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

TABLE 129–3. Frequency (%) and Type of Organ Dysfunction or Other Clinical Manifestations in Case Series of Patients with
Disseminated Intravascular Coagulation
Number of Thrombo- Renal Liver Respiratory CNS Acral
Study Patients Bleeding embolism Failure Failure Failure Manifestation Shock Cyanosis *
Minna et al. 347 60 87 22 67 NR 78 65 NR 14
Al-Mondhiry 89 76 23 39 NR NR 11 NR 0
et al. 116
Siegal et al. 115 118 64 8 25 22 16 2 14 0
Matsuda et 47 87 47 40 NR 38 NR NR NR
al. 348
Spero et al. 122 346 77 NR NR NR NR NR NR NR
Larcan et al. 349 361 73 11 61 57 37 13 55 13

NR, not reported.
*Including necrotizing purpura and acral gangrene.

embolism, and heat stroke, all of which can also incite DIC. Yet only a LABORATORY FEATURES
fraction of patients with ARDS exhibit signs of DIC. When DIC and
ARDS are simultaneously triggered, each aggravates the other. Regard- AND DIAGNOSIS
less of the mechanism, ARDS is a serious complication in patients with
DIC. No single laboratory test is sensitive or specific enough to allow a def-
inite diagnosis of DIC (Table 129–5). However, some sophisticated
laboratory tests, for example, thrombin–AT complex, prothrombin frag-
MORTALITY ment 1.2, are sensitive to ongoing activation of coagulation pathways.
Both DIC and its underlying disorders contribute to the high mortality Determination of soluble fibrin in plasma is one of the best parameters
rate. Mortality correlates independently with the extent of organ dys- for detection of ongoing DIC 125–128 ; when the concentration is above a
function, the degree of hemostatic failure, and increasing age. defined threshold, a diagnosis of DIC is likely. 129,130 Most of the other
122
115
121
Mortality rates in major series of patients with DIC ranged from 31 to parameters show a sensitivity of 90 to 100 percent for the diagnosis of
86 percent, 121–124 whether or not heparin was administrated. Of note, DIC but have a rather low specificity, and a wide discordance among
131
there is a clear correlation between the severity of DIC and the mortality various assays. FDPs may be detected by specific enzyme-linked
132
rate. 121,123,124 In patients with sepsis, the presence of DIC is one of the immunosorbent assays or by latex agglutination assays, allowing rapid
strongest predictors of 28-day mortality. 124 and bedside determination. None of the available assays discriminates
133
TABLE 129–4. Organ Dysfunction Associated with Severe
Disseminated Intravascular Coagulation TABLE 129–5. Routine Laboratory Value Abnormalities in
Organ Manifestation Disseminated Intravascular Coagulation
Skin Purpura, bleeding from injury sites, Causes Other Than DIC
hemorrhagic bullae, focal necrosis, acral Contributing to Test
gangrene Test Abnormality Result
Cardiovascular Shock, acidosis, myocardial infarction, cer- Platelet count Decreased Sepsis, impaired pro-
ebrovascular events, thromboembolism in duction, major blood
all types and caliber blood vessels loss, hypersplenism
Renal Acute renal insufficiency (acute tubular Prothrombin time Prolonged Vitamin K deficiency,
necrosis), oliguria, hematuria, renal cortical liver failure, major
necrosis blood loss
Liver Hepatic failure, jaundice aPTT Prolonged Liver failure, heparin
treatment, major blood
Lungs Adult respiratory distress syndrome, loss
hypoxemia, edema, hemorrhage
Fibrin degradation Elevated Surgery, trauma, infec-
Gastrointestinal Bleeding, mucosal necrosis and ulceration, products tion, hematoma
intestinal ischemia
Protease inhibitors Decreased Liver failure, capillary
Central nervous Coma, convulsions, focal lesions, bleeding (e.g., protein C, AT, leakage
system protein S)
Adrenals Adrenal insufficiency (hemorrhagic
necrosis) aPTT, activated partial thromboplastin time, AT, antithrombin; DIC,
disseminated intravascular coagulation.

Kaushansky_chapter 129_p2199-2220.indd 2205 17/09/15 3:45 pm