Lesson Objective for Disseminated Intravascular Coagulation (DIC)

• Understanding DIC Pathophysiology:
  • Comprehend the underlying pathophysiological mechanisms of DIC, including the imbalance between coagulation and fibrinolysis.
• Identifying Risk Factors:
  • Recognize and identify the risk factors that contribute to the development of DIC, such as sepsis, trauma, or obstetric complications.
• Symptom Recognition:
  • Learn to recognize the clinical manifestations of DIC, including abnormal bleeding and clotting, petechiae, organ dysfunction, and laboratory abnormalities.
• Diagnostic Methods:
  • Understand the diagnostic methods used to confirm DIC, including laboratory tests such as platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and D-dimer levels.
• Intervention Strategies:
  • Gain knowledge of nursing interventions and management strategies aimed at addressing DIC, including supportive measures, monitoring, and addressing the underlying cause.

Pathophysiology of Disseminated Intravascular Coagulation (DIC)

• Triggering Event:
  • DIC often begins with an underlying trigger, such as severe sepsis, trauma, malignancy, obstetric complications, or other conditions that activate the coagulation system.
• Release of Tissue Factor:
  • The triggering event leads to the release of tissue factor, initiating the extrinsic pathway of coagulation. Tissue factor activates factor VII, setting off a cascade of coagulation reactions.
• Excessive Thrombin Generation:
  • Activation of the coagulation cascade results in an excessive generation of thrombin. Thrombin converts fibrinogen to fibrin, leading to the formation of microvascular thrombi throughout the circulation.
• Platelet Consumption:
  • The formation of microvascular thrombi consumes platelets, resulting in thrombocytopenia. Decreased platelet count contributes to the bleeding manifestations observed in DIC.
• Fibrinolysis Activation:
  • Simultaneously, the clotting process activates fibrinolysis, leading to the release of fibrin degradation products (FDPs) and D-dimers. Elevated D-dimer levels are characteristic of ongoing fibrinolysis.
• Microvascular Thrombosis and Organ Dysfunction:
  • Widespread microvascular thrombosis and deposition of fibrin in small blood vessels lead to compromised blood flow, ischemia, and organ dysfunction. The consumption of clotting factors contributes to bleeding tendencies.

Etiology of Disseminated Intravascular Coagulation (DIC)

• Sepsis:
  • DIC is commonly triggered by severe bacterial or viral infections, particularly sepsis. The release of endotoxins or exotoxins can activate the coagulation cascade.
• Trauma:
  • Major trauma, such as extensive injuries or burns, can lead to widespread tissue damage and the release of procoagulant substances, initiating DIC.
• Obstetric Complications:
  • Conditions such as abruptio placentae, amniotic fluid embolism, and severe preeclampsia can trigger DIC during pregnancy.
• Malignancy:
  • Certain cancers, especially those associated with extensive tissue necrosis or metastasis, can activate the coagulation cascade and contribute to DIC.
• Systemic Inflammatory Response Syndrome (SIRS):
  • Conditions causing a systemic inflammatory response, such as severe pancreatitis or major surgery, may lead to DIC due to the release of inflammatory mediators.
• Vascular Disorders:
  • Conditions affecting blood vessels, including vasculitis or atherosclerosis, can disrupt vascular integrity and contribute to the initiation of DIC.
• Transfusion Reactions:
  • Incompatible blood transfusions or massive blood transfusions can introduce foreign substances into the bloodstream, triggering an immune response and activating the coagulation cascade.
• Toxic Injuries:
  • Exposure to toxins or chemicals, such as snake venom or certain medications, may induce a systemic response that activates coagulation pathways, leading to DIC.

Desired Outcomes for Disseminated Intravascular Coagulation (DIC)

• Normalization of Coagulation Parameters:
  • Achieve and maintain a balance in coagulation parameters, including prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, and platelet count.
• Resolution of Underlying Cause:
  • Identify and treat the underlying cause of DIC, addressing conditions such as sepsis, trauma, obstetric complications, malignancy, or systemic inflammatory response syndrome (SIRS).
• Prevention of Organ Dysfunction:
  • Prevent or minimize organ dysfunction resulting from microvascular thrombosis and hemorrhage, focusing on organs such as the kidneys, lungs, and central nervous system.
• Maintenance of Tissue Perfusion:
  • Ensure adequate tissue perfusion by managing fluid balance, hemodynamic stability, and oxygenation to prevent ischemia and multi-organ failure.
• Minimization of Bleeding Complications:
  • Prevent and manage bleeding complications by carefully balancing anticoagulation and hemostasis, considering the risk of both thrombosis and hemorrhage in DIC patients.

Disseminated Intravascular Coagulation (DIC) Nursing Care Plan

Nursing Implementation for Disseminated Intravascular Coagulation (DIC)

• Administer Clotting Factors:
  • Provide blood products, such as fresh frozen plasma or cryoprecipitate, to replace depleted clotting factors and support hemostasis.
• Monitor Fluid Balance:
  • Implement strict intake and output monitoring to manage fluid balance. Adequate hydration helps prevent hypovolemia and supports organ perfusion.
• Administer Anticoagulants or Antiplatelet Agents:
  • Depending on the underlying cause and severity, anticoagulants or antiplatelet medications may be administered to manage excessive clotting. This requires careful assessment of bleeding risk.
• Address Underlying Cause:
  • Treat the primary cause of DIC, whether it’s sepsis, trauma, malignancy, or other triggers. Targeting the root cause is essential for resolving the coagulation abnormalities.
• Implement Bed Rest and Activity Restrictions:
  • Promote bed rest and restrict activities to minimize the risk of bleeding. Patients with DIC are prone to bleeding complications, and careful monitoring of movements is essential.
• Provide Emotional Support:
  • Offer emotional support to patients and their families, as DIC can be a critical and life-threatening condition. Discussing the condition, treatment options, and potential outcomes can help alleviate anxiety and stress.

Nursing Interventions and Rationales

• Assess and monitor respiratory status; note rate, rhythm, cyanosis; auscultate the lungs for areas of absent air movement

• Assess and monitor cardiac status;  perform 12-lead ECG as indicated

• Assess for changes in level of consciousness

• Administer oxygen as necessary; monitor Arterial Blood Gas (ABG) and oxygen saturation

• Provide wound care and pressure for external bleeding

• Assess amount and color of urine

• Monitor for blood in stool; administer stool softeners to avoid straining during bowel movements

• Monitor for hemoptysis or blood in suctioning

• Monitor diagnostic tests (labs):
  • Platelet count- decreased
  • PT / PTT- increased
  • D-dimer level- markedly increased

• Initiate bleeding precautions; no razors, soft toothbrush, limit needle sticks as much as possible, limit BP readings

• Administer medications and blood products as necessary

Evaluation of Nursing Interventions for Disseminated Intravascular Coagulation (DIC)

• Coagulation Parameters:
  • Regularly assess coagulation parameters, including PT, PTT, and platelet count, to evaluate the effectiveness of interventions in improving coagulation status.
• Hemodynamic Stability:
  • Monitor the patient’s hemodynamic status, including blood pressure, heart rate, and perfusion, to determine if interventions have contributed to hemodynamic stability.
• Organ Function:
  • Evaluate organ function through laboratory tests and clinical assessments to determine if the interventions have mitigated organ dysfunction associated with DIC.
• Bleeding Control:
  • Assess the control of bleeding episodes and signs of hemorrhage, such as petechiae and ecchymosis, to determine if interventions have effectively managed coagulation abnormalities.
• Patient Response:
  • Evaluate the overall response of the patient to the implemented nursing interventions, considering factors such as symptom improvement, decreased complications, and the patient’s overall well-being.

References

• https://emedicine.medscape.com/article/199627-treatment#d8
• https://www.nhlbi.nih.gov/health-topics/disseminated-intravascular-coagulation
• https://www.merckmanuals.com/home/blood-disorders/bleeding-due-to-clotting-disorders/disseminated-intravascular-coagulation-dic#v775325