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Course: Oncology Nursing

Topic: Nursing Management of Oncological Emergency DIC

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Module Goals

Learners will be able to:

Explain the underlying pathophysiology of Disseminated Intravascular Coagulopathy (DIC).
Describe the risk factors associated with DIC.
List the clinical manifestations (signs and symptoms) associated with DIC.
Explain the nursing assessment for DIC.
Characterize the nursing interventions and supportive care important to address this problem in a timely and effective manner.

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Disseminated Intravascular Coagulation (DIC)

A syndrome characterized by over activation of the body's normal clotting pathway causing at first many small clots to develop (hyper-coagulation) and once the clotting factors are used up, hemorrhage results. This is an oncologic emergency.

May complicate a variety of diseases, including Cancer.
Can be caused by the cancer itself or other reason (infection, liver disease, transfusion reaction, acidosis).
Thrombosis occurs due to excess fibrin which leads to the clots found in the blood.
Hemorrhage occurs due to consumption of coagulation factors and platelets.

Moake, 2020

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Disseminated Intravascular Coagulation(Pathophysiology)

NHLBI, 2019: Moake, 2020: MedlinePlus, 2020

Caused by certain infections, trauma or certain cancers.
Progresses in two stages:

Begins with excessive clotting.
Later excessive bleeding occurs as the clotting factors and platelets are depleted.

May develop “Suddenly or Slowly”.
Slowly developing DIC typically results from cancer, aneurysms, or cavernous hemangiomas.

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Disseminated intravascular coagulation (DIC) begins with excessive clotting followded by bleeding. The excessive clotting is usually stimulated by a substance that enters the blood as part of a disease (such as an infection or certain cancers) or as a complication of childbirth, retention of a dead fetus, or surgery. People who have a severe head injury or who have tissue damage caused by shock, burns, frostbite, other injuries, or even a bite by a poisonous snake are also at risk. As the clotting factors and platelets (cell fragments that circulate in the bloodstream and help blood clot) are depleted, excessive bleeding occurs.

DIC may develop

Suddenly
Slowly

Slowly developing disseminated intravascular coagulation typically results from cancer, aneurysms, or cavernous hemangiomas (collections of dilated blood vessels).

Pathophysiology:

DIC progresses through two stages:

At first, the clotting factors are overactive leading to the formation of blood clots throughout the blood vessels. Such formed blood clots can obstruct the blood flow to the tissues and organ and can damage it.
In second stage, the overactive clotting uses more platelets (responsible for normal clotting of blood) as a result, there will less platelets left inside the blood vessels and it causes bleeding (could be under the skin, nose, mouth or in the internal organs).

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Risk Factors of DIC

Infections (bacterial, viral, fungal)
Certain types of cancer (tumors, Leukemia)
Complications of childbirth (placenta abruption)
Surgery
Lifestyle or habit
Severe tissue injury (burn, frostbite or head injury)
Bite by a poisonous snake

NHLBI, 2019

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Signs and Symptoms of DIC

Moake, 2020;

MedlinePlus, 2019

Bruising (petechiae or purpura)
Bleeding (wound or invasive procedure)
Bleeding gums, nose, teeth
Blood in the stools or in urine
Chest pain, trouble breathing, and shortness of breath
Headache, Confusion, dizziness, seizures
Low blood pressure
Deep vein thrombosis (pain, redness, swelling in legs)
Unusually heavy periods

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Signs and symptoms varies with the degree of illness i.e. acute (develops quickly and presents with more severity) or chronic (presents slowly and sometimes with no signs and symptoms). DIC presentation in cancer patients can be hard to distinguish (less fulminant presentation) and can be overlooked which might lead to morbidity and mortality. It can be more gradual but chronic; systemic activation of coagulation occurs which can exhaust the platelets and coagulation factors and bleeding at the site of tumor can occurs (first clinical symptom).

DIC can occurs in two ways:�Suddenly: This type of DIC develop suddenly and may cause severe bleeding. Bleeding may occur at the site of invasive procedure like IV injections, and in major organs like brain, skin, muscles, cavities of body. Note: DIC occured in the process of childbirth becomes more uncontrollable.

Slowly: This type of DIC usually occurs in cancer patient. Deep vein thrombosis are common symptoms which later will progress to bleeding. If DVT is present, the patient presents with redness, swelling and tenderness in the area. However, sometimes there would be no any symptoms of DIC.

Signs and symptoms of DIC may include:

Bruising, which may appear easily, and often in various areas as small dots or larger patches
Bleeding at the site of wounds from surgical cuts or from placement of a needle
Bleeding from the nose, gums, or mouth, including when you brush your teeth
Blood in the stools from bleeding in the intestines or stomach. Stools may appear dark red or like tar.
Blood in the urine
Chest pain, trouble breathing, and shortness of breath
Confusion, speech changes or trouble speaking, dizziness, or seizures
Headaches
Hypotension
Deep vein thrombosis: Pain, redness, warmth, and swelling in the lower leg
Unusually heavy periods

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Complications of DIC

NHLBI, 2019

Acute Respiratory Distress Syndrome (ARDS)
Bleeding from internal organs, body cavities like: GI tract
Heart attack and strokes
Multiple organ failure
Deep vein thrombosis

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In early stage, the complications from DIC can occur from the clotting which later (advance stage) will advance to the bleeding . Hemorrhage and organ are the serious complications that can result from DIC.

It may result to the serious complications that include:

Acute Respiratory Distress Syndrome (ARDS):
Bleeding from internal organs, body cavities like: GI tract. However, bleeding may not happen in chronic DIC as clotting develops more slowly.
Heart attack: If the blood clots block or interferes the blood supply to the blood. Sometimes such clots may travel (embolus) and may result heart attack or stroke.
Multiple organ failure, if blood clots prevent oxygen from reaching your organs.
These organs can include the lungs and kidneys, followed by the brain, heart, liver, spleen, adrenal glands, pancreas, and the GI tract.
Deep vein thrombosis: which can include blood clots in the lungs, called pulmonary embolism, or in the deep veins of the legs, called deep vein thrombosis

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Diagnosis of DIC

Following test will be suggested by doctors if a person is suspected of DIC:

Blood clotting tests
Complete blood count (CBC)
Comprehensive metabolic panel (CMP)
D-dimer tests
Peripheral blood smear
Serum fibrinogen tests
Some additional tests: ADAMTS13 testing and Liver biopsy and liver function tests

NHLBI, 2019;

MedlinePlus, 2020

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The diagnosis of DIC is made based on medical history (illness, injury), physical examination (signs and symptoms) and various tests. Cause of DIC are also looked for as it does not happen own its own.

Following tests would be suggested if DIC is suspected in a patient:

Blood clotting tests: This test is done in order to know how long it takes to clot the blood and how well it clots. The test includes prothrombin time (PT) and partial thromboplastin time (PTT). If a person ahs DIC, his/her clotting time may be longer than the normal person’s clotting time.
Complete blood count (CBC) : This test is done to know the status of red blood cell, white blood cells and platelets. A person who is suffering from DIC will have low number of platelets, red blood cells or both.
Comprehensive metabolic panel (CMP) : This test is suggested to know the kidney function, liver function, level of sugar and electrolyte levels in one’s blood. If a person has DIC, that may affect the kidney and liver therefore, any abnormal level may indicate DIC.
D-dimer tests : This test is for ruling out the blood clots. The level of D-dimer may be higher if a person has DIC.
Peripheral blood smear : This test will look at the number, size, and shape of your platelets and other blood cells. The presence of damaged red blood cells may suggest DIC.
Serum fibrinogen tests : It measures the amount of fibrinogen in the blood. It is a protein that helps the blood clot. A person suffering from DIC will have low fibrinogen in the blood.

Based on the platelet count, PT, D-Dimer and fibrinogen levels, a scoring system is made to diagnose DIC. Higher score indicates a person is more likely to have DIC. Your doctor may suggest additional tests or procedures to find out whether another condition is causing your symptoms. These tests may include:

ADAMTS13 testing to check blood levels and activity of this protein, which is low in thrombotic thrombocytopenic purpura (TTP), a type of platelet disorder
Liver biopsy and liver function tests to check for cirrhosis or chronic liver disease, which may have signs and symptoms that are similar to DIC

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Treatment of DIC

Treat the symptoms
Treat the underlying cause
Medicines: Certain anticoagulants/blood thinners (heparin) may be needed - administer critical medications as prescribed by the medical team and monitor patient closely
Procedures and therapies:
Clotting factor replacement (ie. fibrinogen)
Oxygen therapy
Plasma transfusion
Platelet transfusion

NHLBI, 2019;

MedlinePlus, 2020

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Treatment for DIC depends on its severity and symptoms. The main goal of treatment is to control bleeding and clotting. Patient who presents with DIC, the underlying causes are treated (DIC may go away once the underlying cause is treated). Medicines, procedures and Therapies would be suggested for such patients.

Medicines: Certain anticoagulants/blood thinners like heparin would be given to reduce the blood clots if a person has developed DIC. It could be in tablet or in injectables. However, this medications may have possible side effects bleeding.
Procedures and therapies: There are certain procedures and therapies for th treatment of DIC. These include:
Clotting factor replacement (E.g fibrinogen) to stop bleeding.
Oxygen therapy : In DIC, clots may partially or fully block the blood to the vital organs therefore in order to allow more oxygen to reach the lungs, the heart, and the rest of the body oxygen therapies are initiated.
Plasma transfusion (contains clotting factors and prevent bleeding.
Platelet transfusion to quickly raise platelet levels to stop or prevent bleeding.

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Nursing Management of DIC

Assessment:

Assess for the cause of DIC
Monitor vital signs closely, check oxygen levels
Assess level of consciousness
Watch for hemorrhage (external or internal)
Assess IV sites, drains, wounds for bleeding
Review hemoglobin, hematocrit and platelet count
Check other critical lab values, D-dimer, PT, aPTT
Assess peripheral limbs for DVT (especially lower legs)
Assess for signs of heart attack or stroke

NHLBI,2019

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Nursing Assessment:

Watch for signs of internal bleeding (occult blood, petechiae, purpura, blood in urine)
Do neurological assessment during the start and end of each shift (Level of consciousness) confusion or change in LOC occurs with the decrease of fluid or decrease in Hb.
Assess the IV sites, drains or wounds for the presence of bleeding.
Review hemoglobin and hematocrit levels
Assess peripheral limbs for the DVT
Assess the person for the signs of heart attack or stroke:

Symptoms of heart attack include:

Mild or severe chest pain or discomfort in the center of the chest that radiates to the jaw and arms
Pressure, squeezing, fullness, heartburn, or indigestion.
Shortness of breath, nausea, vomiting, unusual tiredness

Symptoms of stroke include:

F—Face: Ask the person to smile. Does one side of the face droop?

A—Arms: Ask the person to raise both arms. Does one arm drift downward?

S—Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange?

T—Time: If you observe any of these signs

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What would the nurse do?

A 42-year-old woman has been diagnosed with colon cancer. She has completed her third dose of chemotherapy has been admitted to the unit for complaints of weakness, confusion and passing black stool for 2 days now.

She complains of having mild chest pain that radiates to her jaw. Her laboratory value (performed 2 days ago) reveals a low platelets count. On examination, she is found to be tachycardic.

What would the nurse do?

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Nursing Management of DIC

Note any hemoptysis or blood obtained during suctioning
Avoid unnecessary invasive procedures
Remove restrictive clothing
Apply firm pressure in bleeding site
Provide/encourage gentle oral care
Provide active and/or passive ROM if needed
Prevent the potential tissue trauma (secure catheter, tubes, lines)

NHLBI, 2019

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Nursing Management of DIC (continued)

Management and Interventions:

Initiate oxygen therapies
Report any abnormal findings to the treating physician
Report any anticoagulant or vitamin K use
Teach the patient and caregiver about warning signs and to return to the emergency department if bleeding recurs

NHLBI, 2019

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What would the nurse do?

A 74 year old female was brought to the ER in acute respiratory distress. While providing care, the nurse noticed hematuria, petechiae, and blood tinged secretions. A coagulation study was ordered and showed a positive d-dimer, prolonged PT and aPTT, and a platelet count of 75,000. On assessment her lung sounds were coarse and blood tinged sputum was being suctioned. She also had blood oozing from her IV sites, bruising and petechiae on all extremities, and several purple toes. after the finding, doctor ordered her one unit of red blood cells (RBC) and FFP and was administered.

What were the most significant clinical manifestations and lab values that led to DIC?
When the doctor’s diagnosed Rosy with DIC, what was the main goal of treatment and why?
Based on the pathophysiology of DIC, what are fatal complications of the disease process?

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Red Flags

Bleeding gums
Pain, redness, swelling in the limbs
Blood oozing from the tumor/wound/IV sites/drains
Blood in urine or stool

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References:

Latif. S., Thorley. A., Villeda. B. (n.d). Nursing Case Studies by and for student nurses. Chapter 24: DIC Case Studies of Rosy McBloom. Retrievd on 11 0f April 2021 from https://sncasestudies.pressbooks.com/chapter/dic-case-study-rosy-mcbloom/

MedlinePlus (2019). Medical Encyclopedia: Disseminated Intravascular Coagulation. Retrieved on 10 of April 2021 from https://medlineplus.gov/ency/article/000573.htm

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References:

Moake. J. L. (2020). Blood Disorders: Disseminated Intravascular Coagulation. Retrieved on 10 of April 2021 from https://www.merckmanuals.com/home/blood-disorders/bleeding-due-to-clotting-disorders/disseminated-intravascular-coagulation-dic

National Heart, Lungs, and Blood Institute (2019). Health Topics: Disseminated Intravascular Coagulation. Retrieved on 10th of April 2021 from https://www.nhlbi.nih.gov/health-topics/disseminated-intravascular-coagulation

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