The criteria for the diagnosis of DIC

Disseminated intravascular coagulation (DIC) - One of the most common acquired disorders of hemostasis.

The process is characterized by total or regional (Available agencies) formation of fibrin in blood clots, aggregates of blood cells and microthrombi, leading to the blockade of the microcirculation, hypoxia, degeneration and functional organ failure and often to be incompatible with life circulatory and metabolic disorders. The reasons for this separation of blood clotting and are most often flow into the blood stream from damaged tissue thromboplastin (factor III, apoprotein C), the formation of its endothelium or blood cells (monocytes, Lymphocytes) when they are damaged and endotoxin activation, immune complexes and other factors, as well as shock and hemolysis, less - arrival outside coagulase (snake venom poisoning gemokoaguliruyuschimi).

Causes damage to the tissue while very diverse - from mechanical influences (trauma, operation and others.) to bacterial viruses, Immune, circulatory (shock, išemiâ, heart failure) etc..

Thus, coagulation process begins in the tissues, It applies to blood and other fluids circulating and ends more severe dystrophy and dysfunction of organs and tissues as a result of a deep violation of microcirculation.

Within DIC It may be acute, subacute and chronic. When the first two forms and in the terminal phase of a chronic course of the process often have a more or less pronounced hypocoagulation (until almost complete blood incoagulability) and profuse bleeding, which explains the name of the syndrome thrombohemorrhagic. However, a variety of other shapes no hemorrhages or minimum, and in the foreground are the effects of ischemia and organ function failure.

Diagnosis of DIC largely situational, it is based on the following criteria.

The presence of etiologic factors and probabilistic incidence of DIC.

1. Generalized infections and septic conditions (bacteraemia, virusemiya), including infection with abortion, in childbirth, vascular catheterization, etc.. d. When septic shock Severe Acute DIC- syndrome detected in 100 % cases. On infections associated with most cases of DIC in the newborn.
   • When the lighter is possible latent infection or erased during DIC, which can detect the results of laboratory tests and the emergence of secondary syndromes (kidney failure, liver, adrenal glands, and so on. d.). In modern conditions, the share of infectious and septic DIC has more than 50 % of all cases of violations of hemostasis.
2. Injuries and traumatic surgery (especially in malignant tumors, operations in the parenchymal organs, heart and blood vessels, the use of extracorporeal circulation devices, etc.. d.). The probability and severity of DIC increases sharply with bleeding, collapse, massive blood transfusion, infection.
3. All kinds of shock and terminal state - in 100% cases.
4. Acute intravascular hemolysis and cytolysis - in 100% cases.
5. Thermal and chemical burns.
6. Obstetric Pathology - amniotic fluid embolism, infection of the amniotic fluid, previa and placental abruption, intrauterine fetal death, etc.. When late toxicosis of pregnancy, caesarean section, atonic hemorrhage - a sharp acceleration of DIC. Its development is triggered by uterine massage to fist, massive blood transfusion (especially with long blood storage).
7. Destructive processes in the heart (acute myocardial infarction, especially with cardiogenic shock), liver (ostraya dystrophy), kidney, pancreas and other organs.
8. Gasser's disease (hemolytic uremic syndrome), hepatorenal syndrome, thrombotic thrombocytopenic purpura, and related processes.
9. Decompensated cirrhosis.
10. Immune and immunocomplex diseases (systemic lupus erythematosus, vasculitis, glomerulonephritis and the like.).
11. Hemorrhea.
12. Massive blood transfusion and administration of drugs with activated coagulation factors (PPSB and others.).
13. Snake venom poisoning gemokoaguliruyuschimi.
14. Hematological malignancies and other malignancies.
15. Myeloproliferative disease and essential thrombocytosis.

In some of these diseases there is acute and subacute DIC, in other - chronic (immune deposit disease, number of malignancies). In the latter case, DIC can be combined with a sharp phlebothrombosis or develop after him (Trousseau Syndrome).

In many of the above exposures and diseases DIC - the only possible form of pathology of hemostasis (infectious-septic processes, shock, destructive processes in the internal organs, etc.. d.). Therefore, the appearance when they thrombohemorrhagic phenomena and disturbances in the hemostatic system immediately be interpreted as a possible DIC. In a number of other processes have to exclude the presence of other changes hemostasis - thrombocytopenia (at the primary and secondary immune disorders), violation of the synthesis of clotting factors (the pathology of the liver), lupus anticoagulant action, etc.. d. It should be taken into account, that this violation can be observed along with DIC.

Target organ damage

Blockade of microcirculation in organs with the most pronounced fibrin deposition and high sensitivity to hypoxia results in the rapid disruption of their function, that should be considered in the diagnosis of disseminated intravascular coagulation. So, suddenly developing at birth, abortion, infectious diseases, operations, etc.. d. pronounced dyspnea with cyanosis (rapid breathing up 25 in 1 min and more) indicates either DIC, or a pulmonary embolism. In this and in the other case is shown immediately (to conduct laboratory studies!) geparinoterapiя.

The presence of DIC indicate changes in the appearance of the urine (protein, erythrocytes) and decreased urine output, t. it is. development of acute renal failure, increase plasma levels of free hemoglobin (gemoliz) and bilirubin, and enzymes, characterizing liver; development of hypotonic syndrome due to acute adrenal insufficiency; signs of insufficient blood supply and oxygenation of the brain (slackness, lethargy). The progression and development of acute shock (hypoxic) bleeding stomach ulcers, diapedetic and massive bleeding from the mucous membrane of the stomach and intestines, surely, indicate the presence of DIC, Although these features are not early.

Extending the range of bleeding and change in its nature

This is an important criterion, Unfortunately, not always taken into account, although sometimes very easier and faster diagnosis. At the same time it must pay attention to changes in the properties of blood, arising out of the uterus, surgical wound, etc.. d. - Deterioration of its clotting, reducing the size and density of the clot (up to their disappearance), the nature of bleeding (diffuse, parenhimatoznыy) of the wound surface.

The second important feature - the accession of hemorrhages other sites. So, if background uterine bleeding blood and begins operating wound, there are bruises in places palpation, measurement of blood pressure and injection site, notes discharge of blood from the gums and nasal cavity, there are bruises on the legs and hemorrhages on the face, as well as to the oral mucosa and into the larynx during intubation, after the operation start to bleed the peritoneum or pleura should be suspected DIC, completely rejecting the treatment of bleeding as those associated with uterine atony, defect local hemostasis in surgery etc.. d.

Laboratory diagnosis of disseminated intravascular coagulation

Clinical symptoms of DIC often so weighty, that laboratory testing confirms the diagnosis, It helps clarify the stage and severity of the process, monitors the effectiveness of the therapy. However, such an examination in risk groups makes it possible to identify the initial (preclinical) phase of DIC- syndrome, its latent form.

In the study of blood coagulation in the initial period of DIC found hypercoagulation (the difficulty of obtaining blood from a vein, folding it into the needle and tube, etc.. d.), that in chronic forms are sometimes protracted or recurrent, and acute - a very short-lived and often not detected.

This hypercoagulable confirmed both by the general coagulation tests (clotting time, APTT and others.), and tromboelastograficheski (shortening parameter R + K, increasing the angle a, increase in the index for hypercoagulable M. A. Kotovshchikova).

Then comes Phase II DIC - Transition, When using one test has revealed hypercoagulation (eg, total shortening clotting time), and with other - the rules- or hypocoagulation. This omni directional indications coagulation tests - an important and a sure sign of DIC, because no other disturbances in the hemostatic system, it is not observed. The earliest method of detecting a transition in hypocoagulation trombinovыy test and the most recent - Sample poison ephah mnogocheshuychatoy.

In the terminal phase hypocoagulation, which develops is not always, All figures are increased clotting time, clots are small, loose, a marked gipofibrinogenemia.

In addition to the general indicators of coagulation disorders, diagnostic value have the following tests:

• determining the number of thrombocytes in the blood;
• methods of detecting soluble fibrin monomer complexes (ethanol, ortofenantrolinovy ​​and protaminsulfatny tests, Sample poison ephah);
• Test adhesion of staphylococci (RFMK and Rannie PDF);
• immunological determination PDF;
• determination of levels of antithrombin III, and plasminogen activators, фактора XIII, identification of fragmentation of red blood cells.

Taking into account the results of more sophisticated studies markers of intravascular coagulation.

Conducting these studies should be comprehensive, as taken separately, these changes can be observed in other types of pathology of hemostasis (eg, for thrombocytopenia) and intravascular coagulation.

In addition to these methods, revealing intravascular coagulation is possible with the more complex and less accessible test - determining neoantigenov thrombin-antithrombin complex and plasmin-antiplasmin, fragments of Factor XIII, activations monotsitov, димеров D-D и т. d.

In general, laboratory diagnosis of DIC in the correct interpretation of test readings and comparing them with the clinical signs of this process does not present much difficulty, and reliable enough.

Gipofibrinogenemia is an important feature of DIC. However, it should be taken into account, that DIC often occurs on the background of the initial increase in plasma fibrinogen (Pregnancy, infectious and inflammatory and immune processes, necrosis of, some tumors). Because of this, the absolute reduction in the concentration of fibrinogen below normal values ​​observed in approximately 50 % Patients with DIC (most acute forms, chronic - less). Identify the lowering of fibrinogen in the dynamics is more important diagnostic value.

Monitoring the dynamics of the above-mentioned laboratory parameters is necessary for a comprehensive treatment of DIC.

A similar set of tests used in the diagnosis and treatment of mikrotrombovaskulitov - hemorrhagic vasculitis (Henoch's disease), hemolytic-uremic syndrome (Gasser's disease), glomerulonephritis, erythema nodosum, etc.. d.