16

Rosy McBloom is an 81 year old female with a history of dementia. She lives in a skilled nursing facility and is visited by her daughter weekly. She was brought to the ER in acute respiratory distress. She was showing signs of sepsis including hypotension, tachycardia, and a temperature of 101.1 degrees F. Her lactic acid level and white blood cell (WBC) count came back elevated. She was admitted to the ICU with a diagnosis of severe sepsis secondary to pneumonia. She was put on vancomycin, ceftriaxone, Levophed, and morphine for pain.

Rosy had to be intubated on her second day while in the ICU and was put on propofol. During the afternoon of the second day, the nurse noticed hematuria, petechiae, and blood tinged secretions. A coagulation study was ordered and showed a positive d-dimer, prolonged PT and aPTT, and a platelet count of 75,000. Rosy was then diagnosed with disseminated intravascular coagulation (DIC) secondary to sepsis. One unit of fresh frozen plasma (FFP) was ordered and administered. Her fingers and toes were cold and pale upon assessment throughout the night shift and started turning purple. She has a foley catheter and her output during the 12 hour night shift was 175 mL. Her BUN and creatinine are also elevated.

Rosy’s morning labs came back for Day 3 showing lactic acid level 3.4, WBC 17,000 hemoglobin 6.8, hematocrit 25%, BUN 42, and creatinine 3.2. Her coagulation study came back with the results as follows: platelets 80,000, PT 31 seconds, aPTT 63 seconds, d-dimer >500 ng/dL, and fibrinogen 88. Her vital signs throughout the day were BP ranging from 80s to 100 systolic, 40s-50s diastolic, MAP range of 57 to 67, RR 20 breaths/min on mechanical ventilation with an FiO2 of 60%, HR from 90s to 120s, temperature of 100.0 degrees F, and SaO2 ranging from 90% to 98%. On assessment her lung sounds were coarse and blood tinged sputum was being suctioned. She also had blood oozing from her IV sites, bruising and petechiae on all extremities, and several purple toes. One unit of red blood cells (RBC) and FFP were ordered and administered. Afternoon labs showed only a slight improvement in her RBCs and coagulation values. Rosy’s daughter met with the physician and palliative nurse to go over Rosy’s status and further treatment. After the meeting, the daughter changed Rosy’s status from a full code to DNR, but made no decisions on whether to further treat her or not.

On the fourth day, Rosy remained hypotensive, septic, and in acute renal failure. Her hemoglobin and platelets remain low despite transfusions of RBCs and FFP. Antibiotic therapy and fluid resuscitation were continued to treat the sepsis with minimal improvement. The DIC has continued to worsen and Rosy now has 6 necrotic toes while her hands are also now turning purple. She also continued to have hematuria. The daughter came in on the morning of the fifth day and made the decision to have Rosy extubated and to sustain from any further treatment. Rosy was extubated at 0900 and comfort measures were implemented. Rosy passed away at 1648 from complications of DIC.

Questions

1. What were the most significant clinical manifestations and lab values that led to DIC?
2. When the doctor’s diagnosed Rosy with DIC, what was the main goal of treatment and what were the secondary treatments, and why?
3. Rosy passed away on her 5th day of care due to complications of DIC. Based on the pathophysiology of DIC, what are fatal complications of the disease process?

Answer Key

Question 1: Hematuria which indicated clotting and renal failure; petechiae; cold and pale fingers and toes, and purple toes from necrosis; blood tinged secretions; bruising; and blood oozing from her IV sites. The most significant lab values were the decreased platelet count, the prolonged PT and aPTT, the low fibrinogen level, and the elevated d-dimer.

Question 2: Primary: Antibiotics. Because Rosy’s DIC is secondary to her sepsis, the main goal of treatment is to resolve the sepsis. If the sepsis is not resolved, the DIC will remain. Secondary: FFP’s, RBC’s, and Levophed. FFP’s were given to replace coagulation factors to decrease bleeding. RBC’s were given to replace blood volume lost from bleeding. Levophed is used to maintain a MAP >65.

Question 3: Stroke, renal failure, heart attack/cardiac arrest, shock, and pulmonary embolism.