HEMATOLOGICAL ALTERATIONS
Disseminated Intravascular Coagulation
(DIC)
DEFINITION
• Is a coagulation disorder in which the
stimulus for coagulation overwhelms the
control mechanisms that normally confine
coagulation to the area of bleeding.
• Disseminated Intravascular Coagulation
ETIOLOGY
• Causes of disseminated intravascular coagulation
Sepsis
Especially gram-negative bacteria
Any widespread infection
Bacteria
Fungal
Protozoal
Viral
Severe tissue injury
Especially burns and head injury
Obstetric complications
Amniotic fluid embolus
Septic abortion
Retained fetus
Cancer
Acute promyelocytic leukemia
Mucinous adenocarcinomas
Major hemolytic transfusion reactions
Anaphylaxis
Hypotension or hypoxia
Shock
Cardiopulmonary arrest
Snake bites
Snake venom
Organ injury
Pancreatitis
Liver disease
PATHOPHYSIOLOGY
• In DIC, a systemic activation of the coagulation system
simultaneously leads to thrombus formation (compromising blood
supply to various organs) and exhaustion of platelets and
coagulation factors (results in hemorrhage). This is a disruption of
body homeostasis.
• Thrombosis - brief period of hypercoagulability
1. Coagulation cascade is initiated, causing widespread fibrin
formation
2. Microthrombi are deposited throughout he microcirculatory
3. Fibrin deposits result in tissue ischemia, hypoxia, necrosis
4. Leads to multi organ dysfunction
• Fibrinolysis - period of hypocoagulability (the hemorrhagic
phase)
1. Activates the complement system
2. Byproducts of fibrinolysis (fibrin/fibrin degradation products
(FDP)) further enhance bleeding by interfering with platelet
aggregation, fibrin polymerization, & thrombin activity
3. Leads to Hemorrhage
CLINICAL MANIFESTATIONS
• The clinical presentation of DIC can be either acute or chronic.
• The acute form - is associated with massive hemorrhage and
thrombosis. It is manifested by:
– oozing from venipuncture sites, arterial lines, or surgical
sites
– bleeding may also occur in the nose, gums, and sclera
or conjunctiva of the eyes
– bleeding will be accompanied by purpura, petechiae,
and hematomas
– bleeding can also occur in closed compartments of the
body
– the organ systems most commonly damaged are the
cardiovascular, pulmonary, CNS, renal, and hepatic
system
• Clinical manifestations of organ damage in DIC
Altered level of consciousness
Behavioral changes
Mental activity changes
Confusion
Seizure activity
Oliguria
Hematuria
Hypoxia
Hypotension
Coughing up blood
Chest pain
Tachycardia
• Children with acute DIC can also develop end organ failure.
• Children with chronic DIC - do not present with these overt
manifestations of hemorrhage and thrombosis because the
pathological mechanisms are partially compensated for by the
body.
– children experience mild hemorrhage and thrombosis
confined to the microcirculation
– these children may present with:
» confusion
» jaundice
» hypoxia
» oliguria (a decreased ability to form and excrete
urine)
DIAGNOSIS
Test Abnormality
Platelet count Decreased
Fibrin degradation product (FDP) Increased
Factor assay Decreased
Prothrombin time (PT)
Prolonged
Activated PTT
Prolonged
Thrombin time
Prolonged
Fibrinogen
Decreased
D-dimer
Increased
Antithrombin
Decreased
TREATMENT
• Identification and correction of the underlying cause
• Replacement therapy, provides the client with adequate amounts
of platelets, fibrinogen, and possibly coagulation factors …
‘platelet transfusion’
• Cryoprecipitate administration is effective in increasing fibrinogen
levels
• Fresh-frozen plasma can be used for replacement if liver is able to
restore coagulation factors
• The use of heparin in the treatment of DIC should be administered
in conjunction with the replacement of these coagulation
components.
NURSING MANAGEMENT
• Assessment, administration of blood products, and supportive care
• Assess for overt bleeding, manifestations of internal bleeding such as
pallor and tachycardia, and signs and symptoms of shock.
• The administration of blood products should be done in accordance with
hospital policy.
• The supportive role of the nurse focuses on the anxiety and fear likely to
be present in both the child and caregivers.
• Nursing interventions that can help calm the child and their caregivers:
– explain all procedures to the family
– allow the child to make choices about care when possible
– encourage open conversation about the situation
– offer to listen and address the family’s questions and
concerns
