DIC syndrome refers to the most frequent and most severe, life-threatening disorders of the hemostatic system (hemostasis is a complex of body reactions aimed at preventing and stopping bleeding).
Synonyms of DIC – thrombohemorrhagic syndrome, consumption coagulopathy, hypercoagulable syndrome, defibrination syndrome.
DIC (disseminated intravascular coagulation syndrome) is:
- secondary pathological process that occurs during continuous and long-term stimulation of the hemostatic system;
- a pathological process having a phase course, with initial activation and subsequent deep progressive depletion of all parts of the hemostasis system, up to a complete loss of the ability of the blood to clot with the development of catastrophic uncontrolled bleeding and severe generalized hemorrhagic syndrome;
- pathological process, in which there is a progressive disseminated intravascular coagulation of blood with multiple and ubiquitous formation of blood microclusters and aggregates of its formed elements, which impairs its rheological characteristics, blocks microcirculation in tissues and organs, causes ischemic damage in them and leads to polyorgan lesions.
Depending on the intensity of the formation and entry into the blood of thromboplastin , which is formed during the destruction of cells, including blood cells, DIC has various clinical forms:
- lightning fast;
The starting factors of DIC-syndrome can be a variety of intensive or long-term stimuli that somehow fit into the Virchow triad – impaired blood circulation, its properties, or the vascular wall.
DIC syndrome occurs:
1. In violation of the rheological characteristics of blood and hemodynamics
- any kind of shock
- blood loss
- rhesus conflict pregnancy
- circulatory arrest and subsequent resuscitation,
- gestosis ,
- uterine atony,
- placenta previa,
- uterus massage
2. Upon contact of blood with damaged cells and tissues.
- fetal fetal death,
- oncological diseases
3. When changing the properties of the blood and with the massive flow of thromboplastic substances into the blood
- embolism amniotic fluid
- incompatible blood transfusion
- septic abortion
- detachment of a normally located placenta with hemorrhage into the uterus,
- increment of the placenta
- uterine rupture,
- surgeries on parenchymatous organs: uterus, liver, lungs, prostate, kidneys;
- acute radiation sickness
- crush syndrome,
- organ transplantation, chemotherapy, pancreatic necrosis, myocardial infarction, etc.).
During ICE, 4 stages are distinguished:
Stage 1 – the phase of hypercoagulation and platelet hypergeneration ;
Stage 2 – transitional phase (multidirectional shifts in blood clotting in the direction of hyper – and in the direction of hypocoagulation );
Stage 3 – Phase deep hypocoagulation (blood does not clot at all);
Stage 4 – resolving phase (either hemostasis normalizes, or complications develop, leading to death).
Symptoms of DIC-syndrome depends on many factors (the reasons that caused it, shock clinics, disorders of all hemostasis, thrombosis, reduced volume of the vascular bed, bleeding, anemia, impaired function and dystrophy of target organs, metabolic disorders).
In the first phase, increased blood clotting, the immediate formation of clots in large vessels and blood clots in small (during surgery). It is impossible to take blood from a patient for analysis, as it immediately collapses. As a rule, the first phase proceeds very quickly and goes unnoticed by doctors. There is a sharp decrease in blood pressure, the skin is pale, covered with cold sticky sweat, the pulse is weak (filiform). Then respiratory failure develops due to lung damage, moist cough and crepitus in the lungs, skin cyanosis, cold feet and hands.
In the second phase, the same symptoms remain as in the first stage of DIC, plus kidneys (renal failure), adrenal glands, digestive tract (nausea, vomiting, abdominal pain, diarrhea) are involved in the process . Mikrotromby (headache, dizziness, convulsions, loss of consciousness up to coma, paresis and paralysis, strokes) are formed in the brain.
The third phase ( hypocoagulation stage ) is characterized by massive bleeding, both from the initial focus and from other organs (intestinal and gastric bleeding due to ulceration of the mucous membrane, blood in the urine – kidney damage, sputum mixed with blood during coughing).
Also characterized by the development of hemorrhagic syndrome (the appearance of massive hemorrhages, hematomas, petechiae, unstoppable bleeding at injection sites and during surgery, bleeding gums, bleeding from the nose, etc.).
The fourth phase with timely and adequate treatment leads to the restoration of hemostasis and stop bleeding, but often ends in death with a massive lesion of the internal organs and bleeding.
Basic laboratory tests:
- determination of platelets (with DIC syndrome there is a decrease in platelets in phases 2, 3 and 4);
- blood clotting time (the norm is 5–9 minutes, in 1 stage the index is shortened, and in the subsequent stages – lengthening of time);
- bleeding time (normal 1 – 3 minutes);
- APTTV (activated partial thromboplastic time – an increase in 2 and 3 phases of DIC);
- prothrombin time, thrombin time, determination of activated plasma recalcification time – ABP (increase during the second and third stage DIC syndrome);
- lysis of the clot (normally not, in phase 3 lysis is fast, and in phase 4 a clot is not formed);
- fibrinogen (norm 2 – 4 g / l, decreases in 2, 3 and 4 stages);
- study of the phenomenon of erythrocyte fragmentation due to damage by fibrin threads (normally, a negative test, a positive test indicates DIC);
- decline red blood cells (anemia, decreased blood volume);
- decrease in hematocrit ( hypovolemia );
- determination of acid-base and electrolyte balance.
Therapy of DIC-syndrome is performed by a doctor who is confronted with this pathology (that is, by the attending physician), together with the resuscitator. In the chronic course of DIC, therapist with a hematologist deals with its treatment.
The first step is to eliminate the cause of DIC. For example, in sepsis, antibacterial and transuphysial (intravenous infusion of blood products) therapy is prescribed; traumatic shock – adequate anesthesia, immobilization, oxygenation and early surgical intervention. Or with tumor diseases – chemotherapy and radiotherapy, with myocardial infarction – relief of pain, recovery of heart rhythm and hemodynamics, with obstetric and gynecological pathology radical measures (extirpation of the uterus, cesarean section).
Hemodynamic and rheological properties of blood are restored by infusion-transfusion infusions.
An injection of fresh frozen plasma, which not only restores the volume of circulating blood, but also contains all clotting factors, is shown.
Also, crystalloid (physical solution, glucose) and colloidal solutions ( polyglucin, reopolyglucin ) in the ratio of 4/1 and protein blood preparations (albumin, protein) are introduced.
A direct acting anticoagulant, heparin, is prescribed. The dose of heparin depends on the stage of DIC syndrome (it is significant in phases 1 to 2). With significant anemia, fresh (no more than 3 days) red cell mass is poured.
In the treatment of severe generalized DIC, fibrinogen and concentrates of blood coagulation factors ( cryoprecipitate ) are used. Use iginbitory proteolysis – antiprotease to suppress tissue proteases that are released during cell damage (contrycal, trasilol, gordoks). Corticosteroids (hydrocortisone, dexamethasone ) are also prescribed , as they increase blood clotting.
In parallel, the fight against polyorgan insufficiency (support functions of the lungs, kidneys, gastrointestinal tract, adrenal glands). In 2 – 4 phases of DIC-syndrome, a mixture of aminocaproic acid, dry thrombin, etamzilat sodium and adroxone is used to restore local hemostasis . This mixture is introduced into the abdominal cavity through the drainage, orally, in the form of tampons into the uterus and vagina, and wipes moistened with a solution of a napkin are applied to the wound.
The whole process of intensive therapy takes 1 to 5 days (depending on the severity of DIC syndrome), and subsequent treatment continues until full or almost complete recovery of all multiorgan disorders.
The main complications of DIC-syndrome include:
- hemocoagulation shock (critical drop in blood pressure, disorders of the respiratory and cardiac systems, etc.);
- post-hemorrhagic anemia;
The prognosis depends on the severity, course and stage of DIC. In stages 1 and 2, the prognosis is favorable, in stage 3 it is doubtful, in 4 (with inadequate or missing treatment) lethal.