DIC Year 4 Internal Medicine Notes OmpathStudy

DIC Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / IMED 4.2 / Mogere -- Slide 1 DIC Dr. Alex Mogere Consultant Physician Slide 2 DIC Defined as a clinico-pathological syndrome characterized by widespread intravascular fibrin formation in response to excessive blood protease activity that overcomes the natural anticoagulant mechanisms. There is acute /chronic types Slide 3 Acute DIC: Slide 5 Common clinical conditions associated with Disseminated Intravascular Coagulation Sepsis Trauma Head injury Fat embolism Malignancy Obstetrical complications Amniotic fluid embolism Abruptio placentae Vascular disorders Reaction to toxin (e.g. snake venom, drugs) Immunologic disorders Severe allergic reaction Transplant rejection Activation of both coagulation and fibrinolysis\nTriggered by Slide 6 Disseminated Intravascular Coagulation (DIC) Mechanism Systemic activation of coagulation Intravascular deposition of fibrin Depletion of platelets and coagulation factors Bleeding Thrombosis of small and midsize vessels with organ failure Slide 7 Pathogenesis of DIC Coagulation Fibrinolysis Fibrinogen Fibrin Monomers Fibrin Clot (intravascular) Fibrin(ogen) Degradation Products Plasmin Thrombin Plasmin Release of thromboplastic material into circulation Consumption of coagulation factors; presence of FDPs  aPTT  PT  TT  Fibrinogen Presence of plasmin  FDP Intravascular clot  Platelets Schistocytes Elevated thrombomodulin Low prot C and antithrombin Slide 9 CLINICAL FEATURES RS- Cyanosis, respiratory failure CNS – conulsions, coma Cvs- progressive cardiac failure, shock Renal- oliguria, acute renal failure Slide 10 labs Red plt and clotting factors Increased PT, aPTT Increased d-dimer, FDPs Schistocytes, burr cells, helmet cells Slide 11 complications Waterhouse-friderichsen syndrome Sheehan’s syndrome Kasabach –merit syndrome Slide 12 Disseminated Intravascular Coagulation Treatment approaches Treatment of underlying disorder Anticoagulation with heparin(IV Unfractionated heparin, s.c LMWH).Others-daparanoid sodium, recombinant hirudin, recombinant tissue factor pathway inhibitor Platelet transfusion Fresh frozen plasma Coagulation inhibitor concentrate (ATIII) Slide 13 CLASSIFICATION OF PLATELET DISORDERS Quantitative disorders Abnormal distribution Dilution effect Decreased production\nIncreased destruction Qualitative disorders Inherited disorders (rare) Acquired disorders Medications Chronic renal failure Cardiopulmonary bypass Slide 14 Thrombocytopenia Immune-mediated\nIdioapathic\nDrug-induced\nCollagen vascular disease\nLymphoproliferative disease\nSarcoidosis Non-immune mediated\nDIC\nMicroangiopathic hemolytic anemia Slide 15 LIVER DISEASE AND HEMOSTASIS Decreased synthesis of II, VII, IX, X, XI, and fibrinogen Dietary Vitamin K deficiency (Inadequate intake or malabsortion) Dysfibrinogenemia Enhanced fibrinolysis (Decreased alpha-2-antiplasmin) DIC Thrombocytopenia due to hypersplenism Slide 16 Management of Hemostatic Defects in Liver Disease Treatment for prolonged PT/PTT Vitamin K 10 mg SQ x 3 days - usually ineffective Fresh-frozen plasma infusion 25-30% of plasma volume (1200-1500 ml)\nimmediate but temporary effect Treatment for low fibrinogen Cryoprecipitate (1 unit/10kg body weight) Treatment for DIC (Elevated D-dimer, low factor VIII, thrombocytopenia Replacement therapy Slide 17 Vitamin K deficiency due to warfarin overdose Managing high INR values Clinical situation Guidelines INR therapeutic-5 Lower or omit next dose;\nResume therapy when INR is therapeutic INR 5-9; no bleeding Lower or omit next dose;\nResume therapy when INR is therapeutic \nOmit dose and give vitamin K (1-2.5 mg po) \nRapid reversal: vitamin K 2-4 mg po (repeat) INR 9; no bleeding Omit dose; vitamin K 3-5 mg po; repeat as necessary\nResume therapy at lower dose when INR therapeutic Chest 2001:119;22-38s (supplement) Slide 18 Vitamin K deficiency due to warfarin overdose Managing high INR values in bleeding patients Clinical situation Guidelines INR 20; serious bleeding Omit warfarin\nVitamin K 10 mg slow IV infusion\nFFP or PCC (depending on urgency)\nRepeat vitamin K injections every 12 hrs as needed Any life-threatening bleeding Omit warfarin\nVitamin K 10 mg slow IV infusion\nPCC ( or recombinant human factor VIIa)\nRepeat vitamin K injections every 12 hrs as needed Chest 2001:119;22-38s (supplement) Slide 19 Approach to Post-operative bleeding Is the bleeding local or due to a hemostatic failure? Local: Single site of bleeding usually rapid with minimal coagulation test abnormalities Hemostatic failure: Multiple site or unusual pattern with abnormal coagulation tests Evaluate for causes of peri-operative hemostatic failure Preexisting abnormality Special cases (e.g. Cardiopulmonary bypass) Diagnosis of hemostatic failure Review pre-operative testing Obtain updated testing Slide 20 Laboratory Evaluation of Bleeding Overview CBC and smear Platelet count Thrombocytopenia\nRBC and platelet morphology TTP, DIC