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The main triggers for DIC are sepsis, trauma, cancer, shock, abruptio placenta, toxins, and allergic reactions. Accelerated clotting starts due to the activation of prothrombin and a consequent excess of thrombin. Excess thrombin converts fibrinogen to fibrin, producing fibrin clots in the vascular system. This process consumes exorbitant amounts of coagulation factors causing thrombocytopenia, deficiencies in clotting factors, hypoprothrombinemia, and hypofibrinogenemia. Circulating thrombin activates the process to lyse fibrin clots into fibrinogen degradation products (FDPs). This can cause excessive bleeding to occur due mainly to the depletion of coagulation factors and platelets (Lippincott Advisor).

References
Lippincott Advisor. Retrieved October 10, 2020, from https://advisor-edu.lww.com/lna/document.do?bid=4

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Disseminated Intravascular Coagulation (DIC) for Nursing Students

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Clotting phase manifestations:

Clotting within the CNS can present as:

Headache

Weakness

Seizures

Coma

Clotting with in the renal system can present as:

poor urine output

renal failure

Respiratory and Cardiovascular clots result in:

Pulmonary Emboli and Myocardial infarction which can present as:

cough

SOB

Respiratory distress

Chest pain

Once all the clotting factors are used up then the Hemorrhagic stage occurs which presents as:

Ecchymosis

Hematomas

Hemoptysis

Hematuria

Melena

Pallor

Confusion

Anxiety

Petechiae

Epistaxis

hypotension

Manifestations start at 2 minutes 2 seconds.

References:

Haws, J. (Director). (2015, October 2). DIC (Disseminated Intravascular Coagulation) NCLEX review [Video file]. Retrieved October 10, 2020, from https://youtu.be/np6aiDcrU2Y Gamel-McCormick, S. (2010). DIC. Retrieved October 10, 2020, from https://youtu.be/87uBWZmZGWk

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DIC (Disseminated Intravascular Coagulation) NCLEX® Review

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Uses and contains

Whole blood- volume replacement; increase oxygen carrying capacity. Contains cells and plasma (hematocrit about 40%).

PRBCs (packed red blood cells)- increase RBC mass. Contains RBCs, little plasma, some platelets,, and WBCs (hematocrit about 75%).

Platelets- bleeding due to severely decreased platelets. Contains platelets, plasma, some RBCs, and WBCs.

FFP (fresh frozen plasma)- bleeding in pt with coagulation factor deficiencies; plasmaphoresis. Contains plasma and all coagulation factors.

WBCs-

1. Granulocytes- severe neutropenia. Contains neutrophils.

2. Lymphocytes- stimulate graft vs host disease effect. Contains lymphocytes.

Cryoprecipitate- von Willebrand disease; hypofibrinogenemia; hemophilia A. Contains fibrinogen, AHF (antihemophilic factor), von Willebrand factor fibronectin.

Albumin- hypoproteinemia; burns; increase blood volume. Contains albumin.

Clotting factors-

1. AHF- hemophilia A. Contains factor VIII.

2. Factor IX concentrate- hemophilia B. Contains factor IX.

3. Factor IX complex- hereditary factor VII, IX, X deficiencies; hemophilia A. Contains factors II, VII, IX, and X.

References-
Cheever, J.L.H.K. H. (2017). Lippincott’s CoursePoint for Hinkle & Cheever: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. [CoursePoint]. Retrieved from https://coursepoint.vitalsource.com/#/books/9781496379054/

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Pre-Transfusion Assessment

·       Hx of previous transfusions

·       # of pregnancies (increased chances of antibodies)

·       Other health concerns; cardiac, pulmonary and vascular diseases

·       Baseline vital signs

·       Auscultation of lung sounds

·       Look for signs of edema and JVD (fluid overload a concern)

·       Assess the skin for petechiae and ecchymosis (to determine if they appeared before or after transfusion)

Ideally, the nurse will use an 18 gauge needle for transfusing blood. However, if this is not possible than a 22 gauge may be used (This will prolong infusion time and increase risk of blood clotting). When initiating a transfusion, the nurse MUST remain with the patient for the first 15 mins as this is the time frame that a reaction could most likely occur.

The nurse will then assess the patient's vital signs

·       Every 15 mins 2x

·       Then every 30 mins 2x

·       Followed by once an hour until transfusion is finished

The transfusion should not last longer than 4 hrs as blood can easily become contaminated with bacteria. Tubing for the transfusion should be changed every other unit of blood.

Potential complications the nurse should be aware of when giving blood include:

·       Bacterial contamination of blood

·       Possibility of diseases from donor blood

·       Allergic reactions

·       Hemolytic immune reactions to blood products

·       Circulatory overload

·       Acute lung injury from transfusion

·       Delayed reactions

·       Complications of long-term infusions

Porth, Carol. (2004). Essentials of pathophysiology : concepts of altered health states. Philadelphia :Lippincott Williams & Wilkins,

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Identify Risks Associated with a Blood Transfusion

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Identify Risks Associated with a Blood Transfusion

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Allergic Transfusion Reaction

·         Results from a sensitivity reaction to a component of the transfused blood products.

·         Findings are usually mild and include itching, urticaria, and flushing.

·         The client can develop an anaphylactic transfusion reaction resulting in bronchospasm, laryngeal edema, hypotension, and shock.

·         Occurs during or up to 24 hours after transfusion.

Bacterial Transfusion Reaction

·         Results from a transfusion of contaminated blood products.

·         Findings include wheezing, dyspnea, chest tightness, cyanosis, hypotension, and shock.

·         Can occur during or up to several hours after transfusion.

Circulatory Overload

·         Results from a transfusion rate that is too rapid for the client.

·         Older adult clients or those who have a preexisting increased circulatory volume are at an increased risk.

·         Findings include crackles, dyspnea, cough, anxiety, jugular vein distention, and tachycardia.

·         Manifestations can progress to pulmonary edema.

Iron Overload

·         Patient may accumulate too much iron after multiple blood transfusions.

Hemolysis

·         Low-level mismatch that leads to rapid destruction of the red blood cells.

References

Blood and Blood Product Transfusions. (2019). In RN adult medical surgical nursing: Review module (11.0 ed., p. 261). Assessment Technologies Institute.

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Identify Risks Associated with a Blood Transfusion

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Identify Risks Associated with a Blood Transfusion

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Bejar, R., & O’Connell, C. (2020, October 08). Are blood transfusions safe? Are there risks? Retrieved October 09, 2020, from https://www.youandmds.com/en-mds/view/m601-e607-are-blood-transfusions-safe-are-there-risks-expert-video

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MDS experts, Dr Rafael Bejar and Dr Casey O'Connell discuss the safety of blood transfusions for MDS-related anemia. They explain that blood transfusions are generally very safe because the donor blood is carefully tested for any potential disease. The main concern that doctors have is the risk that a patient may accumulate too much iron in the blood (" iron overload ") after multiple blood transfusions. They also talk about other risks that are extremely rare, including allergic reactions to donor blood, or low-level mismatch that reduces the effectiveness of the red blood cells being given.

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Are blood transfusions safe? Are there risks?

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MDS experts, Dr Rafael Bejar and Dr Casey O'Connell discuss the safety of blood transfusions for MDS-related anemia. They explain that blood transfusions are generally very safe because the donor blood is carefully tested for any potential disease.

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Describe How DIC Compromises the Function of Two Organs

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Describe How DIC Compromises the Function of Two Organs

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There are two major organs that are particularly affected from Disseminated Intravascular Coagulation. The first of those being the brain. The body is basically working against itself trying to maintain homeostasis. With the excessive clotting factors and platelets being used faster than what can be produced there is a chance for multiple bleeding sites. In return this causes a decrease in blood flow, more specifically oxygenated blood to the brain and other organs. Lack of oxygenated blood will cause confusion and changes in mental status. Necrosis of the brain tissue will occur if the bleeding is not controlled and oxygenation is not restored, rather quickly.  A person may also experience a stroke due to the micro thrombi, limited blood flow or a brain bleed. As with the brain, the lungs can experience Acute Respiratory Distress Syndrome or ARDS. The lungs are not receiving enough oxygen due to blood flow, SOB, wheezing or fluid on the lungs. The lungs can not fully expand and result in low oxygen levels in the blood which is sent to the other organs of the body, at which this causes Multi Organ Dysfunction Syndrome (MODS). Like the brain, depending on the amount of micro thrombi in the blood, a pulmonary embolism can occur.

References

Wolters Kluwer. (2020). Diseases and conditions. Retrieved from Lippincott Advisor for                    Education: http://advisor-edu.lww.com/lna/home.do

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No single laboratory test is sensitive or specific enough to diagnose DIC definitively. Still, it can be diagnosed using multiple clinical and laboratory tests that reflect the pathophysiology of the syndrome. Laboratory studies that assist in the diagnosis include: Decreased fibrinogen and platelets, Prolonged PT and aPTT Positive D-dimer tests, and fibrin (split) degradation products (objective evidence of the simultaneous formation of thrombin and plasmin) (Martina, 2010) (Carman, 10/1/2016, p. 702)

This video greatly explains what is DIC. It talks about labs @401-450

References                                         Carman, S. K.  (2016). Lippincott CoursePoint for Ricci, Kyle & Carman: Essentials of Maternity, Newborn and Women's Health Nursing,  3rd Edition. [[VitalSource Bookshelf version]].  Retrieved from vbk://9781469898162

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Disseminated intravascular coagulation - causes, symptoms, diagnosis, treatment, pathology

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General

Treatment of the underlying condition

Possibly supportive care alone if the patient isn't actively bleeding

Venous thromboembolism (VTE) prophylaxis while the patient is hospitalized

Diet

Dietary changes as needed, based on causative factors and complications

Activity

Activity, as tolerated

Safety precautions to decrease chance of injury and bleeding

Medications

Replacement therapy with administration of fresh frozen plasma, platelets, fibrinogen concentrates, or cryoprecipitate

Anticoagulants, such as unfractionated heparin or low-molecular-weight heparin sodium

Concentrates of coagulation inhibitors, such as recombinant activated protein C or antithrombin III

Antifibrinolytic agents such as aminocaproic acid

Broad-spectrum antibiotics for gram-negative sepsis

Analgesics for pain

Fluid replacement

Oxygen administration

References

Wolters Kluwer. (2020). Diseases and conditions. Retrieved from Lippincott Advisor for                    Education: http://advisor-edu.lww.com/lna/home.do

Great video to watch overall
Treatments start at 17:33

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The Reason for Use of Blood Products with Clotting Disorders

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The Reason for Use of Blood Products with Clotting Disorders

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Platelets are given for DIC if the platelet count is below 50,000 and if there is active bleeding, or if they are going to undergo a procedure that is a bleeding risk. The platelets help to form blood clots.

FFP is given for DIC when the clotting factors in the blood are low because FFP provides clotting factors.

After giving FFP, if the fibrinogen level is still critically low, less than 1g/l, 3 g of fibrinogen concentrate may be given.

Heparin is sometimes given early on in DIC to help prevent thrombus formation that can lead to thromboembolism, and is sometimes given for mild cases of DIC.

References

Anaesth, A. J. (2014, September/October). Disseminated intravascular coagulation. Retrieved October 11, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4260307