DIC: Sepsis and Trauma

Disseminated Intravascular Coagulation (DIC) in Sepsis

• Sepsis can lead to DIC by causing defects in platelet function, thus impairing clot formation
• Liver dysfunction due to sepsis reduces the production of coagulation factors and inhibitors
• Bacterial endotoxins can trigger the coagulation cascade, resulting in a hypercoagulable state
• Thromboplastin and D-Dimer levels increase in DIC
• Prothrombin and fibrinogen levels decrease in DIC
• Heparin is given to patients with sepsis and potential DIC due to coagulation issues

Trauma-Induced DIC

• Trauma patients develop DIC due to increased thromboplastin in the blood
• Thromboplastin causes widespread clotting, consuming fibrin and fibrinogen
• Simultaneous bleeding and clotting occur due to depleted clotting factors and activation of fibrinolysis

Fresh Frozen Plasma (FFP) for DIC

• FFP increases prothrombin and fibrinogen levels
• This increase promotes scabbing (fibrin) and the production of thrombin, which is needed to produce fibrin

Normal Clotting Mechanism

• Injury or bleeding increases thrombocytes
• Thrombocytes release thromboplastin, which converts prothrombin into thrombin
• Prothrombin, made by the liver, is a plasma protein
• Thrombin converts fibrinogen into fibrin, forming the clot and scab
• Once the wound heals, fibrin breaks down

Development of DIC

• Injury or bleeding increases thrombocytes
• Thrombocytes release thromboplastin, increasing thromboplastin levels
• Prothrombin and fibrinogen levels decrease
• D-Dimer levels increase
• Bleeding increases due to a lack of fibrin and fibrinogen

Arterial Lines: Purpose

• They provide continuous and direct blood pressure monitoring

Allen Test

• Radial and ulnar nerves are compressed
• Hand color should return to normal after releasing the ulnar nerve
• Normal hand color indicates adequate ulnar artery flow

Arterial Line: Observations

• Monitor neurovascular status, bleeding, and swelling
• Assess the insertion site for infection, bleeding, and hematoma formation
• Monitor arterial waveform and pressure readings
• Check distal pulses, capillary refill, and skin temperature/color of the affected extremity

Arterial Line: Complications

• Ischemia, numbness, tingling, or loss of pulse distal to the line can occur
• Hemorrhage can occur if the catheter dislodges or the line disconnects
• Infections and thrombus formation at the insertion site are complications
• Neurovascular impairment or ischemia of the limb and limb loss, if untreated, are possible

Preventing Arterial Line Complications

• Secure and immobilize the line to prevent dislodgement or kinking
• Inspect the line frequently
• Monitor pulses and observe for pain, numbness, tingling, coolness, or color changes
• Keep the dressing clean, dry, and intact
• Follow sterile technique when changing the dressing/tubing per protocol

Phlebostatic Axis

• The phlebostatic axis is an imaginary horizontal line at the midpoint of the chest at the level of the right atrium
• It serves as a reference point for accurate central venous pressure measurement by leveling the transducer

Zeroing a Line: Definition

• Atmospheric pressure clears and resets the pressure monitoring system prior to measuring a patient’s blood pressure or other physiological pressures.

Purpose of Zeroing a Line

• To ensure accurate pressure readings by eliminating residual pressure in the tubing
• To establish a consistent baseline for measuring pressure changes

Lines Typically Zeroed

• Arterial lines for invasive blood pressure monitoring
• Central venous pressure (CVP) lines
• Intracranial pressure (ICP) monitoring lines
• Pulmonary artery pressure monitoring lines

Key action before measuring CVP

• Ensure the line aligns with the phlebostatic axis

Central Venous Pressure (CVP)

• CVP measures pressure in the vena cava, estimating preload and right atrial pressure
• Normal CVP range: 4-12mmHg
• High CVP: >12mmHg, indicates fluid overload or right ventricular heart failure, often with pulmonary edema
• Low CVP: