PREVENTION

ANEMIA Oral iron

IV iron gluconate (order set #233)

TRANSEXAMIC ACID Efficacy of IV TXA in Reducing Blood Loss

After Elective C-section: Prospective, Randomized, Double-blind, Placebo Controlled Study

660 women – 330 in each arm 1 g TXA IV over 5 minutes at least 10

minutes prior to skin incision Oxytocin given after delivery

TXA Mean blood loss less in TXA group

TXA group has less patients with >1000

ml bleeds

No increase in thrombotic events

DIC AND TRANSFUSION

DIC DIAGNOSIS Depends on the appropriate test results in the proper clinical setting

DIC ETIOLOGIES – Sepsis (up to 50%) – Obstetrical complications – Malignancy (up to 20%) – Trauma (especially brain and crush) – Severe toxins (snakes) – Immunologic reaction (incompatible blood) – Organ destruction (acute pancreatitis) – Vascular abnormalities

OB DIC Acute Hemorrhagic DIC

– Placental abruption (50%) – Eclampsia (up to 7%) – Amniotic fluid embolus (50%) – HELLP (20 to 84%) – Eclampsia – Acute fatty liver of pregnancy – Massive Hemorrhage – Septic abortion

DIC Activation of BOTH procoagulant and fibrinolytic pathways leading to thrombosis and bleeding Diverse etiologies

DIC Two PARADOXICAL clinical problems

– Tissue injury caused by disseminated microvascular thrombosis (macro too)

– Hemorrhage caused by consumption of coagulation factors and accelerated fibrinolysis

– Thrombosis AND Hemorrhage

DIC Clinical features

ACUTE

CHRONIC

DIC ACUTE

–Usually hemorrhage and thrombosis –Diffuse bleeding –Multi-organ failure –Skin necrosis

DIC Major bleeding occurs in a minority (5-

12%) of patients

More common is organ failure secondary to intravascular thrombi

DIC Placental abruption

– The degree of placental separation tends to correlate with the severity of DIC

– The leakage of thromboplastin-like material (tissue factor) from the placenta may initiate the DIC

Amniotic fluid embolism – Amniotic fluid also can initiate the DIC

DIC DIAGNOSIS Diagnosis of DIC must encompass both clinical and laboratory information that is being continually monitored by repeating both lab tests and the clinical evaluation

DIC LABS DIC Profile (Wesley Lab)

– CBC (WBC, HBG, PLATELET COUNT) – PTT – PT/INR – FIBRINOGEN – D-DIMER – FSP

ORDER TESTS EVERY 30 MINUTES

DIC LAB RESULTS WITH ACUTE DIC

– Decreased platelet count – Decreasing fibrinogen (look at trends) – Increased PT/INR – Increased PTT – Increased D-DIMER – Increased FSP

DIC LAB RESULTS WITH CHRONIC DIC

– Variable platelet count – Normal PT/INR – Normal PTT – Normal or increased fibrinogen – Increased D-DIMER – Increased FSP

DIC FSP

– Detects BOTH Fibrinolysis Fibrinogenolysis

D-DIMER – Detects Fibrinolysis Plasmin degradation crosslinked fibrin

DIC FSP and D-DIMER

–They do NOT differentiate between SYSTEMIC fibrinolysis of DIC and the LOCALIZED fibrinolysis seen with surgery and trauma

TREATMENT DIC MOST IMPORTANT Control/correct the underlying triggering pathologic disease

TREATMENT DIC SUPPORTIVE CARE

– VOLUME EXPANSION TO CORRECT HYPOTENSION

– BLOOD PRODUCTS ONLY IF BLEEDING OR HIGH RISK FOR BLEEDING

– MBT

TREATMENT DIC BLOOD PRODUCTS

– ONLY IF BLEEDING OR HIGH RISK FOR

BLEEDING (e.g. going to surgery)

– ONLY IF COAGULATION LABS ABNORMAL

– REPEAT COAG TESTS EVERY 30 MINUTES

TREATMENT DIC IF BLEEDING

– YELLOW blood can be life saving with severe hemorrhage If platelets less than 50,000, then transfuse

platelets One plateletpheresis pack = therapeutic dose Transfuse as quickly as possible Keep at room temperature (do NOT put on ice)

TREATMENT DIC IF BLEEDING

– YELLOW blood can be life saving with severe hemorrhage If INR greater than or equal to 2 , then transfuse

Fresh Frozen Plasma (FFP) Therapeutic dose = 15 to 30 ml per kg (3-6 units) FFP must be thawed first (30 minutes) Transfuse as quickly as possible Blood warmer can be used Can be stored on ice in cooler

TREATMENT DIC IF BLEEDING

YELLOW blood can be life saving with severe hemorrhage

If fibrinogen less than 200, then transfuse cryo

Therapeutic dose = 10 – 20 units cryoprecipitate Cryoprecipitate must be thawed first Individual units that need to be pooled (30 minute) Prepooled 5 unit packs (15 minutes) Transfuse as quickly as possible Do not put cryoprecipitate on ice or in refrigerator

TREATMENT DIC IF BLEEDING

-- RED blood can be life saving with severe hemorrhage

-- RED blood used to keep hemoglobin greater than at least 7 (some say 8 to 10)

-- Transfuse as quickly as possible (after first 15 minutes)

-- Blood warmer can be used -- Blood can be stored on ice in cooler

TREATMENT DIC BLOOD PRODUCT USAGE IF BLEEDING

– YELLOW blood can be life saving with severe hemorrhage

If fibrinogen less than 200…transfuse cryo

If platelets less than 50,000…transfuse platelets If INR greater than or equal to 2 ...transfuse FFP

– RED blood used to keep hemoglobin greater than 7 at least (some say 8 to 10)

TREATMENT DIC REMEMBER

– IF BLEEDING IS ONLY MILD, THEN DO NOT TRANSFUSE JUST BECAUSE THE LABS ARE ABNORMAL

– BLOOD PRODUCTS JUST BUY YOU TIME TO TREAT THE UNDERLYING PROBLEM

– ONLY TRANSFUSE IF SIGNIFICANT BLEEDING OR INVASIVE PROCEDURE WITH RISK OF SIGNIFICANT BLEEDING

DIC Important to stress that DIC is NOT a

disease in itself

DIC is ALWAYS secondary to an underlying disorder that activates the coagulation and fibrinolytic systems

TREAT THE UNDERLYING PROCESS FIRST

TREATMENT DIC If bleeding is uncontrollable Then order MASSIVE BLOOD TRANSFUSION (MBT) PROTOCOL