Question 24.2

College answer

Not available.

Discussion

Explain the abnormalities:

• The FBC is boring:
  • There is anaemia
  • Normocytosis suggests this has nothing to do with iron deficiency
  • Normal cell volume suggests that vitamin deficiency is not to blame
  • The raised WCC suggests that some sort of infection is occurring
• The coags are hideous:
  • All of the parameters are markedly deranged
  • The extremely low fibrinogen and profound thrombocytopenia suggests that there is a consumptive coagulopathy occurring
  • It would have been nice to have a quantitative D-dimer, but let's face it, we all know it would have been raised.

List one likely pathological diagnosis: 

• Disseminated intravascular coagulation (DIC); or, to use a more modern redefinition of the term, "sepsis-induced coagulopathy (SIC)".

Principles of management of DIC(SIC):

• Treat the cause:
  • Evacuate the retained products
  • Treat the polymicrobial sepsis with antibiotics
• Limit clotting factor replacement
  • Give blood instead to maintain haemoglobin
  • Only administer blood products if the patient is having life-threatening (eg. intracerebral) bleeding
  • Consider supplementing fibrinogen until it is over 1g/L
  • Though there is a theoretical concern that replacing clotting factors will increase the risk of microthrombosis and microemboli, these appear to be largely unfounded  
• Theoretical therapies
  • Antithrombin-III concentrate (Gando et al, 2013)
  • Activated protein C (Aoki et al, 2002)
  • Thrombomodulin (Saito et al, 2007)
  • Tissue factor pathway inhibitor, also known as tifacogin (Abraham et al, 2003)
  • Heparin, in slowly developing DIC (Jaimes et al, 2009)