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Download induced DIC Coagulopathies in the Critical Care Setting Differential
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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
