Transcript induced DIC Coagulopathies in the Critical Care Setting Differential

Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC,
Education Specialist
LRM Consulting
Nashville, TN
CNRN, CEN, NP
Objectives
 Identify the most likely type of
coagulopathy with regards to INR,
aPTT, platelet numbers and function.
 Discuss the four causes of
thrombocytopenia.
 Describe the priorities in the
management of patients with life –
threatening coagulopathies.
Admission Screening
• identify defects in hemostasis
that can be corrected
• guide the management of
hemostatic defects that cannot
be corrected
• help manage the bleeding that
cannot be prevented
Preoperative Screening
• History & Physical
unlikely congenital or familial
coagulopathy
– no personal or family history of
bleeding
– no abnormal bleeding associated
with:
• dental extractions
• previous surgery
• routine childhood trauma
Preoperative Screening
• CBC
–  Hgb/Hct
–  platelets
• PT/PTT
• Bleeding Time
Admission Screening
• Assessment of Coagulopathy
–
–
–
–
CBC with coagulation studies
check for and correct hypothermia
review the history
review medications
Symptom
INR
aPTT
Platelet #
Platelet
Function
History Diagnosis
Major/minor
bleeding
N
N

N
Massive
transfusion;
fluids
Dilutional
thrombocytopenia
Major/minor
bleeding
N
Prolonged
N
N
negative
Drug induced heparin
Major/minor
bleeding

N
N
n/a
Vitamin K
deficiency
Liver disease,
warfarin,
antibiotics
Major
bleeding
prolonged
prolonged

N
DIC
Postoperative Bleeding
• Vascular integrity
disruption
– reoperation
Medical Causes of Bleeding
• residual heparin effect
• platelet consumption (CPB)
• preoperative platelet inactivation
Protamine Reactions
• Type I
– benign reaction
– Histamine release  systemic
hypotension
– administer protamine slowly
Protamine Reactions
• Type II
– anaphylactoid reaction
– occurs within 10 to 20
minutes of administration
– symptoms
•
•
•
•
hypotension
flushing
edema
bronchospasm
Protamine Reactions
• Type III
– catastrophic pulmonary
vasoconstriction
• elevated pulmonary pressures
• cardiopulmonary collapse
• noncardiogenic pulmonary edema
– reaction occurs between 10
to 20 minutes after start of
administration
Medical Causes of Bleeding
• depletion of clotting factors
• pre-existing coagulopathy
• fibrinolysis
• Thrombocytopenia
–  platelet destruction
• drug – induced
• DIC
Differential diagnosis
• A platelet count fall that begins 5 to
10 days after cardiac surgery or that
occurs abruptly after starting heparin
in a patient previously exposed to
heparin within the past 5 to 100 days,
is very suggestive of HIT.
• Thrombocytopenia
– Etiology
• abnormal distribution
or sequestration in
spleen
– portal hypertension
• Thrombocytopenia
– Etiology
• dilutional after
hemorrhage, RBC
transfusions
• Thrombocytopenia
– Diagnosis
•  hemoglobin,hematocrit,
platelets
• prolonged bleeding time,
PT, PTT
Disseminated Intravascular Coagulation
Definition
• serious bleeding
disorder
• thrombosis; then
hemorrhage
Pathophysiology
• Intrinsic Clotting
Cascade
– endothelial injury
– assessed by PTT
Pathophysiology
• Extrinsic Clotting
Cascade
– tissue thromboplastin
– assessed by PT
Etiology of DIC
• Obstetric
– abruptio placentae
– amniotic fluid
embolus
– eclampsia
Etiology of DIC
• Hemolytic/Immunologic
– anaphylaxis
– hemolytic blood reaction
– massive blood transfusion
Etiology of DIC
• Infectious
– bacterial
– fungal
– viral
– rickettsial
Etiology of DIC
• Vascular
– shock
– dissecting aneurysm
Etiology of DIC
• Miscellaneous
– Emboli (fat)
– ASA poisoning
– GI disturbances pancreatitis
•
•
•
•
•
Laboratory Findings
 platelets
 fibrinogen
 PT &/or PTT
 d - dimer or FSP
 ATIII
Management
• Treat underlying cause
– surgery
– antimicrobials
– antineoplastics
Management
• Stop Thrombosis
– IV heparin
– AT III
– plasmapheresis
Management
• Administer blood products
– pRBCs
– platelets
– FFP
– cryoprecipitate
Complications
• hypovolemic shock
• acute renal failure
• infection
• ARDS
Postoperative Bleeding
• Platelet Dysfunction
– Platelets
– FFP/cryoprecipitate
– DDAVP
Postoperative Bleeding
• Coagulation Factor
Deficiency
– FFP/cryoprecipitate
– protamine
Postoperative Bleeding
• Hyperfibrinolysis
– DDAVP
– Antifibrinolytics
• Amicar
•
•
•
•
Case Study
62 – year old male
admitted to CVICU post
bypass
complications postop
(tamponade) – stabilized
& on IABP
required CPR several
times
Case Study
• 3 days later diminished
leg circulation – IABP
removed
• pneumonia, groin
infection, renal failure
• step – down develops
sternal wound infection
Lab Values
• ABGs
pH
pO2
pCO2
HCO3
SaO2
7.26
55
52
18
84%
CV Status
BP
88/56
MAP
67
CVP
4
ECG
ST
T
39.2°C
Case Study
Hgb/Hct
8.8 / 30%
PT
38 seconds
Fibrinogen
102 mg/dL
Platelets
50,000/mm3
D – dimer
> 2500 ng/dL
FSP
80 mcg/dL
IN CONCLUSION