DIC - is general pathological nonspecific process, the occurrence of which is due to entering into the general circulation stimulants coagulative properties of the blood and stimulating platelet aggregation, in which conditions are createdfor increased education thrombin formation of blood clots, a plurality of small size, impeding blood circulation.
In connection with intensive blood clotting, leading to the lower level of the main coagulative factors stemming from the rise of consumption, there are thrombocytopenia, activation of fibrinolysis and development of severe hemorrhagic syndrome.
DIC refers to the category of a serious condition requiring immediate intervention, as indicators of global statistics related deaths are within 60-65%.
Causes of DIC
DIC should be considered as comorbidities, occurring against the background of other diseases.DIC develops in the following pathological processes:
- infectious complications with concomitant sepsis therapeutic abortion, birth
- traumatization of the vascular walls and parenchyma of various organs during surgery on parenchymatous organs, as well as when performing vascular prosthesis;
- shock of hemorrhagic, traumatic, cardiogenic, septic and anaphylactic nature;
- various pathologies in obstetrics and gynecology, which should include amniotic fluid embolism, hand manual removal of the placenta, placenta previa and its premature detachment, operational delivery methods;
- lesions of blood (erythremia, multiple myeloma);
- malignant tumors localized in the lungs, pancreas, and prostate;
- hemolysis, caused by thermal and chemical burns;
- caused acute haemolysis in the lumen of the vessel;
- diseases associated with autoimmune disorders (hemorrhagic vasculitis, glomerulonephritis, systemic lupus erythematosus);
- the use of drugs that can increase the thrombogenic properties of blood, as well as conducting a massive blood transfusion;
- prolonged use of drugs that enhance the ability of platelet aggregation of cells and increase blood clotting;
- toxic damage of the organism occurs during penetration into the bloodstream of snake venom.
Despite the diversity of etiological factors that can provoke the development of DIC, the most frequent cause of this disease is a generalized septicemia.
Symptoms of DIC
form of clinical manifestations of DIC is primarily dependent on the disease against which developed this pathology.
Acute DIC almost immediately seen the development of signs of shock due to violation of all components of hemostasis.
Chronic DIC is characterized by a gradual increase in the clinical picture, due to small hemorrhages with signs of hypovolemia, degenerative lesions of all organs and severe violation of the metabolic processes in the body.
course particularly acute DIC is the presence of short-term phase hypercoagulable and sustainable progressive hypocoagulation accompanied by bleeding disorders.Such pathogenesis of DIC is more common in patients with generalized sepsis syndrome compression of long, toxic and cardiogenic shock.
clinical manifestations in acute DIC depends on the timeliness of medical assistance and the selection of the correct tactics of treatment of the patient as well as on the degree of central hemodynamics.
With insufficient patient deriving from the state of shock, accompanied by severe hypotension, increased trauma bodies during the operational benefits, insufficient correction of hypovolemic condition and replace the transfusion of whole blood preserved in large volumes, the conditions not only for appearance but also for the progression of DICsyndrome.
Patients with destructive forms of lung disease, degenerative changes in the liver and pancreas, are prone to intermittent stream DIC with an abrupt change of periods of improvement and deterioration of the patient.
severity of the patient with DIC largely due to the development hemocoagulation shock and occur when the blood flow at the microcirculatory level and total development of tissue hypoxia.Manifestation hemocoagulation shock syndrome is indicative of complete violation of central hemodynamics and symptoms of acute liver and kidney failure.Hemocoagulation shock is very difficult to treat and in most cases ends with a detailed outcome.
In the absence of timely diagnosis and medication events happening burdening the patient's condition due to hemorrhagic manifestations.During hypocoagulation phase, hemorrhagic syndrome manifests the appearance of multiple sources of heavy bleeding.
local type of hemorrhagic manifestations result from damage and destructive changes in the internal organs, while provoking factor generalized hemorrhagic syndrome is a shift in the functioning of the hemostatic system.Local bleeding of varying intensity may occur during a surgical intervention on the internal organs, and in obstetrics as uterine bleeding.In this regard, treatment of DIC in this case would be not only to conduct adequate hemostatic therapy, but also events that eliminate the cause of bleeding (e.g., toning the uterus or local endoscopic treatment of acute bleeding ulcer).
hemorrhagic syndrome, generalized type is accompanied by 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 the cough with bloody sputum abundant.In severe cases of DIC holds propotevanie blood in the pericardium, abdominal and chest cavity.
Where the hemorrhagic syndrome manifests itself sharply and is accompanied by massive bleeding, the conditions for the development of acute hemorrhagic shock, requiring the application of urgent remedial measures.In chronic type DIC bleeding is minimal, but it marked a permanent character, so over time the patient has formed signs of chronic post-hemorrhagic anemia requiring replacement therapy with blood transfusions.
In connection with the pathogenetic mechanisms of DIC, is a violation of the circulation of blood through the microvasculature in almost all organs of the patient, so he begin to appear clinical symptoms that characterize the dysfunction of a particular organ or the whole system.
most heavily tolerated by patients with DIC respiratory dysfunction caused by the entry of large number of fibrin proteolysis microclots and products in small pulmonary venous network.This condition is manifested as the appearance of the patient's pulmonary signs of circulatory failure (shortness of breath until apnea, acrocyanosis, frothy sputum excretion of the oral and nasal cavity).The appearance of the above symptoms requires immediate termination transfusion therapy, which is used in the treatment of DIC, due to the fact that the addition of solutions containing albumin and sodium aggravate the course of pulmonary edema.The appearance of signs of "shock lung" translated requires immediate patient on a ventilator and destination diuretics.
Very often when DIC is affected kidney filtration function, and therefore, developing a clinical symptom of acute renal failure (the contents of a large amount of protein and red blood cells in the urine, and the violation of its allocation until the complete absence).In some cases, when DIC occurs in patients suffering from severe liver damage, created the conditions for the development of signs of renal failure, accompanied by acute pain upper half of the abdomen and jaundice.
Due to the fact that DIC in a large percentage of cases need to apply massive hormonal therapy with high doses of corticosteroids, patients often lesion of the digestive tract in the form of large numbers of foci of hemorrhages and source of bleeding in the stomach and the initial parts ofsmall intestine.Violation of the functions of all parts of the intestine is not uncommon in the DIC, so patients have signs of severe intoxication syndrome.
As a result, the formation of foci in violation of the microcirculation in the brain there are signs of both focal and cerebral nature (headache, with no clear localization, frequent episodes of dizziness, varying degrees of impaired consciousness, meningeal signs).
DIC, which occurs in septic shock and, accompanied by the formation of thrombotic masses in the lumen of the vessel is not large caliber feeding adrenal and pituitary glands.This condition is accompanied by severe electrolyte disturbances, dehydration and prolonged collapse, that is formed by a typical clinical symptoms of adrenal insufficiency.
The division of clinical and laboratory stages of development of DIC is important because each period has its own peculiarities of the pathogenesis and related features necessary therapeutic interventions.
initial stage of a hypercoagulable due to severe intravascular platelet aggregation and activation of the kallikrein-kinin system, and manifests itself in the form of numerous small blood clots form in the lumen of the vessel is not large caliber different shapes.This stage is poorly tolerated by patients, as accompanied by the development of symptoms of shock, in some cases, has been fatal.
next stage of DIC is called "thrombocytopenia consumption", since in this period there is a significant reduction of platelet cells, due to their increased aggregation.At this stage, it marked a partial lysis of intravascular microclots, due to activation of phagocytic cells of the vascular wall endothelial membrane and leukocytes.
stage fibrinolytic DIC accompanied by a full restoration of microcirculation, but there are negative effects of activation of fibrinolysis, consisting in damage circulating blood coagulation factors and fibrinogen.
Last, reconstructive stage DIC is characterized by necrotic and degenerative lesions in various tissues.A favorable outcome of this stage is considered to be a full restoration of the structure and function of the tissue, and in the absence of the full amount of medication events, triggered by the development of symptoms of multiple organ failure.
DIC during pregnancy
hemostatic disorders are considered to be frequent during severe pregnancy and various gynecological diseases.DIC in obstetrics is a leading cause of death due to the development of massive bleeding and thrombosis.DIC can occur not only during pregnancy, but in the early postpartum period in mothers and newborn child.
In obstetrics secrete several forms of progression of DIC from lightning fatalities, creeping up from the prolonged absence of a violation of hemostasis.Chronic type DIC is more common in pregnant women with extragenital pathology of chronic cardiovascular and urinary systems.Provocateurs of acute DIC is the loss of large amounts of blood observed in massive uterine bleeding.
In gynecology DIC develops against the background of infectious and inflammatory processes that occur in such pathologies as embolic loss of amniotic fluid, the early detachment of the placenta, endometritis, and generalized sepsis.
in hypercoagulable phase, the duration of which is not more than 2-3 days, there is a moderately severe common flushing of the skin, acrocyanosis, sinus tachycardia.Hypocoagulation phase without signs of thrombolysis is characterized by increased uterine bleeding and the appearance of the nose bleeding, the appearance of hemorrhage and petechial rash in the area of the front of the chest wall and hips.During hypocoagulation phase with thrombolysis observed multiple sources of bleeding of different intensity, accompanied by the outpouring incoagulable blood.
as signs of DIC can occur in pregnant women, even against the background of well-being, to the standard algorithm for the study included pregnant laboratory analysis of "coagulation", which allows to recognize the hemostatic disorders and eliminate their medication and medical methods.Frequency studies coagulation parameters in the normal course of pregnancy is 1 every three months, and the recognition of changes in its main indicators is the justification for the hospitalization of a pregnant woman to the hospital.
risk for the emergence of signs of DIC are children in the neonatal period and the share of this pathology accounts for at least 15%.Unlike adults, children are suffering DIC caused by severe intrauterine infection and viral infection of the body.In addition, the occurrence of violations of provocateurs in the hemostatic system can be a long period of hypothermia, severe intrauterine fetal hypoxia, as well as expressed acidotic state.
etiopathogenetical With all types of DIC, which occur in childhood, the trigger occurrence of violations in the hemostatic system is cardiovascular shock, resulting in progressive damage to the vascular endothelium and the release of the blood factors activation of platelet aggregation.
in the pathogenesis of DIC in children decided to allocate the following processes:
- a large amount of thrombin or so-called "proteolytic explosion";
- total damaging effect on the vascular wall endotoxins;
- hypercoagulable period due to the stimulation of both internal and external pathways of the coagulation process;
- a huge number of simultaneous formation of fibrin thrombi in the lumen of small caliber vessels and changes in blood rheology;
- multiple organ failure, provoked by the total tissue hypoxia;
- coagulopathy and thrombocytopenia;
- violation of the primary and secondary hemostasis, due to abnormal fibrinolysis.
development of clinical manifestations depends on what stage of development is the pathophysiological process of disorders of hemostasis.
So, for hypercoagulable phase is characterized by expression of specific symptoms of DIC, and to a greater extent due to the manifestation of clinical symptoms of the disease which appeared to the root cause of this complication.