DIC-syndrome is a general pathological nonspecific process, the emergence of which is caused by the introduction of coagulant properties of blood into the general bloodstream of stimulants, as well as stimulation of platelet aggregation abilities, which creates conditions for enhanced education thrombin, the formation in the blood of many clots of small sizes that impede blood circulation.
In connection with the intensive clotting of blood, leading to a lower level of the basic coagulant factors, caused by their increased consumption, thrombocytopenia , activation of fibrinolysis processes and development of severe hemorrhagic syndrome occur.
DIC-syndrome refers to the category of severe conditions that require immediate intervention, since the world statistics for lethal cases are within the range of 60-65%.
Causes of DIC Syndrome
DIC-syndrome should be regarded as a concomitant pathology that occurs against the background of other diseases. DIC-syndrome develops with the following pathological processes:
- infectious complications with concomitant septic process of medical abortion , childbirth and long catheterization of large vessels;
- traumatization of the vascular walls and parenchyma of various organs during the operative intervention on the parenchymal organs, as well as in the implementation of vascular prosthetics;
- Shock states of hemorrhagic, traumatic, cardiogenic, septic and anaphylactic nature;
- Various pathologies in obstetrics and gynecology, which include embolism by amniotic fluid, manual benefits of the placenta, placenta previa and its premature detachment, surgical methods of delivery;
- malignant neoplasms with localization in the lungs, pancreas and prostate gland;
- hemolysis caused by thermal and chemical burns;
- Acutely arose hemolysis in the lumen of the vessel;
- use of drugs that can increase the thrombogenic properties of blood, as well as carrying out massive blood transfusion;
- long-term use of drugs that increase the aggregation capacity of thrombocyte cells and increase blood coagulability;
- toxic damage to the body, which occurs when penetrating the bloodstream of snake venom.
Despite all the variety of etiological factors that can provoke the development of DIC syndrome, the most common cause of this pathology is generalized septicemia.
Symptoms of DIC syndrome
The form of clinical manifestations of DIC-syndrome primarily depends on the disease, against which this pathology developed.
Acute DVS-syndrome almost immediately manifests itself in the development of signs of a shock condition caused by violation of all links of hemostasis.
Chronic DVS-syndrome is characterized by a gradual increase in the clinical picture, due to small bleeding with signs of hypovolemia , dystrophic injuries of all organs and a profound violation of metabolic processes in the body.
A distinctive feature of the acute course of DIC syndrome is the presence of a short-term phase of hypercoagulation and stable progressive hypocoagulation, accompanied by increased bleeding. This pathogenesis of DIC syndrome is more typical for patients suffering from generalized sepsis, prolonged-pressure syndrome, toxic and cardiogenic shock .
The severity of clinical manifestations in acute DVS-syndrome directly depends on the timeliness of the provision of medication and the selection of the right tactics for treating the patient, as well as the degree of disruption of central hemodynamics.
If the patient is inadequately removed from the shock state, accompanied by severe hypotension , increased traumatization of organs during the execution of surgical benefits, insufficient correction of the hypovolemic state and replacement of the transfusion of canned whole blood in large volumes, conditions are created not only for the onset but also for the progression of the DIC syndrome.
Patients suffering from destructive forms of pulmonary pathology, dystrophic changes in the liver and pancreas, are prone to intermittent flow of DIC syndrome with a sharp change in the periods of improvement and deterioration of the patient's condition.
The severity of the condition of the patient with DIC syndrome is largely due to the development of hemocoagulation shock, which occurs when blood flow disorders at the microcirculatory level and the development of total tissue hypoxia. The manifestation of hemocoagulation shock is a symptom complex, which indicates a complete violation of central hemodynamics and symptoms of acute hepatic and renal insufficiency. Hemocoagulation shock is very hard to treat and in most cases ends in a detailed outcome.
In the absence of timely diagnosis and medication, there is an aggravation of the patient's condition, caused by hemorrhagic manifestations. During the hypocoagulation phase, hemorrhagic syndrome is manifested by the appearance of multiple abundant sources of bleeding.
Hemorrhagic manifestations of a local type arise as a result of damage and destructive changes in internal organs, while a provoking factor of the generalized hemorrhagic syndrome is a shift in the functioning of the hemostatic system. Local bleeding of varying degrees of intensity can occur when performing surgery on internal organs, as well as in obstetrics in the form of uterine bleeding. In this regard, treatment of DIC-syndrome in this case will consist not only in the conduct of adequate haemostatic therapy, but also measures that eliminate the cause of bleeding (eg, restoration of the uterine tone or local endoscopic treatment of an acute bleeding stomach ulcer).
Hemorrhagic syndrome of the generalized type is accompanied by the appearance of a large number of bruises on the skin of various shapes and sizes, foci of hemorrhage in the lungs, brain and spinal cord, uterus and adrenal glands. Patients with a common type of hemorrhagic syndrome complain of frequent episodes of nasal bleeding of varying intensity, and in some cases, coughing with abundant bloody sputum. In severe cases of DVS-syndrome, sweatings of blood into the pericardium, abdominal and pleural cavities takes place.
In the case when the hemorrhagic syndrome manifests itself sharply and is accompanied by massive bleeding, conditions are created for the development of acute posthemorrhagic shock requiring the use of urgent medical measures. In chronic type of DIC-syndrome, bleeding is minimal, but its permanent character is noted, therefore, over time, the patient develops signs of chronic post-hemorrhagic anemia requiring replacement therapy with transfusion of erythrocyte mass.
In connection with the pathogenetic mechanisms of the development of the DIC syndrome, there is a violation of blood circulation through the microcirculatory channel in almost all organs of the patient, therefore, clinical symptoms characterizing the dysfunction of a particular organ or the whole system begin to appear.
The most difficult for patients with DIC syndrome is dysfunction of the respiratory system, caused by the introduction of a large number of fibrin microclots and products of proteolysis into the small pulmonary venous network. This condition manifests itself in the appearance of signs of pulmonary circulatory insufficiency in the patient (difficulty breathing up to apnea , acrocyanosis, excretion of foamy sputum from the oral and nasal cavity). The appearance of the above symptoms requires the immediate cessation of transfusion therapy, which is used in the treatment of DIC syndrome, due to the fact that the additional administration of solutions containing albumin and sodium aggravate the course of pulmonary edema . The appearance of signs of "shock lung" requires immediate transfer of the patient to the device of artificial ventilation of the lungs and the appointment of diuretic drugs.
Very often, in the DIC syndrome, the filtration function of the kidneys is affected, in connection with which, the clinical symptom complex of acute renal failure develops (the content of large amounts of protein and erythrocytes in the urine and the violation of its secretion until complete absence). In some cases, when the DIC syndrome occurs in a patient suffering from severe liver damage, conditions are created for the development of signs of hepatic renal failure accompanied by acute pain of the upper half of the abdominal cavity and jaundice.
Due to the fact that DIC-syndrome in a large percentage of cases requires the use of massive hormone therapy with the use of large doses of corticosteroids, patients often have a lesion of the digestive tract in the form of a large number of foci of hemorrhages and sources of bleeding in the stomach and the initial parts of the small intestine . Violation of the function of all parts of the intestine is not uncommon in the DIC syndrome, so patients have signs of severe intoxication syndrome.
As a result of the formation of foci with a violation of microcirculation in the brain, there are signs of both focal and general cerebral character (headache that does not have a clear localization, frequent episodes of dizziness, varying degrees of impaired consciousness, meningeal signs).
DIC-syndrome, which occurs in a septic and shock state, is accompanied by the formation of thrombotic masses in the lumen of vessels of large caliber feeding the adrenal glands and the pituitary gland. This condition is accompanied by severe electrolyte disturbances, dehydration and protracted collapse, that is, a typical clinical symptomatology of adrenal insufficiency is formed.
Stages of DIC syndrome
The separation of clinico-laboratory stages of development of DIC syndrome is important, because each of the periods differs in its features of pathogenesis and the associated features of the necessary therapeutic measures.
The initial is the hypercoagulable stage, caused by the expressed intravascular aggregation of platelets and activation of the kallikrein-kinin system, and manifested as the formation of numerous small thrombi in the lumen of vessels not of large caliber of various shapes. This stage is difficult to tolerate by patients, as it is accompanied by the development of symptoms of a shock state, in some cases having a lethal outcome.
The next stage of the DIC syndrome is called "consumption thrombocytopenia," because during this period there is a significant decrease in the level of platelets due to their increased aggregation. At this stage, partial lysis of intravascular microclots is noted, due to the activation of phagocytosis by cells of the vascular wall endothelial membrane and leukocytes.
The fibrinolytic stage of the DIC syndrome is accompanied by a complete recovery of microcirculation, but there are also negative effects of the activation process of fibrinolysis, consisting in damage to circulating clotting factors and fibrinogen in the blood.
The last, reconstructive stage of DIC syndrome is characterized by necrotic and dystrophic lesions in various tissues. A favorable outcome of this stage is the complete restoration of the structure and function of the tissue, and in the absence of a full volume of medical measures, the development of symptoms of multi-organ failure is provoked.
DIC-Syndrome in Pregnancy
Disturbances in the system of hemostasis are considered a frequent phenomenon during the severe course of pregnancy and various gynecological diseases. DIC-syndrome in obstetrics occupies a leading position among the causes of death due to the development of massive bleeding and thrombosis . DIC-syndrome can occur not only during pregnancy, but also in the early postpartum period in the mother and the newborn child.
In obstetrics, several forms of the progression of DIC-syndrome are isolated, from the fulminant with a lethal outcome, to a slow flow with prolonged absence of signs of hemostasis disturbance. Chronic type of DIC-syndrome is more typical for pregnant women who have extragenital chronic pathology of the organs of the cardiovascular and urinary systems. Provocateur of acute DIC-syndrome is the loss of a large amount of blood, observed with massive uterine bleeding.
In gynecology DIC-syndrome develops against the background of infectious and inflammatory processes that are observed in pathologies such as embolism with amniotic fluid, early placental abruption, endometritis and generalized sepsis.
In the hypercoagulable phase, which lasts no more than 2-3 days, there is a moderately expressed widespread hyperemia of the skin, acrocyanosis, sinus tachycardia . The hypocoagulant phase without signs of thrombolysis is characterized by increased uterine bleeding and the appearance of nasal bleeding, the appearance of hemorrhages and petechial rash in the region of the anterior thoracic wall and thighs. During the hypocoagulation phase with thrombolysis, multiple sources of bleeding of various intensity are observed, accompanied by a spill of non-coagulating blood.
Since signs of DIC syndrome can occur in a pregnant woman even against the background of complete well-being, the standard algorithm for the study of pregnant women includes a laboratory analysis of the "coagulogram", which allows to recognize in time the violations in the hemostatic system and eliminate them with medication and non-medicament methods. The frequency of coagulogram examination during normal pregnancy is 1 time in three months, and the recognition of changes in its main indicators is the justification for the hospitalization of a pregnant woman in a hospital.
DIC-Syndrome in children
The risk group for the emergence of signs of DIC syndrome is children in the period of newborns and the share of this pathology accounts for not less than 15%. Unlike adults, children suffer from DIC syndrome due to severe intrauterine infection and viral damage to the body. In addition, provocateurs of disturbances in the hemostasis system can be a long period of hypothermia, severe intrauterine hypoxia of the fetus, as well as a pronounced acidotic state.
For all etiopathogenetic types of DIC syndrome that occur in childhood, the cardiac shock is the trigger mechanism for the appearance of disturbances in the hemostatic system, resulting in a progressive damage to the vascular wall endothelium and the release of platelet aggregation activation factors into the blood.
In the pathogenesis of the development of DIC syndrome in children, it is customary to distinguish the following processes:
- the formation of a large amount of thrombin or the so-called "proteolytic explosion";
- total damaging effect on the vascular wall with endotoxins;
- period of hypercoagulation due to stimulation of both internal and external ways of the coagulation process;
- the simultaneous formation of a large number of fibrin clots in the lumen of small-caliber vessels and a change in the rheological properties of the blood;
- multi-organ failure, provoked by total tissue hypoxia;
- coagulopathy and thrombocytopenia;
- violation of primary and secondary hemostasis, caused by pathological fibrinolysis.
The development of clinical manifestations depends on what pathophysiological stage of development is the process of disturbance of the hemostasis system.
Thus, for the hypercoagulant phase, the manifestation of specific symptoms of DIC syndrome is not typical and the clinical symptoms are mostly caused by the manifestation of the disease, which was the primary cause of the development of this complication. In some cases, acrocyanosis of the skin can occur, an increase in heart rate and frequency of respiratory movements, a tendency to hypotension, difficulty urinating. With an objective examination of palpation, the enlarged dimensions of the liver and spleen are determined.
In the coagulopathic phase, at which there is a marked decrease in the content of platelets in the blood, the skin becomes bluish, and a clinic of hemorrhagic shock due to bleeding from various sources develops. A frequent situation in this phase is the occurrence of hemorrhages in the brain, accompanied by deep disturbances of focal and general cerebral nature. At this stage, the risk of a fatal outcome is significantly increased, amounting to at least 50% of cases, however, with timely medical care, it is possible to achieve a favorable outcome of the disease.
In the case of an adequate volume of therapeutic measures, a recovery phase occurs, characterized by relief of bleeding symptoms and partial or complete restoration of the lost function of damaged organs.
When choosing the method of drug correction of disorders of the hemostasis system in children, it is necessary to give preference to the etiopathogenetic orientation of therapy, that is, treatment in the first place should ensure complete elimination of the underlying cause of the DIC syndrome and take into account the stage of its development.
So during the period of the hypercoagulant phase, the use of transfusion therapy is advisable, for which a solution of freshly frozen plasma is used by the method of intravenous injection with the calculation of 10ml per kg of weight in combination with a 2% solution of Pentoxifylline in a dose of 0.1 ml. Complete microcirculatory blockade is the rationale for the administration of monoamine oxidase inhibitors (intravenous administration of Dopamine in a dose of 5 μg / kg).
In the coagulopathy and thrombocytopenia phase, preparations containing the coagulation factor VIII, as well as replacement transfusion of erythroconcentrate and platelet mass, are pathogenetically substantiated. At this stage, infusion therapy is continued to replenish the required amount of fluid and subcutaneous administration of heparin at a dose of 25 U / kg every 8 hours under constant monitoring of coagulogram parameters.
The recovery period requires the use of symptomatic groups of drugs aimed at restoring the function of a particular organ. In some cases, thrombolytic therapy is used in this phase to eliminate large blood clots.
Diagnosis of ICE-syndrome
In some cases, the appearance of the first signs of DIC-syndrome allows you to correctly establish the diagnosis, because there are severe diseases, which are almost 100% of cases accompanied by a violation of hemostasis. Such pathological conditions include: shock of various etiopathogenetic nature, generalized form of sepsis, burn disease with a large area of damage, bites of poisonous snakes.
However, there are a number of diseases that impede the timely diagnosis of DIC syndrome, since they have a large number of symptoms not characteristic of hemostasis ( leukemia , systemic lupus erythematosus). In this situation, the use of a differentiated approach to the recognition of hemostasis disorders is recommended, which consists in carrying out a full range of coagulation tests. In favor of the development of DIC-syndrome in this case, the expressed thrombocytopenia, deviations of the coagulogram indices and a significant increase in the fibrinogen degradation products contained in plasma are indicated.
The first stage of diagnostic measures in case of suspected development of DIC syndrome is the implementation of a set of laboratory-instrumental methods for examining the patient directly in the ward (determination of coagulation indicators, qualitative analysis of the blood clot and calculation of prothrombin time, determination of abnormalities in the parameters of thromboelastograms, paracoagulation tests).
Subsequently this volume of diagnostic manipulations is supplemented with specific tests: anticoagulation test, percentage of fibrinogen destruction products in plasma, samples with snake venom toxins.
In order to select the most rational treatment for a patient, it is absolutely necessary to conduct a laboratory analysis of the content of antithrombin III, as well as the study of the patient's plasma for sensitivity to the effects of heparin drugs.
In no case can we evaluate each laboratory indicator separately, since there is no single specific test, on the basis of which it is possible to diagnose the DIC-syndrome with confidence. For example, pronounced thrombocytopenia, which occurs with DIC syndrome in 90% of cases, can be a sign of another pathology (systemic lupus erythematosus, autoimmune thrombocytopenia).
It is a mistake to assume that patients suffering from DIC-syndrome are subject only to studies of hemostatic parameters. Due to the fact that this pathology affects all structural units of the human body, it is recommended to apply a comprehensive approach to the examination of the patient (definition of hematocrit changes, detailed analysis of blood counts, determination of the level of hypoxemia, electrolyte level in blood, biochemical blood test).
A prolonged period of hypercoagulation and spontaneous aggregation capacity of platelets, as well as a gradual increase in the level of fibrinogen degradation products, supports the chronic course of DIC syndrome, the diagnosis of which is possible already in the terminal state of the patient. The chronic type of DIC syndrome is observed in cancer patients, as well as in severe congestive cardiovascular failure .
Chronic DVS-syndrome, which is observed in patients suffering from myeloproliferative diseases, is manifested by high blood viscosity, increased hematocrit, microcirculatory disorders in all organs with the formation of small foci of infarction.
In chronic renal failure, on the contrary, the coagulation unit of hemostasis is activated, which develops against a background of severe anemia and thrombocytopathy. Patients on chronic hemodialysis are characterized by a severe degree of DIC syndrome, due to the increased content of fibrin destruction products.
Treatment of ICE-syndrome
Treatment of patients with signs of DIC-syndrome should be dealt with by intensive care specialists in the intensive care unit under constant monitoring of clinical and laboratory changes in dynamics.
Medical measures used in the development of DIC syndrome, unfortunately, do not always have a positive effect, and therefore, the level of mortality in the acute form of this pathology is at least 30%. Etiopatogenetic therapy of DIC-syndrome consists in the application of measures aimed at combating diseases that are provocateurs of disturbance of the hemostasis system and aggravating its course.
Since the DIC syndrome is most often found in the purulent-septic state, the pathogenetically substantiated in this situation is the use of empirical antibiotic therapy for clinical indications with subsequent correction after the sensitivity analysis to a particular group of drugs. Indications for massive antimicrobial therapy include the fact of possible infection (criminal abortion, early discharge of amniotic fluid), and the presence of symptoms of intoxication syndrome (hectic type of fever, meningism, auscultatory changes in the lungs).
Simultaneously with the appointment of massive antibacterial therapy with the use of antibacterial agents of a wide spectrum, the use of antiprotein drugs at the maximum dose (300,000 U / day Intravenous drip) is recommended. Preparations of this group contribute to reducing the intoxication syndrome, as well as inhibiting the destruction of various tissues of the human body.
Due to the fact that DVS-syndrome develops against the background of a shock state of one or another nature, and can act as a provocateur of shock, an obligatory component of adequate therapy for this condition is carrying out anti-shock measures in full. Massive transfusion of saline solutions and Reopoliglyukin in a volume of at least 500 ml per day, especially in combination with the appointment of glucocorticosteroids (prednisolone in a daily dose of 80 mg) allows to significantly improve the patient's condition and prevent severe complications.
In order to improve blood circulation at the microcirculatory level, reduce thrombus formation in the lumen of blood vessels, and also inhibit platelet aggregation processes, it is advisable to assign a group of a-adrenoblocator preparations to the patient (Fentolamine 0.5% solution 1 ml intramuscularly) followed by long-term administration of complex drugs (Trental 100 mg by the method of intravenous infusion). Particularly effective are the preparations of this group with respect to the pathogenetic treatment of DIC syndrome in the conduct of active plasmapheresis and hemodialysis.
Particular attention should be paid to the desirability of prescribing heparin therapy for patients with DIC syndrome, since the use of Heparin in some cases may be accompanied by the development of bleeding due to severe thrombocytopenia, therefore, the appointment of this type of treatment requires constant monitoring of laboratory platelet levels in the blood. Absolutely inexpedient application of Heparin in a situation where there is a significant deficit of antithrombin III and a high content of proteins in the blood, which have an inhibitory effect on Heparin.
The main area of application of Heparin is finding the DIC syndrome in the hypercoagulable phase at elevated doses of 40,000 units / day, and during the transition phase at a dose of 20,000 units / day. In the hypocoagulation phase, Heparin is prescribed only for the purpose of "covering up" during massive transfusion therapy at a minimum dose of 2500 units before transfusion of blood and plasma preparations. If there is a need for a larger dose of Heparin, antiprotease preparations should be additionally prescribed. As a transfusion therapy in order to replenish the volume of circulating blood, it is not expedient to use Reopoliglyukin, which breaks the hemostasis.
The third stage of DIC syndrome is accompanied by heavy bleeding, a violation of blood coagulability, therefore, in these conditions, the use of heparin is contraindicated. Indication for emergency cancellation of Heparin is the progression of signs of a collapoid state with a sharp drop in the numbers of blood pressure, as well as an increase in thrombocytopenic syndrome.
With a combination of severe thrombocytopenia with deep hypocoagulant disorders, a short-term appointment of antiprotein drugs before the disappearance of signs of bleeding (intravenous drip infusion Kontrikala in a dose of 50,000 units / day). This group of drugs is used for long-term courses only in the case of staphylococcal infection with signs of destruction of certain organs, as they ensure the prevention of decay processes and reduce the intoxication syndrome.
In order to correct violations of the hemostasis system and ensure the recovery of the volume of circulating blood, observed in shock conditions, it is necessary to conduct adequate transfusion therapy. For this purpose, it is recommended to perform transfusion of fresh frozen plasma preparations in large volumes until the signs of DIC syndrome are completely eliminated. The positive effects of plasma preparations include not only the correction of hemostasis, but also the elimination of destructive processes in tissues, as well as the elimination of immunity disorders.
The field of application of salt solutions and albumin preparations is exclusively the hypercoagulable phase of the DIC syndrome. In addition, in some cases, a transfusion of erythrocyte mass (pronounced anemic syndrome, heavy bleeding) is necessary, until the hematocrit and erythrocyte parameters are normalized.
The chronic course of the DIC syndrome is well treatable by the plasmapheresis method, for which the patient is taken about 600 ml of plasma, followed by the replacement of freshly frozen plasma with the preparations. The conducted plasmapheresis promotes the removal of the diseased part of the immune and protein complexes, as well as activated clotting factors, from the body. Plasmapheresis has good efficacy in treating patients with DIC syndrome, against hepatic renal failure and purulent-destructive processes. A good therapeutic effect is the combination of erythrothrombocytopheresis with the appointment of Trental, Dipyridamole.
Surgical interventions for DIC syndrome are used only in the case of an established source of bleeding, for example, the local use of haemostatic drugs with the help of gastrofibroscope.