6.7 DIC / Txfn Issues

Question 1

Define the pathogenesis of DIC

Answer 1

• Precipitating event (sepsis, trauma, uterine injury) leads to cytokine activity and TNF/endotoxin release
• Tissue factor activated
• Increased thrombin activity
  
  • Increased clotting activity -> ischemia, end organ damage
    
    • Clots trap platelets, leading to larger clots
    • Clotting inhibitors inactivated
    • Clotting in micro and macro vasculature leads to consumption & depletion of clotting factors and platelets
  • Increased fibrinolysis –> hemorrhage
    
    • Excess thrombin leads to excess conversion of plasminogen to plasmin –> prolonged fibrinolysis
    • Fibrin degradation/split products are anticoagulants
  • Meanwhile, clotting factors and platelets exhausted
    
    • Overstimulated fibrinolytic phase leads to excessive bleeding
    • Hemorrhagic shock
    • Increased vascular permeability exacerbated volume loss

Question 2

Your patient has DIC. How will you treat?

Answer 2

• Treat inciting event
  
  • Abx for sepsis
  • Volume resuscitation
  • Hemostasis
• Replete clotting factors and platelets
  
  • Check CBC, PT/INR, fibrinogen
  • Give platelets, FFP, cryoprecipitate
• Consider heparin gtt for inhibitation of Factor Xa and thrombin -> interupt excessive thrombin production

Question 3

When transfusing your patient, remember the following:

• PRBCs can be transfused for patients with __________, ______________, _____________, and for symptomatic patients with acute or chronic ___________ or ___________________.
• 1 unit PRBC raises hgb ____ and hct ____
• Transfuse for hgb _____ unles evidence of ________________ or _______________ for which you should transfuse at hgb of ______.

Answer 3

• PRBCs can be transfused for patients with active hemorrhage, to improve tissue perfusion and oxygen delivery, and for symptomatic patients with acute or chronic anemia or bleeding disorders.
• 1 unit PRBC raises hgb 1g/dL and hct 3%
• Transfuse for hgb 7g/dL unles evidence of coronary artery ischemia or active bleeding for which you should transfuse at hgb of 8g/dL.

Question 4

Transfuse platelets if:

• Less than ________ in patients with multi-trauma, TBI, or spontaneous ICH. Can also consider this level for higher risk surgical procedures.
• Less than ________ in patients with active bleeding
• Less than ________ in patients planning invasive/surgical procedure.
• Less than ________ for outpatients, septic patients, or minor procedures.
• Less than ________ for stable patients.
• Regardless of platelet count for patients who are _______________________________.

Answer 4

Transfuse platelets if:

• Less than 100k in patients with multi-trauma, TBI, or spontaneous ICH. Can also consider this level for higher risk surgical procedures.
• Less than 50k in patients with active bleeding
• Less than 50k in patients planning invasive/surgical procedure.
• Less than 20k for outpatients, septic patients, or minor procedures otherwise stable.
• Less than 10k for stable patients.
• Regardless of platelet count for patients who are actively bleeding with use of platelet inhibitor medications.

Question 5

• FFP is a blood component that contains:
• Txfn of FFP should be considered for:

Answer 5

• FFP is a blood component that contains:
  
  • Albumin
  • Fibrinogen
  • Factors II, VII, IX, X, and XI
• Txfn of FFP should be considered for:
  
  • Massive transfusion
  • Pts with INR > 1.6
  • Emergency reversal of warfarin (and oral ACs, but less effective)
  • Tx of DIC
  • Replacement fluid for apheresis in patients with thrombotic microangiopathies

Question 6

Cryo

• 1u cryoprecipitate is pooled from ____ units of plasma
• Cryo contains:
• Should only be used in:

Answer 6

• 1u cryoprecipitate is pooled from 10 units of plasma
• Cryo contains
  
  • vW Factor
  • Factors VIII and XIII
  • Fibrinogen by the bushel
• Should only be used in:
  
  • Low fibrinogen states
    
    • Hemorrhage
    • DIC

Question 7

What ratio of what products should your massive transfusion protocol contain

Answer 7

• 6 pRBCs : 1 plt (comes from 6u WB) : 6 FFP
  
  • 1:1:1