Disseminated Intravascular Coagulation
Patient Presentation:
A 62 year-old male R.S. presents to the emergency department with influenza-like symptoms, shortness of breath, cough with yellow mucous production, fever, fatigue, weakness, and chest pain with coughing for the past 5 days. Patient denies any nausea, vomiting, or diarrhea at this time. R.S. did state he had an upper respiratory cold just before the onset of all these more severe symptoms. Patient has a history of smoking cigarettes for 20 years, hypertension, and high cholesterol. R.S’s Vitals were Temp: 38.5, BP: 110/58, HR 109, O2 Sat 86% on 3L O2. R.S’s WBC count was elevated (20,000) and his ABG was pH 7.25, PaCO2 50, Bicarb 24 which provided evidence of respiratory acidosis. Chest X-ray revealed bilateral lung consolidates in bilateral bases. R.S. progressively dropped his oxygen saturations and was placed on BiPAP®. R.S. was diagnosis with pneumonia, started on antibiotics, and sent to the MICU for further evaluation.
Throughout R.S’s MICU stay he progressively declined. Patient went into respiratory distress two days after admission and was intubated. A central line was placed. Antibiotics were evaluated. Subcutaneous heparin was given prophylactically to prevent thrombus formation. R.S. later dropped his BP, was started on a vasopressor medication, and his ventilator settings were increased. Arterial line was placed for blood draws. Labs sent: blood cultures, urine culture, ABG (showed metabolic acidosis), bronchial brush, and lactate were sent. Patient at this time was diagnosed with sepsis (bacteria septicemia).
As the patient was fighting the sepsis infection, the bedside nurse noticed the patient coughing up large amounts of think frothy bright blood in his endotracheal tube on day six of admission. The patient was also oozing blood from his central line and arterial line puncture sites. Increase ecchymosis was noted on extremities. Patient was placed on BiVent via ventilator to further help oxygenation. Urine output was 10-20 ml an hour. Labs were sent to look for bleeding cause.
Differential List:
Severe Septic Shock, HIT, ITP, DIC, Coagulopathy (Acquired platelet function defects), Bone Marrow dysfunction
Labs results & Diagnosis:
CBC, CMP, ABG, Lactate, Coags/DIC panel, including fibrinogen
Significant lab results: Hbg 6.8 HCT 22.0, WBC count 24,000, ABG pH 7.1, PaCO2 36, Bicarb 15, lactate 2.2, elevated D-dimer 3ug/ml, Platelet count 12,000, PT/INR 5.0, PTT 70 sec, Decreased Fibrinogen level and elevated D-dimer.
Patient was diagnosed with disseminated intravascular coagulation (DIC).
Treatment:
The only effective treatment would be to treat the underlying cause, in this case the sepsis from the pneumonia, and prevent multisystem organ failure by maintaining hemodynamics. Platelets and FFP transfusions may be given if massive bleeding is occurring and platelets fall less than 10,000. Transfusion with blood products as well as heparin is controversial because of their affects. At times transfusion of antithrombin may be vital.
Outcome:
In R.S.’s case the prognosis was not looking good. Over a three day period of time the patient continued to get worse. R.S.’s kidneys started to shut down and he continued to show signs of bleeding and sepsis. The patient was on three different vasopressor drips Neosynephrine®, norepinephrine, and vasopressin for hemodynamic support. The patient was volume resuscitated a few times and platelets and FFP products were given. The patient also remained on high BiVent ventilator settings for oxygenation requirements. Hemoialysis was refused per patient’s sister to whom was assigned the Health Care Surrogate.
A family meeting was held on day eight of hospitalization. MDs discussed how critically ill R.S. was with the family and discussed withdrawing of medical treatment and progression to palliative care. The family decided that they did not want to see their brother suffering and decided to go ahead and withdraw treatments. R.S. died that night from multisystem organ failure shortly after withdrawal of medical treatments.
Case created by Randi Shupp, 2012.