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					                       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.

				
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