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2204 Part XII: Hemostasis and Thrombosis Chapter 129: Disseminated Intravascular Coagulation 2205

TABLE 129–1. Clinical Conditions That May Be SHOCK
Complicated By Disseminated Intravascular Coagulation Both the diseases underlying DIC and the DIC itself can cause shock.
For example, septicemia and excessive blood loss because of trauma
Infectious diseases
or obstetric complications by themselves can cause shock. Whatever
Purpura fulminans the cause of shock, its advent in cases with DIC is a serious adverse
Malignancy event.
Solid tumors
Leukemias RENAL DYSFUNCTION
Trauma Renal cortical ischemia induced by microthrombosis of afferent glomer-
ular arterioles and acute tubular necrosis related to hypotension are the
Brain injury
major causes of renal dysfunction in DIC. Oliguria, anuria, azotemia,
Burns and hematuria were observed in 25 to 67 percent of cases in all series
Liver diseases (see Table 129–3).
Heat stroke
Severe allergic/toxic reactions LIVER DYSFUNCTION
Snake bites Hepatocellular dysfunction sufficient to cause jaundice has been
reported in 20 to 50 percent of patients with DIC. 4,115 Infectious diseases
Vascular abnormalities/Hemangiomas and prolonged hypotension contribute to hepatic dysfunction.
Kasabach-Merritt syndrome
Other vascular malformations CENTRAL NERVOUS SYSTEM DYSFUNCTION
Aortic aneurysms Microthrombi, macrothrombi, emboli, and hemorrhage in the cerebral
Severe immunologic reactions (e.g., transfusion reaction) vasculature all have been held responsible for the nonspecific neurologic
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symptoms and signs displayed by patients with DIC. These manifes-
Obstetrical conditions
tations include coma, delirium, transient focal neurologic symptoms,
Abruptio placentae and signs of meningeal irritation. Careful exclusion of causes other than
Amniotic fluid embolism DIC is essential.
Preeclampsia/eclampsia
HELLP (hemolysis, elevated liver enzymes, and low platelet PULMONARY DYSFUNCTION
count) syndrome Symptoms and signs of respiratory dysfunction in DIC range from tran-
Sepsis during pregnancy sient hypoxemia in mild cases to pulmonary hemorrhage and ARDS in
severe cases. 117–119 Pulmonary hemorrhage is heralded by hemoptysis,
Acute fatty liver
dyspnea, and chest pain. Physical examination reveals rales, wheezing,
and occasionally a pleural friction rub. Chest imaging shows diffuse
infiltration resulting from excessive intraalveolar hemorrhage. ARDS
THROMBOSIS AND THROMBOEMBOLISM is characterized by tachypnea, auscultatory silence, hypoxemia, low
Extensive organ dysfunction can result from microvascular thrombi lung compliance, normal wedge pressure, and “white lungs” on chest
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or from venous and/or arterial thromboembolism (Table 129–4). For images. It stems from severe damage to the pulmonary vascular endo-
example, involvement of the skin can cause hemorrhagic bullae, acral thelium, which permits egress of blood components into the pulmonary
necrosis, and gangrene. Thrombosis of major veins and arteries and pul- interstitium and alveoli. This situation leads to intraalveolar hyaline
monary embolism occur but are rare. Cerebral embolism can compli- membrane formation and severe respiratory insufficiency. ARDS can
cate nonbacterial thrombotic endocarditis in patients with chronic DIC. be caused by septic shock, severe trauma, fat embolism, amniotic fluid

TABLE 129–2. Relative Frequency (%) of Major Underlying Diseases in Case Series of Patients with Disseminated
Intravascular Coagulation
Number of Infectious Trauma and Malignant Obstetric Miscellaneous
Study Patients Disease Major Surgery Disease Liver Disease Complications Diseases
Minna et al. 347 60 41 30 2 5 2 20
Siegal et al. 115 118 40 24 7 4 4 21
Spero et al. 122 346 26 19 24 8 0 23
Matsuda 503 15 2 61 6 4 12
et al. 348
Kobayash et 345 16 — 55 4 5 20
al. 139
Larcan et al. 349 361 15 14 6 3 38 24

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