d - death i - is c - coming dic is an important contributor to maternal mortality and morbidity
TRANSCRIPT
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ABC OF Critical Care in DIC
Dr.jyoti agarwal
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D - DEATH
I - IS
C - COMING DIC is an important contributor to
maternal mortality and morbidity
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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.
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• DIC is a red flag for a severe underlying disease
• DIC is never a primary diagnosis• It is always a secondary diagnosis
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INTRINSIC PATHWAY EXTRINSIC PATHWAY XII XIIa VIIa XIa
IXa Ca VIIIa
Xa (COMMON PATHWAY)
Prothrombin Thrombin Plasmin Fibrinogen Fibrin D-dimer Plasmin FDPs
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Coagulation is always the initial event
A delicate balance exists between coagulation mechanism & fibrinolytic system.
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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.
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CLINICAL MANIFESTATIONS
• Bleeding from multiple sites ( most common )
( either oozing or frank bleeding)• Renal dysfunction • Hepatic dysfunction • Respiratory dysfunction • Shock and death
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Diagonosis of DIC
• No single test diagnoses DIC• Clinical picture leads to diagnosis of
DIC
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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.
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Lab parameters usually associated with DIC are
Thrombocytopenia
Develops due to activation of clotting system and consumption by clot formation
Sensitive but not specific
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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
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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
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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%
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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
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Schistocytes (Fragmented RBCs)
•Fragmented red blood cells rarely constitute >10% of the red cells.
•Neither sensitive nor specific to DIC.
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Antithrombin & Protein C
• Antithrombin and protein C are often reduced in DIC.
• Have shown to have both diagnostic and prognostic significance .
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DIC Scoring System
International Society for thrombosis and Haemostasis ( ISTH )
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5 step diagnostic algorithm
Sensitivity 91%
Specificity 97%
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ISTH Scoring System Prerequisite
Does the patient have an underlying disorder known to be associated with overt DIC ?
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NO
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Do NOT use this algorithm.
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YES
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Coagulation Tests
• Prothrombin time• Platelet count• Fibrinogen levels• Fibrin related marker (FDPs, D-dimer)
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Score Test Results
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Prothrombin Time
<3 sec = 0
>3 but <6 sec = 1
>6 sec = 2
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Platelet Count
> 100,000 /cumm = 0 50-100,000 /cumm = 1< 50,000 /cumm = 2
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Fibrinogen Level
•> 1 g / l = 0•< 1 g / l = 1
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Fibrin Marker (e.g. D-dimer, FDPs)
• No increase = 0• Moderate increase = 2• Strong increase = 3
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Calculate score
• > or = to 5 compatible with overt DIC
• < 5 suggestive for non - overt DIC
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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
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• 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
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Blood component therapy
• Fresh frozen plasma• Cryoprecipitate• Platelets• Packed red blood cells
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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 %.
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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.
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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
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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.
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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
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Treatment of the underlying condition
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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
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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
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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 )
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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
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SEPSIS
• Intensive antibiotic therapy followed by evacuation of uterine contents.
• Prompt restoration and maintenance of circulation.
• Removal of septic focus
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To concludeThe only proven treatment of DIC
Stop the triggering
process .
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CRITICAL CARE
CAN MAKE A GREAT DIFFERENCE
ALERT MIND !
TIMELY INTERVENTION !
AGGRESSIVE MANAGEMENT !
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THANK YOU
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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