DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

DISSEMINATED INTRAVASCULAR COAGULATION (DIC) – Etiology, Risk Factors, Types, Pathophysiology, Clinical Manifestations, Diagnostic Evaluations and Management

DIC is an acquired thrombotic and hemorrhagic syndrome characterized by abnormal activation of the clotting cascade and accelerated fibrinolysis. This result in widespread clotting in small vessels with consumption of clotting factors and platelets, so that bleeding and thrombosis occur simultaneously

ETIOLOGY

• Venomous snake bites
• Burns, trauma stimulates the changes in blood clotting process
• Small blood clots form in the blood vessels
• Inflammation, infection, or cancer (leukemia)
• Bleeding or injury
• Pancreatitis, blood transfusion reaction
• Severe hepatic failure
• Hemorrhagic skin necrosis
• Sepsis and shock
• Obstetric complications: abruptio placenta, eclampsia, preeclampsia, septic abortion
• Viral, fungal, infections
• Recent surgery or anesthesia
• Severe tissue injury (as in burns and head injury)
• Large hemangioma (a blood vessel that is not formed properly)
• Client with incomplete miscarriage

RISK FACTORS

• Blood transfusion reaction
• Cancer, especially certain types of leukemia
• Inflammation of the pancreas (pancreatitis)
• Infection in the blood, especially by bacteria or fungus
• Liver disease
• Pregnancy complications (such as placenta that is left behind after delivery)
• Recent surgery or anesthesia
• Severe tissue injury (as in burns and head injury)
• Large hemangioma (a blood vessel that is not formed properly)

TYPES

• Acute disseminated intravascular coagulation (acute DIC)
• Chronic disseminated intravascular coagulation (chronic DIC)
• Acute disseminated intravascular coagulation: acute DIC begins with clotting in the small blood vessels and quickly leads to serious bleeding
• Chronic Disseminated intravascular coagulation: chronic DIC causes blood clotting, but it usually does not lead to bleeding. Cancer is the most common cause of chronic DIC

PATHOPHYSIOLOGY

Underlying disorder —- systemic activation of coagulation —-

(1) enhanced fibrin formation —- microvascular thrombosis —- organ failure.

(2) Consumption of platelets and clotting factors —- bleeding

CLINICAL MANIFESTATIONS

• Bleeding, possibly from many sites in the body
• Blood clots
• Bruising
• Drop in blood pressure
• Coolness of extremities
• Fever, breathing difficulty
• Bloody stools
• Joint pain
• Headache, fatigue
• Gum bleeding, excess bleeding from any wound
• Nose bleeds, blood in urine, heavy menstrual bleeding
• Tachycardia
• Restlessness, dyspnea, chest pain with deep inspirations
• Altered mental status
• Gangrene

DIAGNOSTIC EVALUATION

• History: ask patient for the presence of any past history of disease. Ask him for the changes in the body and for the presence of sign and symptoms in the body
• Physical examination: in physical examination assess patient for presence of signs and symptoms. Monitor patient vital signs. Observe for bleeding from any site of body
• Laboratory tests: complete blood count, platelet count, normal value is 150,000 to 450,000/mm³. There is decrease in platelet count. A complete blood count measures the number of red blood cells, white blood cells, platelets in body. Abnormal platelet numbers may be a sign of a bleeding disorder

Pro thrombin time, normal value is 11-12.5 sec, there is a increase in prothrombin time. This test measure how long it takes blood clot to form

Thrombin time, normal value is 8-11 sec, there is increase in thrombin time

Fibrinogen normal value is 170-340 mg/dl and there is decrease in fibrinogen. Fibrinogen is a protein help in blood clot. This test measures how much fibrinogen is in body

MANAGEMENT

There is no specific treatment for DIC

The goal is to determine and treat the underlying cause of DIC

• Supportive treatments may include:

Plasma transfusions to replace blood clotting factors, coagulation factors if a large amount of bleeding is occurring

Blood thinner medicine (heparin) to prevent blood clotting if a large amount of clotting is occurring

Transfusions of platelets or fresh frozen plasma can be considered in cases of significant bleeding

Aspirin to stop blood clots, it help to thin the blood to keep blood clots from forming

DIETARY MANAGEMENT

In case of disseminated intravascular coagulation provide vitamin K. low level of vitamin K lead to increased bleeding

• Vitamin K is found in green leafy vegetables
• Provide spinach, cabbage, cauliflower, green peas, beans, soybeans to the client

PREVENTION

There is specific prevention for DIC

• Get the prompt treatment for the conditions known to bring on this disorder or results this disorder
• Eat healthy diet and take medicine properly
• Exercise regularly, it helps to maintain a healthy weight. Exercise help to keep the muscles flexible and prevent damage to muscles and joints
• Client need to rest in bed and breath through mouth if nosebleed
• Avoid playing sports such as football to prevent bleeding or bruising

NURSING MANAGEMENT

Nursing Assessment

Nurses need to be aware of patients who are at risk for DIC

• Assess the patient for bleeding from any of the site
• Nurse should assessed the patient thoroughly and frequently for the signs and symptoms of thrombi and breeding
• Nurse should assess the patient for the progression of the signs and symptoms

Nursing Diagnosis

• Risk for deficient fluid volume related to bleeding
• Risk for impaired skin integrity related to bleeding or ischemia
• Risk for injury related to bleeding due to thrombocytopenia
• Ineffective tissue perfusion related to microthrombi
• Anxiety and fear related to disease condition
• Deficient knowledge related to disease condition and treatment

1. Risk for Fluid Volume Deficient Related to Bleeding

Interventions

• Monitor vital signs closely
• Monitor urine output of the patient
• Avoid the medications that interfere with platelet count (NSAIDs)
• Avoid IM injections because it decreases the chances for intramuscular bleeding
• Monitor the external bleeding
• Avoid dislodging any clots, including those around IV sites and injection sites
• Blood components should be administered
• Provide packed red blood cells are to improve oxygen delivery by increasing the hemoglobin content of the blood
• Administer platelet transfusion when the platelet count falls below 100,000/mm³.

• Risk for impaired skin integrity related to bleeding or ischemia 

Interventions

• Assess the skin of patient
• Reposition the patient frequently
• Use pressure reducing mattress
• Perform skin care every 2 hour
• Use prolonged pressure usually 5 min after injection because platelet plug is unstable and easily dislodged leads to increased bleeding
• Provide oral care carefully
• Maintain personal hygiene

• Anxiety and fear related to disease condition

Interventions

• Identify the patient previous coping mechanisms, if possible
• Encourage patient to use that coping mechanisms in this condition
• Explain all procedures and rationale for all procedures to patient
• Assist the family in supporting patient
• Explain about the causes and treatment of the disease to the patient
• Provide psychological support to the patient
• Advice to take medications at right time

HEALTH EDUCATION

• When a bleeding disorder occurs in addition to another condition, the patient’s and significant others coping skills and resiliency may be at a low point
• During this time, the patient and significant others need accurate information, honest reports about the patient’s condition and prognosis, and an attentive nurse to listen to their concerns
• Provide emotional support and educate them as to the interventions and expected outcomes
• Help them understand the severity of the condition and the treatments; do not present false hopes
• The patient is usually maintained on complete bed rest
• Pad the side rails to help prevent injury. Reposition the patient every 2 hours, and provide skin care. Gently touch the skin when repositioning and bathing; vigorous rubbing could dislodge a clot and initiate fresh bleeding