kidneys and the liver and cause the organs to stop functioning. Over time, the clotting proteins are depleted faster than the bone marrow can produce them. (Stetham, 2008) As the microclots continue to form, circulating clotting factors become so depleted that a stable clot can‟t form at any injury site, and hemorrhage occurs. (See Table I) In a patient suffering from DIC, survival depends on early identification and treatment, and in treating its underlying cause. Because DIC is always secondary to an underlying disorder and is associated with a number of clinical conditions, it is imperative that nurses in critical care settings be aware of the signs and symptoms associated with DIC and know how to act quickly to save their patients‟ lives. The widespread association of DIC with multiple simultaneous conditions is one of the key elements that make it so specific to critical care nursing. DIC is life- threatening, is usually acute, and requires immediate intervention and urgent care. DIC is most commonly observed in severe sepsis and septic shock. The development and severity of DIC correlates with death in severe sepsis. (DeLoughery, 2005) Trauma, especially DIC as a topic in critical care nursing 3 neurotrauma, is also frequently associated with DIC. DIC is more frequently observed in those patients with trauma who develop the systemic inflammatory response syndrome. (Wada & Hatada, 2008) Evidence indicates that inflammatory cytokines play a central role in DIC in both trauma patients and septic patients. In fact, systemic cytokine profiles in both septic patients and trauma patients are nearly identical. (Levi, 2005) DIC is also commonly associated with obstetrical emergencies. Conditions such as amniotic fluid embolism, HELLP syndrome and severe post-partum hemorrhage can lead to DIC. In women who develop DIC through these obstetrical complications, the mortality rate is close to 50%, so it is imperative that the underlying conditions are diagnosed and treated before DIC develops. (Stetham, 2008) Research and Current Trends in Critical Care Nursing related to DIC While it is known that DIC (once called consumption coagulopathy) is both a bleeding and thrombotic disorder, and that it is always a complication of another condition, the specific markers of an impending DIC catastrophe have lacked definition. The goal of research over the last decade has been to qualify and correlate events that contribute to the onset of DIC, and provide direction in its prevention, diagnosis and treatment. Marcel Levi writing in The British Journal of Hematology describes this problem and calls attention to the fact that “less than 1% of the articles report on clinical studies that may be helpful in guiding the clinician to proper „evidenced-based‟ management strategies in patients with DIC.”(Levi, 2004) The purpose of Levi‟s research as described in his 2004 publication is to provide a comprehensive definition of DIC for the clinician and scientific community, and to synthesize from studies conducted on the pathogenesis, etiology, clinical descriptions and laboratory test results, a diagnostic algorithm for the clinician and researcher. DIC as a topic in critical care nursing 4 Levi approaches the problem of definition and diagnosis with a chart which shows how proper treatment is complicated by the simultaneous occurrence of thrombotic and bleeding problems. He continues by listing common clinical conditions associated with DIC. (See Table II) He again states that these conditions include bacterial infections, particularly septicemia, severe trauma, tumors and hematological malignancies, obstetrical calamities such as amniotic fluid emboli and placental abruption, as well as vascular disorders and microangiopathetic hemolytic anemia. A more recent discussion of DIC appears in Lawrence LK Leung‟s publication of October 1st 2008 (update January 8, 2008).entitled Clinical features, diagnosis, and treatment of disseminated intravascular coagulation in adults. Leung reviews the clinical manifestations, diagnosis, treatment and prognosis of DIC in extensive detail. In one study involving 118 patients with acute DIC, the main clinical manifestations included bleeding (64%), renal dysfunction (25%), hepatic dysfunction (19 %), respiratory dysfunction (16%), shock (14 %), thromboembolism (7%) and central nervous system involvement (2%). (Leung, 2008) For the practicing nurse, these clinical conditions may not follow a predictable pattern. Clearly, observation of excessive bleeding from puncture sites, surgical incisions or drainage tubes, thrombosis, or respiratory insufficiency are indicators that need to be supported by thorough laboratory tests. Following Levi and Leung‟s, research the patient needs a complete set of coagulation studies, repeated every four hours and compared to baseline values. (Levi. 2004) Table 3 compares normal lab values with typical abnormal values demonstrated by a patient with DIC. DIC as a topic in critical care nursing 5 In an important observation Leung in Pathogenesis and etiology of disseminated intravascular coagulation differentiates between acute versus chronic DIC and its implications for diagnosis. “DIC is a dynamic process and its consequences depend on its cause and the rapidity with which the initiating event is propagated. If the activation occurs slowly, an excess of procoagulants is produced, predisposing to thrombosis. At the same time, as long as the liver can compensate for the consumption of clotting factors, and the bone marrow maintains an adequate platelet count, the bleeding diathesis will not be clinically apparent. This is the picture of chronic compensated DIC; its clinical presentation consists of primarily thrombotic manifestations, which can be both venous and arterial.” (Leung, 2008) A major focus for Levi‟s research is the depression of the protein C system. Tests for protein C are not routinely performed in cases of suspected DIC. Yet, Levi‟s 2004 article, already sited above, describes a study based on the notion that low protein C concentrations may contribute to the pathophysiology of DIC. He reports, “a phase III trial of activated C concentrate in patients with sepsis was prematurely stopped because of the efficacy in reducing mortality in these patients. (as reported by Bernard et al, 2001)” Research continues in this aspect of DIC. Fourrier concludes in Recombinant human activated protein C in the treatment of severe sepsis; an evidence-based review that “Recombinant human activated protein C is recommended in patients at high risk of death…and no absolute contradiction related to bleeding risk or relative contraindication that outweighs the potential benefit.”(Fourrier, 2004) Additional research by the French scientists Dhainaut, Yan and Claessens suggests that treatment with protein C concentrate is followed by an improvement of the coagulopathy. (Dhainaut, Yan, and Claessans, 2004) While research into the use of protein C in the treatment of DIC is promising, it does not impact on current nursing practices beyond the careful monitoring of fibrinolytic system. DIC as a topic in critical care nursing 6 Treatment, Nursing Interventions, and Implications Since research shows that DIC is associated with various life-threatening conditions, the first series of interventions are aimed at basic life support including airway management, breathing and circulation. Monitor pulse oximetry and ABG‟s and provide ventilatory assistance as needed. Remembering that DIC is triggered by an avalanche in the clotting cascade and depletion of all clotting factors, the removal of those triggers gives the patient the best chance of recovery. Preventing hypovolemia and hypotension are top priorities. Prepare to administer volume replacement with I.V. fluid and blood products to restore intravascular fluid volume. An infusion of dopamine or another vasopressor may be indicated to maintain cardiac output and support organ function. Other common treatments include PRBCs, fresh frozen plasma, cryoprecipitate, and platelet concentrate. Packed red blood cells restore oxygen carrying capacity, fresh frozen plasma replaces depleted clotting factors, and cryoprecipitate is indicated when fibrinogen is severely depleted. Platelet transfusions correct thrombocytopenia from ongoing bleeding. (Dressler, 2004) In some cases, unfractionated or low-molecular weight heparin may be prescribed. Although heparin doesn‟t dissolve existing clots, it can help to break the cycle of DIC by blocking formation of new microclots. However, heparin may be contraindicated in patients who have had recent surgery or in patients with GI or CNS bleeding. Other nursing implications include monitoring the patient‟s mental status, renal function, cardiopulmonary function and skin for signs of impaired organ or tissue perfusion. Avoid unnecessary needle sticks and other procedures that could trigger bleeding, bruising or hematoma formation. Instead, draw blood from arterial and venous lines that are already in DIC as a topic in critical care nursing 7 place. Stay away from manual or automatic BP cuffs, if possible, because the pressure can cause petechiae and ecchymosis. If the patient must undergo an invasive procedure, make sure all staff members know of the potential for bleeding. Even basic care should be done with caution. Trach care, skin care, and turning should be done carefully to prevent trauma, and also provides an opportunity to assess the patient for new hematomas or wounds. During a bleeding crisis, patients and family members may experience tremendous anxiety, especially because DIC often accompanies another life-threatening disorder. When bleeding is obvious, stay calm and try to be reassuring. Explain the treatments being given to control the bleeding, and point out any good signs that may not be obvious to the patient or family, such as improving lab results. (Dressler, 2004) Conclusion DIC is a syndrome characterized by systemic intravascular activation of coagulation in the circulation, which contributes to organ failure. Simultaneously, the consumption of platelets and coagulation factors may lead to bleeding. Recent knowledge on important pathogenic mechanisms that may lead to DIC resulted in better clinical management strategies. The most important pathways are tissue factor-mediated thrombin generation, impairment of physiological anticoagulant systems, such as the antithrombin and protein C pathway, and inhibition of endogenous fibrinolysis. Being cognizant of the signs and symptoms associated with DIC in combination with a number of simple laboratory tests, can ensure an accurate diagnosis of DIC. The cornerstone of the management of DIC is the specific and vigorous treatment of the underlying disorder. In addition, strategies that interfere with the coagulation system, such as activated protein C, were found to be beneficial in experimental and clinical studies. Nursing DIC as a topic in critical care nursing 8 interventions that reduce injury and further trauma to the patient can prevent the proliferation of DIC. New research in the diagnosis, management, prevention and treatment of DIC has greatly increased the survival rate of patients faced with a coagulation crisis. DIC as a topic in critical care nursing 9 Table I (Levi, 2004) DIC as a topic in critical care nursing 10 Table II (Levi, 2004) DIC as a topic in critical care nursing 11 Table III (Levi, 2004) ( Dressler, 2004) Test Normal Results DIC results PT or INR 12 sec (INR 1.0) Prolonged Activated PTT <33 sec Prolonged Platelet Count 150,000-400,000/mm3 Reduced Plasma fibrinogen 150-400 mg/dl Reduced Plasma fibrin degradation <10 mcg.ml Elevated products D-dimer test <200 ng/ml Elevated Factor V assay 50-150% Reduced Antithrombin 80-120% Decreased DIC as a topic in critical care nursing 12 References . Backhouse, R. (2004). Understanding Disseminated Intravascular Coagulation. Nursing Times, 100(36), 38-42. DeLoughery, T. G. (2005). Critical care clotting catastrophes. Critical Care Clinician, 21(3), 531-62. Dhainaut, J; Yan. (2004). Protein C/activated protein C pathway: overview of clinical trial results in severe sepsis. Critical Care Medicine, 32(5), 194-201. Diseases and Conditions: Disseminated Intravascular Coagulation. (2008). Retrieved January 22, 2009, from http://clineguide.ovid.com/clinicalresource/re/nursingAdvisor Dressler, D. (2004). Nursing2004. DIC; Coping with a Coagulation Crisis, 34(5), 58-62. Fourrier, F. (2004). Recombinant human activated protein C in the treatment of severe sepsis: an evidence-based review. Critical Care Medicine, 32(11), 534-541. Leung, L. (2008). Clinical features, diagnosis, and treatment of disseminated intravascular coagulation in adults (P. Mannucci, Ed.). Retrieved February 1, 2009, from www.uptodate.com Web site: http://uptodate.com/online/content/ topic.do?topicKey=coagulation Levi, M. (2005). Disseminated intravascular coagulation: What's new? Critical Care Clinician, 21(3), 449-67. Levi, M. (2004). Current understanding of disseminated intravascular coagulation. British Journal of Hematology, 124(5), 567-576. Levi, M. (2007). Disseminated intravascular coagulation. Critical Care Medicine, 35(9), 2191- 2195. DIC as a topic in critical care nursing 13 Stetham, S. (2008). Medical Encyclopedia: disseminated Intravascular Coagulation. Retrieved January 23, 2009, from http://www.nlm.nih.gov/medlineplus/ency/article/000573.htm Wada, H., & Hatada, T. (2008). Pathophysiology and Diagnostic Criteria for Disseminated Intravascular Coagulation Associated with Sepsis. Critical Care Medicine, 36(1), 348- 349.