DIC Disseminated Intravascular Coagulation

1. DIC Disseminated Intravascular Coagulation Erinn Halligan & Katie Compton

2. What is DIC? It's a paradox! • DIC is a serious bleeding and thrombotic disorder that results from abnormal accelerated clotting • clotting factors and platelets leads to severe bleeding • It is always caused by a underlying disease or condition

3. Pathophysiology of DIC tissue factor released at site of injury enhanced normal coagulation abundant intravascular thrombin fibrinogen converted to fibrin enhanced platelet aggregation widespread fibrin and platelets in capillaries and arterioles thrombosis clotting factors being overused BLEEDING!

4. Coagulation Pathway in DIC

5. Case Study Scenario • Pt D.V, 38 y.o female • diagnosed with recent ruptured appendix peritonitis • d/c after 9 hospital days with PICC line in L arm to home health care for antibiotic therapy • You are assigned to be her nurse. On your first home visit you do a full assessment and find a large ecchymotic area over her left arm • You ask D.V if she fell and hit her arm. She tells you “The nurses took my BP so many times it bruised.”

6. Case Study Progress • You examine D.V further and find a fine, non-raised, dark red rash over her trunk (petechiae). • D.V hadn't noticed the petechiae before you pointed it out. She tells you the rash doesn't itch or cause her any pain. She's never had one like it before. • Her wound is not discolored or draining. • Her abdomen is tender to palpation. • You find oozing serosanguinous fluid around her PICC insertion site.

7. Relaying Information to the Physician D.V. started having many symptoms of DIC and the nurse decided to call the physician and alert. How would you relay the information? SBAR

8. Conditions that may lead to DIC • Widespread tissue damage • trauma, burns, necrosis • OB complications • neoplasms • infection (peritonitis) • Hemolysis • drugs, toxins • transfusion reactions • uremic syndrome • acute pancreatitis • Hypotension • hypovolemic shock • Sepsis • Hypoxia and circulatory stasis • sickle cell • MI, cardiac arrest • PE, ARDS, near drowning (fresh water) • Metabolic acidosis

9. Signs and Symptoms • Integumentary: petechiae, purpura, ecchymosis, pallor, oozing blood, venipuncture site bleeding, hematoma, occult hemorrhage, cyanosis, gangrene • Respiratory: tachypnea, hemoptysis, orthopnea, decreased breath sounds, ARDS • Cardiovascular: hypotension, tachycardia • GI: hematemesis, occult bleeding/ bloody stools, abdominal distension/tenderness • Urinary: oliguria/ anuria, hematuria • Neurologic:dizziness, headache, changes in mental status, irritability, increased ICP, anxiety, stupor, coma • MSK: bone & joint pain

10. Case Study Progress • The physician orders blood to be drawn for coagulation studies & a CBC with differential. He says he would like to evaluate D.V for DIC. • Later on you go back to visit D.V to give her the antibiotic & draw her blood to bring back to the lab. She greets you at the door visibly upset. During the visit you find that D.V has... • Hematuria (D.V shows you blood in the toilet when you arrive and says she has been urinating blood for the past 2-3 hrs.) • Bloody sputum (coughing into a tissue, D.V states she has been coughing up blood) • Bloody drainage (from blood draw 6 hrs. earlier) • You notify the MD, who instructs you to call 911 and get the pt to the ED stat. You call the ED and give report to the triage nurse on duty.

11. Diagnostics = prolonged = elevated = reduced • S/S (bleeding, thrombotic) • Labs • Prothrombin time (PT) • Partial thromboplastin time (PTT) • Activated partial thromboplastin time (aPTT) • Thrombin time • Fibrinogen • Platelets • Fibrin split products (FSPs) • Factor assays (V, VII, VIII, X, XIII) • D-dimers (cross-linked fibrin fragments) • Antithrombin III (AT III) • Protein S • Protein C • Tests to dx underlying condition

12. Case Study Progress D.V's lab results are back.... • The following labs were prolonged: • PT/INR • PTT • Split fibrin products • D-dimer (especially) • The following labs were decreased • Platelets • Platelet time aggregation time • Clot retration time • Fibrinogen level • The WBC was 12.5 thou/cmm, and platelet count 46 thou/cmm. • D.V is diagnosed with DIC ·

13. Nursing Diagnosis • Ineffective peripheral tissue perfusion r/t bleeding & sluggish or diminished blood flow secondary to thrombosis • Acute pain r/t bleeding into tissues and diagnostic procedures • Decreased CO r/t fluid volume deficit • Anxiety r/t fear of the unknown, disease process, diagnostic procedures, and therapy

14. Nursing Interventions • Bleeding precautions • Avoid unnecessary needle sticks or procedures that could cause bruising & bleeding (don't take BP more than necessary) • Personal care (toothette/ soft bristled toothbrush, no shaving/ electric razor...) • Fall precautions • Psychosocial • Pt teaching • Emotional support (talking, being with, validating feelings) • Monitor/Asses VS • Skin (hematomas, ischemic changes, petechiae, purpura, ecchymosis...) • Mentail Status • Renal function (labs, urine output) • Cardiopulmonary function (assess for s/s impaired organ/ tissue perfusion- skin temp, cyanosis) ¨

15. Complications • hemorrhage • gangrene amputation • coma • acute renal failure • PE • respiratory failure • cardiac tamponade • hemothorax • stroke • shock • multiple organ failure • death

16. Case Study Progress • D.V is stabilized with O2, fluids, and blood products and medication therapy is initiated. • She is transferred to the ICU in guarded condition. • The prognosis for someone with DIC depends on treating the underlying cause- in this case, her peritoneal infection. • If we were the ICU nurse caring for D.V, how could we help her cope with this scary situation and environment?

17. Collaborative Care Erinn- Do you think we should have a separate slide for medical treatment? Like go into heparin and transfusion stuff? Or just talk about it with this slide? We don't need to focus on that stuff but it shoud be mentioned. Let's just mention it...I think we have a lot to cover already We must remember to provide appropriate care for the underlying disorder (peritonitis) while also providing care and support for D.V.'s DIC • Stabilize the patient! • Monitor platelet count • Treat the underlying condition

18. How do we treat D.V.s underlying peritoneal infection? • D.V. has secondary peritonitis because it developed after her appendix ruptured • vs. spontaneous peritonitis from an infection • Surgery will have to be done to locate the main cause of the inflammation, drain fluids, remove appendix (what's left of it) and repair any damage • D.V. will also be put on antibiotics

19. Resources Bucher, L., Camera, I. M., Dirksen, S. R., Heitkemper, M. M., & Lewis, S. L. (2011). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (8th ed.). St. Louis, MI: Mosby, Inc. Damon, B., Brant, J., Belansky, H., Friend, P., Samsonow, S., & Schaal, A. (2009). Putting evidence into practice:prevention and management of bleeding in patients with cancer. Clinical Journal of Oncology Nursing, 13(5), 573-583. doi:10.1188/09.CJON.573-583 Disseminated Intravascular Coagulation (DIC). In WebMD. Retrieved March 7, 2012, from http://www.webmd.com/a-to-z-guides/disseminated-intravascular-coagulation-dic-topic-overview Dressler, D. (2004). DIC: coping with a coagulation crisis. Nursing, 34(5), 58-63. Healthwise, Incorporated. (December 17, 2010). Huether, S. E., & McCance, K. L. (2008). Understanding Pathophysiology (4th ed.). St. Louis, MI: Mosby, Inc.Mitchell, M., Courtney, M., & Coyer, F. (2003). Understanding uncertainty and minimizing families' anxiety at the time of transfer from intensive care. Nursing & Health Sciences, 5(3), 207-217.

20. Resources Continued National Heart Lung and Blood Institute. (n.d.). What is Disseminated Intravascular Coagulation?. National Heart Lung and Blood Institute: People Health Science. Retrieved March 12, 2012, fromhttp://www.nhlbi.nih.gov/health/health-topics/topics/dic/. Papathanassoglou E. (2010). Psychological support and outcomes for ICU patients. Nursing In Critical Care, 15(3), 118-128. doi:10.1111/j.1478-5153.2009.00383.x The Merck Manual. Disseminated Intravascular Coagulation. The Merck Manual for Healthcare Professionals. Retrieved March 14, 2012, from http://www.merckmanuals.com/professional/hematology_and_oncology/ coagulation_disorders/disseminated_intravascular_coagulation_dic.html?qt=DIC&alt=sh Tschannan, D., Keenan, G., Aebersold, M., Kocan, M., Lundy, F., & Averhart, V. (2011). Implications of Nurse-Physician Relations: Report of a Successful Intervention. Nursing Economic$, 29(3), 127-135.WebMD. Disseminated Intravascular Coagulation. Healthwise, Inc. Retrieved March 15, 2012, fromhttp://www.webmd.com/a-to-z-guides/disseminated-intravascular-coagulation-dic-topic-overview