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Disseminated Intravascular Coagulation Prepared by Kozhabaeva M. 12-068-1 GM faculty student

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Plan Definition Laboratory methods and their description DIC scoring system Conclusion

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Disseminated Intravascular Coagulation Definition Is considered an “acquired bleeding disorder” Is not a disease entity but an event that can accompany various disease processes Is an alteration in the blood clotting mechanism:abnormal acceleration of the coagulation cascade, resulting in thrombosis

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Hemostatic Balance

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Conditions Associated With DIC Infectious/Septicemia Bacterial Gm - / Gm + Viral CMV Varicella Hepatitis Fungal Intravascular hemolysis Acute Liver Disease

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Laboratory studies used in the diagnosis and evaluation of patients with DIC need to reflect the changes in haemostatic function and keep pace with the critical nature of the condition.

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The severity and extent of DIC can change over time so laboratory testing is often performed at several intervals to monitor a person's status. Some routine tests that may be performed include: The severity and extent of DIC can change over time so laboratory testing is often performed at several intervals to monitor a person's status. Some routine tests that may be performed include: CBC (complete blood count) – includes a platelet count; in DIC, platelets are often low. Blood smears from individuals with DIC often show decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes). PT (prothrombin time) – often prolonged with DIC as coagulation factors are consumed PTT (partial thromboplastin time) – may be prolonged D-dimer – a test that detects a protein that results from clot break-down; it is often markedly elevated with DIC; if normal, then DIC is unlikely. Fibrinogen – one of the clotting factors; is low with DIC

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Platelet count is a sensitive (though not specific) sign of DIC. Thrombocytopenia is a feature in up to 98% of DIC cases with the platelet count

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Fibrin degradation products and D-dimers Detection of neo-antigens on degraded cross linked fibrin It is important to remember that many conditions other than DIC, such as trauma, recent surgery or venous thromboembolism, are associated with elevated FDPs including D-dimer. Soluble fibrin monomer (SF) measurements offer theoretical advantages in DIC in reflecting thrombin action on fibrinogen.

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Prothrombin time and activated partial thromboplastin time the PT and aPTT are normal or even shortened. The reasons for normal or shorter times are the presence of circulating activated clotting factors, such as thrombin or Xa, which can accelerate the formation of thrombin

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Fibrinogen Fibrinogen acts as an acute-phase reactant and despite ongoing consumption, plasma levels can remain well within the normal range for a long period of time.

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Blood film

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Other markers of haemostasis The natural anticoagulants antithrombin and protein C are often reduced in DIC and these have been shown to have prognostic significance

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Differential Diagnosis Severe liver failure Vitamin K deficiency Liver disease Thrombotic thrombocytopenic purpura Congenital abnormalities of fibrinogen HELLP syndrome

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The ISTH Sub-Committee of the Scientific and Standardization Committee (SSC) on DIC has recommended the use of a scoring system for overt DIC. Based on the Japanese Ministry of Health and Welfare score, which has demonstrated a close correlation between an increasing score and increasing mortality.

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Conclusion Laboratory diagnosis of DIC is based on tests that demonstrate activation of coagulation and consumption of clotting factors, coagulation inhibitors and platelets. The first-line tests should ideally be simple, and readily and rapidly available.

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Conclusion Prothrombin and activated partial thromboplastin times are prolonged. Levels of fibrinogen and clotting factors (particularly Factors II, V, VII and X) and platelet counts are reduced. A parallel reduction is observed in the levels of physiological inhibitors: antithrombin, but also protein C and protein S. Levels of fibrin-related markers are also elevated: markers of fibrin formation such as fibrin monomers and soluble fibrin complexes, markers of fibrinogenolysis (FgDP: fibrinogen degradation products), and markers of fibrinolysis (FnDP, D-dimers).

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References: Guidelines for the diagnosis and management of disseminated intravascular coagulation, British Journal of Haemotology, M. Levi, C. H. Toh, J. Thachil , H. G. Watson American Association for Clinical Chemistry: AACC, recommendations for Disseminated Intravascular Coagulation, webpage: DIC scoring system Taylor et al, 2001; Toh & Hoots, 2007,