Hematologic Emergencies
Disseminated Intravascular Coagulation
EPIDEMIOLOGY
• Risk increases when associated with:
• In persons with cancer, disseminated intravascular coagulation (DIC) is the most common serious thrombotic state that occurs.
PATHOPHYSIOLOGY
• In the normal coagulation system, hemostasis is maintained through a balance between the processes of clot formation (thrombosis) and clot breakdown (fibrinolysis).
• One component of the DIC process is abnormal thrombus formation.
• When part of the thrombus is dislodged, then an embolus (or “thromboembolus”) is formed. This traveling clot can lead to diffuse microvascular obstruction and result in ischemia, impaired organ perfusion, and end-organ damage.
• Second component is fibrinolysis.
DIAGNOSTIC TESTS
TREATMENT
• Treatment of the underlying, predisposing condition(s) causing the DIC
• Supporting the patient’s hemodynamic status
• Managing the signs/symptoms related to bleeding or thrombosis that are present
Pharmacologic Management
• Remove the trigger of the DIC by treating the underlying, predisposing condition.
• IV vasopressor (i.e., dopamine)
• Washed, packed red blood cells (RBCs)
• Blood components that contain fibrinogen (e.g., fresh-frozen plasma [FFP], cryoprecipitate, whole blood)
• Heparin (IV or subcutaneous)
• Fibrinolytic inhibitor medications
• Tranexamic acid (Cyklokapron)
Nonpharmacologic Management
• Monitor hemodynamic signs and symptoms and vital signs often.
• Monitor intake and output every 1-2 hours during periods of acute DIC.
• Monitor all sites of bleeding often.
• Note amount of bleeding: count peripads, weigh affected dressings, measure bloody drainage.
• Measure abdominal girth every 4 hours if abdominal bleeding is suspected.
• Apply direct pressure or apply pressure dressings or sandbags to sites of active bleeding.
PATIENT TEACHING
• Goal of treatment is to reverse the hypercoagulable state and to maintain normal coagulation levels.
• Define DIC and describe the signs and symptoms.
• Explain the purpose of the laboratory tests, nursing care, and treatments for DIC.
• Teach patients self-care measures to maximize their safety: maintain bed in a low position with side rails up; clear pathways in room and hallway; minimize activities that trigger bleeding; take precautions against accidental bleeding because even minor scrapes or bumps could result in bleeding.
• Teach patients to minimize activities that contribute to clot formation, including avoid constrictive clothing or devices; do not dangle feet on side of bed; do not use pillows under knees or knee gatch; and move the toes, feet, and legs often.
• Teach patient and family to save urine, stool, and emesis for nurse to check for blood.
• Teach patient about critical signs and symptoms to report: any bruising, red rash, headache, black stools, blood in the urine or stools, and bleeding from the gums, nose, eyes, vagina, or rectum.
FOLLOW-UP
• Continue to monitor for signs and symptoms of DIC.
• Monitor laboratory findings as to the continuation or resolution of DIC.
• Provide additional resources, such as home equipment or assistance, as needed, as a result of severe complications of DIC (e.g., organ dysfunction, activity limitations).
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Deep Vein Thrombosis
EPIDEMIOLOGY
• Third most common type of vascular disease
• The two most common presentations:
• In persons with cancer, thrombosis is a common complication of malignancy.
• Potentially fatal complication that primarily affects hospitalized patients
CANCERS ASSOCIATED WITH DISORDER
PATHOPHYSIOLOGY
• Patients with cancer have a higher incidence of development of DVT because thrombi formation is a common complication of malignancy.
• Three factors predispose cancer patients to a higher risk of thrombus formation:
Tumor cells often induce this hypercoagulable state directly through the secretion of procoagulant factors.
Pooling allows coagulation factors to accumulate and increases the chance of platelet aggregation and clot formation.
Direct invasion of blood vessels by tumors can affect the vascular endothelium and promote clot formation.• A life-threatening complication of DVT is development of PE.
SIGNS AND SYMPTOMS
• Assessing for Homan’s sign as part of the physical examination
• Signs and symptoms of PE may be first indication of DVT.
DIAGNOSTIC TESTS
Uses both scanning and compression to detect the thrombus by direct visualization or by interference when the vein does not collapse during gentle compression
• Contrast venography (phlebography)
• Magnetic resonance imaging (MRI)
DIFFERENTIAL DIAGNOSIS
TREATMENT
Pharmacologic Management
Nonpharmacologic Management
• Bed rest is indicated for the first 5 to 7 days, with leg elevation, for acute DVT.
• Mild analgesics and warm compresses may be used for comfort for persons with acute DVT.
• Frequent leg exercises (range of motion [ROM] or isometric), if bedridden:
• Supplemental oxygen by nasal cannula may be administered to maintain a PaO2 of higher than 80 mm Hg in persons with acute DVT.
• Frequent ambulation, if able to tolerate, after the 5-7 days of bed rest
• Antiembolitic stockings/hose should be applied before surgery.
• Pneumatic compression stockings/devices may be used postoperatively to stimulate circulation and prevent DVT.
• Elevation of foot of bed 15-20 inches, with slight knee flexion
• Avoid popliteal pressure, which is produced by crossing the legs, placing pillows behind the knees, and elevation of the knee gatch.
• Do not massage the legs of persons with DVT.
• Regular position changes should be encouraged to prevent hypoventilation.
• Avoid smoking and caffeine to prevent vasoconstriction.
• Do not perform Homan’s test once DVT is diagnosed or test result is positive.
PATIENT TEACHING
• Describe the signs and symptoms of DVT.
• Explain the purpose of the laboratory and diagnostic tests, nursing care, and treatments.
• Encourage patient to wear the pneumatic compression stockings/devices, as ordered.
• Teach patient the rationale for ambulating as soon as possible after surgery.
• Encourage patient to change position regularly, avoid sitting or standing for long periods, drink 8-10 glasses of fluid per day, avoid smoking and caffeine, and perform ROM or isometric exercises.
• Teach patients to avoid constrictive clothing or devices; to keep the legs elevated and straight; to move the toes, feet, and legs often; and to avoid pressure in the back of their knees (popliteal) to prevent a clot from forming in the arms or legs.
• Teach patient to take warfarin at the same time every day.
• Teach patient to avoid any contact sports that could lead to serious injury.
• Teach patient to use a soft toothbrush for oral care and use an electric razor, if there is a need to shave.
• Teach patient to maintain a diet consistent in the amount of vitamin K, if on warfarin.
• Patient is to report any leg pain, bleeding, or signs of thrombophlebitis or PE.
FOLLOW-UP
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