abc of critical care in dic

ABC OF Critical Care in DIC

Dr.jyoti agarwal

D - DEATH

I - IS

C - COMING DIC is an important contributor to maternal mortality and morbidity

What is DIC ?• DIC is a massive activation of

the coagulation system leading to multiple clot formation throughout the body.

• As a result there is rapid consumption of clotting factors which leads to bleeding.

• So it is a paradoxical condition characterised by both thrombosis & haemorrhage.

• DIC is a red flag for a severe underlying disease

• DIC is never a primary diagnosis• It is always a secondary diagnosis

INTRINSIC PATHWAY EXTRINSIC PATHWAY XII XIIa VIIa XIa

IXa Ca VIIIa

Xa (COMMON PATHWAY)

Prothrombin Thrombin Plasmin Fibrinogen Fibrin D-dimer Plasmin FDPs

Coagulation is always the initial event

A delicate balance exists between coagulation mechanism & fibrinolytic system.

TRIGGER MECHANISMS OF DIC DURING PREGNANCY

Pre- eclampsia• Hypovolaemia• Septicaemia • Large foetomaternal

bleed• Incompatible blood

transfusion

• Abruptio placentae• Amniotic fluid

embolism• Retained dead foetus• Intrauterine sepsis• H. mole• Placenta accreta• Abortion induced by

hypertonic fluids.

CLINICAL MANIFESTATIONS• Bleeding from multiple sites ( most common ) ( either oozing or frank bleeding)• Renal dysfunction • Hepatic dysfunction • Respiratory dysfunction • Shock and death

Diagonosis of DIC

• No single test diagnoses DIC• Clinical picture leads to diagnosis of

DIC

Bed side Tests• Clot Observation Test (CT)- if a firm clot

forms within 10 mins it is unlikely that pt has DIC and that fibrinogen levels are normal.

• Clot Retraction Time-if the clot retracts well by end of one hour it means the platelets are adequate

• An unstable or fragile clot indicates presence of FDPs in blood.

Lab parameters usually associated with DIC are

Thrombocytopenia Develops due to activation of clotting

system and consumption by clot formation Sensitive but not specific

Fibrinogen degradation products and D- Dimer

• It is the most sensitive test for DIC. (85-100%)• It is unlikely to be DIC if FDP’s levels are normal.• FDPs are metabolized in liver and kidney.• Hepatic or renal dysfunction may lead to falsely

elevated levels of FDPs

PT & PTT• PTT measures intrinsic pathway• PT measures extrinsic pathway

• PT and PTT prolonged in 50-60% of DIC cases

Can use PT and PTT to monitor DIC

Fibrinogen• Classically use to diagnose and

monitor DIC.• Most cases not very helpful.• Sensitivity of a low fibrinogen level for

the diagnosis of DIC is only 28%

Fibrinogen• Fibrinogen is an acute-phase reactant so

may be falsely normal in DIC.• Hypofibrinogenemia is detected only in very

severe cases of DIC.• The blood fibrinogen level of 100mgm/100ml

is considered to be the critical level

Schistocytes (Fragmented RBCs)

•Fragmented red blood cells rarely constitute >10% of the red cells.•Neither sensitive nor specific to DIC.

Antithrombin & Protein C• Antithrombin and protein C are often

reduced in DIC.• Have shown to have both diagnostic and

prognostic significance .

DIC Scoring System

International Society for thrombosis and Haemostasis ( ISTH )

5 step diagnostic algorithm

Sensitivity 91% Specificity 97%

ISTH Scoring System Prerequisite

Does the patient have an underlying disorder known to be associated with overt DIC ?

NO

Do NOT use this algorithm.

YES

Coagulation Tests• Prothrombin time• Platelet count• Fibrinogen levels• Fibrin related marker (FDPs, D-dimer)

Score Test Results

Prothrombin Time

<3 sec = 0>3 but <6 sec = 1>6 sec = 2

Platelet Count> 100,000 /cumm = 0 50-100,000 /cumm = 1< 50,000 /cumm = 2

Fibrinogen Level

•> 1 g / l = 0•< 1 g / l = 1

Fibrin Marker (e.g. D-dimer, FDPs)

• No increase = 0• Moderate increase = 2• Strong increase = 3

Calculate score

• > or = to 5 compatible with overt DIC

• < 5 suggestive for non - overt DIC

PROTOCOL OF MANAGEMENT• Maintenance of blood pressure and oxygenation

• Maintenance of blood volume (crystalloids, albumin, plasma expanders).

• Blood Component therapy

• Treatment of underlying etiology of DIC

• Management of blood volume includes prompt & adequate fluid replacement to prevent

renal shutdown.

• Crystalloids (Ringer lactate) / Haemaccel• Colloids XWhatever fluid is used, it only acts as a stop gap

until suitable blood component therapy is available

Blood component therapy

• Fresh frozen plasma• Cryoprecipitate• Platelets• Packed red blood cells

Packed red blood cells• Are most effective to improve oxygen carrying

capacity• Each unit contains about 300 ml ( 250 ml RBC &

50 ml plasma)• One unit of PRBC raises the Hb by 1 gm/dl and

PCV by 3 %.

Platelet concentrates• Platelets should be given rapidly over 10 mins.• One unit raises the count between 5000 –

10,000/ ml.• Dose is = one unit / 10 kg.• single donor concentrates are preferred as the

antigenic risk is low.• Platelets count can be assessed 10 – 60 mins

after transfusion.

Fresh Frozen Plasma (FFP)• Provides both volume & coagulation factor

replacement.• One unit of FFP (250 ml) raises fibrinogen by 5 – 10 mgm /dl.• Dose 10 – 15 ml/ kg or one bag / 10 kg

Cryoprecipitate• It is rich in fibrinogen so its use is indicated if blood

fibrinogen levels are < 1 gm / L.• One unit increases the fibrinogen level by 5- 10

mg/dl.• Dose is 1 unit/ 5 kg.• No. of bags required is =0.2 x body weight in kg.

The main therapeutic goal is to maintain

• Hb > 8 gm / L• Platelet count > 75 ,000 / cumm• Prothrombin time < 1.5 times the normal• Activated prothrombin time < 1.5 • Fibrinogen > 1.0 gm / L

Treatment of the underlying condition

PLACENTAL ABRUPTION--

• The severity of DIC is directly related to time interval between the placental separation and delivery

• Management thus includes emptying the uterus as soon as possible

PRE ECLAMPSIA- ECCLAMPSIA SYNDROME

• Majority of women with pre-ecclampsia have sub-clinical consumptive coagulopathy.

• Frank DIC is seen when there is associated placental abruption or HELLP syndrome.

Immediate delivery is recommended

AMNIOTIC FLUID EMBOLISM• Carries high maternal mortality (80%)• Treatment is mainly supportive as there is no

proven effective therapy.• Heparin may be considered (80-100 units /kg s/c 4-6 hly )

INTRAUTERINE FETAL DEMISE

• Goal: to raise fibrinogen level to 200-300 mg/dL before termination of pregnancy.

• Heparin may be considered for chronic DIC associated with IUD

SEPSIS

• Intensive antibiotic therapy followed by evacuation of uterine contents.

• Prompt restoration and maintenance of circulation.

• Removal of septic focus

To concludeThe only proven treatment of DIC

Stop the triggering process .

CRITICAL CARE

CAN MAKE A GREAT DIFFERENCE

ALERT MIND !

TIMELY INTERVENTION !

AGGRESSIVE MANAGEMENT !

THANK YOU

Normal values of blood coagulation profile

Prothrombin time(11-16s)-Extr.pathway

• PTT-(30-45s) –Intrinsic pathway

• Thrombin time (TT) 10-15s

• S. Fibrinogen- (300-600mg%)

• Platelets (1.5-3.0L)

• D-dimer (<0.5mg/L) 0-200mgm/ml

Fibrin degradation products (10µ/dl) 0-5 microgm/ml