13 .

Thrombin Generation

: . . : , , 3 . ( , ) 40- , .

 1000 1
. , , 40 40% .

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 : : 50- , : , : , . ,

Inherited (Primary) Hypercoaguable States

Activated Protein C Resistance: Factor V Leiden Prothrombin Gene Mutation 20210 (G-A) Antithrombin III deficiency Protein C deficiency Protein S deficiency Dysfibrinogenemias (rare) Hyperhomocystenemia

Acquired(Secondary) Hypercoaguable States

Immobilization Trauma Surgery (postoperative state) Obesity Pregnancy (especially postpartum period) Estrogen use (oral contraceptives, estrogen replacement therapy) Prolonged Air Travel Antiphospholipid Antibody Syndrome/Lupus Anticoagulant

Acquired (Secondary) Hypercoaguable States

Nephrotic Syndrome Paroxysmal Nocturnal Hemoglobinuria Myeloproliferative Syndromes (especially Polycythermia Vera & Essential Thrombocythemia) Heparin-induced thrombocytopenia (HIT) Disseminated Intravascular Coagulation (DIC) Malignancy

Disseminated intravascular coagulation (DIC)

Characteristics of DIC

Arterial thrombosis

DIC

Venous thrombosis

Hemostatic Balance

PAI-1

Prot. S Prot. C TFPI

Fibrinolytic System

Antiplasmin Tissue factor Clotting Factors

ATIII

Procoagulant

Anticoagulant

Introduction
Thrombotic microangiopathy (TMA) and disseminated intravascular coagulation (DIC) are disorders causing obstruction of the microvascular circulation

Trombotic microangiopathy Increased platelet aggregation

DIC Increased fibrin formation

Thrombotic microangiopathy

Trombotic microangiopathy Increased platelet aggregation

TTP

HELLP

HUS

TTP:

Thrombotic Thrombocytopenic Purpura

HELLP: Haemolysis, Elevated Liver enzymes, Low Platelets HUS: Haemolytic Uremic Syndrome

DIC
An acquired syndrome characterized by systemic intravascular coagulation Coagulation is always the initial event

SYSTEMIC ACTIVATION OF COAGULATION

Intravascular deposition of fibrin

Depletion of platelets and coagulation factors

Thrombosis of small and midsize vessels

Bleeding

Organ failure

DEATH

Causes of DIC
Tissue damage (release of tissue factor) e.g. trauma (esp brain or crush injury), thermal injury (burns, hyperthermia, hypothermia), surgery, shock, asphyxia/hypoxia, ischaemia/infarction, rhabdomyolysis, fat embolism. Complications of pregnancy (release of tissue factor) e.g. amniotic fluid embolism, abruptio placentae, eclampsia and pre-eclampsia, retained dead fetus, uterine rupture, septic abortion. Neoplasia (release of tissue factor, TNF, proteases) e.g. solid tumours, leukaemias (esp. acute promyelocytic).

Infection (endotoxin release, endothelial cell damage) e.g. Gram ve bacteria (e.g. meningococcus), Gram +ve bacteria (e.g. pneumococcus), anaerobes, M tuberculosis, toxic shock syndrome, viruses (e.g. Lassa fever), protozoa (e.g. malaria), fungi (e.g. candidiasis). Vascular disorders (abnormal endothelium, platelet activation) e.g. giant hemangioma (KasabachMerritt syndrome), vascular tumours, aortic aneurysm, vascular surgery, cardiac surgery, malignant hypertension, pulmonary embolism, acute MI, stroke, subarachnoid hemorrhage. Immunological (complement activation, release of tissue factor) anaphylaxis, acute hemolytic transfusion reaction, heparin-associated thrombocytopenia, renal allograft rejection, acute vasculitis, drug reactions (quinine).

Proteolytic activation of coagulation factors e.g. pancreatitis, snake venom, insect bites. Neonatal disorders e.g. infection, aspiration syndromes, small-for-dates infant, respiratory distress syndrome, purpura fulminans. Other disorders e.g. fulminant hepatic failure, cirrhosis, Reyes syndrome, acute fatty liver of pregnancy, ARDS, therapy with fibrinolytic agents, therapy with factor IX concentrates, massive transfusion, acute intravascular hemolysis familial, ATIII deficiency, homozygous protein C or S deficiency.

Conditions Associated With DIC

Malignancy
Leukemia Metastatic disease

Pulmonary
ARDS/RDS Pulmonary embolism

Cardiovascular
Post cardiac arrest Acute MI Prosthetic devices

Hypothermia/Hyperthermia

Severe acidosis Severe anoxia Collagen vascular disease Anaphylaxis

Conditions Associated With DIC

Infectious/Septicemia
Bacterial
Gm - / Gm +

Tissue Injury
trauma extensive surgery tissue necrosis head trauma

Viral
CMV Varicella Hepatitis

Obstetric
Amniotic fluid emboli Placental abruption Eclampsia Missed abortion

Fungal

Intravascular hemolysis Acute Liver Disease

NORMAL HAEMOSTASIS
Intravascular Haemostatic clot formation mechanisms TF TF

Cytokines
TF
Monocyte monocyte
Activated

TF TF

Activation of monocytes

SYSTEMIC INFLAMMATION

Local haemostatic response to an injury

Local immunological response to an injury

Circulating mediators

Modification (Amplification)

Circulating mediators

DIC
Ischaemia

SIRS
Destruction

MODS

Progression of SEPSIS
Non-adhesive Adhesive surface surface

Platelets

Monocytes
Cytokines Tissue factor

Endothelial cells

Leukocytes

Accelerates coagulation

Activation of coagulation Thrombin Fibrin

Trauma-induced DIC Phases

Activation phase
Clinical: No DIC-symptoms Paraclinical: Short APTT and PT High fibrinolytic activity

Death

Early consumption phase

Clinical: Paraclinical: Microthrombosis Thrombocytopenia, high D-dimer and soluble fibrin

Recovery
Regression of clinical and paraclinical changes

Late consumption phase

Microthrombosis and bleeding Paraclinical: Severe thrombocytopenia Prolonged APTT and PT Clinical:

Progression of DIC
Systemic fibrin formation Systemic inflammation Multiple organ dysfunction Systemic bleeding

Onset of DIC

Time

Progression of DIC
Systemic fibrin formation Systemic inflammation Multiple organ dysfunction Low Systemic fibrinolytic bleeding activity

Abrupt onset of DIC

High fibrinolytic activity

Onset of DIC

Time

PathophysiologyDIC may be initiated by

Exposure of blood to tissue factor (e.g. after trauma). Endothelial cell damage (e.g. by endotoxin or cytokines). Release of proteolytic enzymes into the blood (e.g. pancreas, snake venom). Infusion or release of activated clotting factors (factor IX concentrate). Massive thrombosis Severe hypoxia and acidosis.

Pathophysiology of DIC
Activation of Blood Coagulation Suppression of Physiologic Anticoagulant Pathways Impaired Fibrinolysis Cytokines

Pathophysiology of DIC
Activation of Blood Coagulation
Tissue factor/factor VIIa mediated thrombin generation via the extrinsic pathway
complex activates factor IX and X

TF
endothelial cells monocytes Extravascular: lung kidney epithelial cells

Pathophysiology of DIC
Suppression of Physiologic Anticoagulant Pathways
reduced antithrombin III levels reduced activity of the protein C-protein S system Insufficient regulation of tissue factor activity by tissue factor pathway inhibitor (TFPI)
inhibits TF/FVIIa/Fxa complex activity

Pathophysiology of DIC
Impaired Fibrinolysis relatively suppressed at time of maximal activation of coagulation due to increased plasminogen activator inhibitor type 1

Fibrinolytic activity in patients with DIC

Thrombin- and stasis-induced release of tissue plasminogen activator FXII FXIIa PrekallikreinKallikrein PC APC inhibits PAI-1

Abrupt onset of DIC

During DIC Plasminogen activator inhibitor-1 Plasmin 2-Plasmin inhibitor

Plasminogen

Fibrin

Fibrin degradation products

Clinical features:
Acute (uncompensated) DIC: Rapid and extensive activation of coagulation, fibrinolysis or both, with depletion of procoagulant factors and inhibitors and significant haemorrhage.

Chronic (compensated) DIC: Slow consumption of factors with normal or increased levels; often asymptomatic or associated with thrombosis.

Hyper- and non-hyperfibrinolytic DIC

Hyperfibrinolytic DIC
Main problem: Severe bleeding

Non-hyperfibrinolytic DIC
Main problem: Microvascular occlusion

DIC in septic patients is a

non-hyperfibrinolytic type of DIC

Pathophysiology of DIC Cytokines

Cytokines
IL-6, and IL-1 mediates coagulation activation in DIC TNF- mediates dysregulation of physiologic anticoagulant pathways and fibrinolysis modulates IL-6 activity IL-10 may modulate the activation of coagulation
Inflamation Coagulation

Clinical Manifestations of DIC

ISCHEMIC
Pur. Fulminans Gangrene Acral cyanosis Delirium/Coma Infarcts Oliguria/Azotemia Cortical Necrosis Myocardial Dysfxn Dyspnea/Hypoxia Infarct Ulcers, Infarcts Adrenal infarcts

Ischemic Findings ORGAN are earliest!

HEMOR.
Petechiae Echymosis Oozing Intracranial bleeding Hematuria

Skin

CNS Renal Cardiovascular Pulmonary GI Endocrine

Hemorrhagic Bleeding is the most lung obvious Massive clinical finding hemorrhage.

Clinical Manifestations of DIC

Microscopic findings in DIC

Fragments Schistocytes Paucity of platelets

Laboratory Tests Used in DIC

D-dimer* Antithrombin III* F. 1+2* Fibrinopeptide A* Platelet factor 4* Fibrin Degradation Prod Platelet count Protamine test Thrombin time Fibrinogen Prothrombin time Activated PTT Protamine test Reptilase time Coagulation factor levels

*Most reliable test

Laboratory diagnosis
Thrombocytopenia
plat count <100,000 or rapidly declining

Prolonged clotting times (PT, APTT) Presence of Fibrin degradation products or positive D-dimer Low levels of coagulation inhibitors
AT III, protein C

Low levels of coagulation factors

Factors V,VIII,X,XIII

Fibrinogen levels not useful diagnostically

Scoring system for overt DIC

Underlying disorder known to be associated with overt DIC

YES
continue

NO
stop

Platelet count
(>100=0, <100=1, <50=2) ..............................

Soluble fibrin/D-dimer
(normal=0, =2, =3) .............................

Prolongation of PT
(<3s=0, 3-6s=1, >6s=2) ................................

Fibrinogen
(>1g/l=0, <1g/l=1) ..........................................

Calculate sum ........................................

Scoring system for overt DIC

- Example Underlying disorder known to be associated with overt DIC Polytrauma Platelet count

YES
continue

NO
stop

85 ........... 1 (>100=0, <100=1, <50=2) ................... Soluble fibrin/D-dimer 8 3 (normal=0, =2, =3) ............................. Prolongation of PT +3 1 (<3s=0, 3-6s=1, >6s=2) ................................

Fibrinogen
2,2 0 (>1g/l=0, <1g/l=1) .......................................... 5 Calculate sum ........................................

Scoring system for overt DIC

If the calculated score is 5: compatible with overt DIC repeat scoring daily <5: suggestive (not affirmative) for non-overt DIC repeat next 1-2 days.

Scoring system for non-overt DIC

Presence of underlying disorder

(no=0, yes=2) ..........................................................

Platelet count + changes

(100=0, <100=1) + (=-1, stable=0, =1) ....... (normal=0, =1) + (=-1, stable=0, =1) ........ (3s=0, >3s=1) + (=-1, stable=0, =1) ........... (normal=-1, low=1) .................................................

Sol.fibrin/D-dimer + changes

Prolongation of PT + changes Antithrombin

Protein C
(normal=-1, low=1) .................................................

Calculate sum ................................................

Differential Diagnosis
Severe liver failure Vitamin K deficiency Liver disease Thrombotic thrombocytopenic purpura Congenital abnormalities of fibrinogen HELLP syndrome

Treatment of DIC
directed against etiological factors

Infections
Trauma Obstetric complications

Antibiotics Removal of damaged tissue stabilisation of fractures Evacuation of the uterus

Treatment of DIC
Stop the triggering process .
The only proven treatment!

Supportive therapy No specific treatments

Plasma and platelet substitution therapy Anticoagulants Physiologic coagulation inhibitors

Plasma therapy
Indications
Active bleeding Patient requiring invasive procedures Patient at high risk for bleeding complications

Fresh frozen plasma(FFP):

provides clotting factors, fibrinogen, inhibitors, and platelets in balanced amounts. Usual dose is 10-15 ml/kg

Platelet therapy
Indications Active bleeding Patient requiring invasive procedures Patient at high risk for bleeding complications Platelets approximate dose 1 unit/10kg

Blood
Replaced as needed to maintain adequate oxygen delivery.
Blood loss due to bleeding RBC destruction (hemolysis)

Coagulation Inhibitor Therapy

Antithrombin III Protein C concentrate Tissue Factor Pathway Inhibitor (TFPI) Heparin

Antithrombin III
The major inhibitor of the coagulation cascade
Levels are decreased in DIC. Anticoagulant and antiinflammatory properties

Therapeutic goal is to achieve supranormal levels of ATIII (>125-150%).

Experimental data indicated a beneficial effect in preventing or attenuating DIC in septic shock
reduced DIC scores, DIC duration, and some improvement in organ function

Clinical trials have shown laboratory evidence of attenuation of DIC and trends toward improved outcomes. A clear benefit has not been established in clinical trials.

Protein C Concentrates
Inhibits Factor Va, VIIa and PAI-1 in conjunction with thrombomodulin. Protein S is a cofactor Therapeutic use in DIC is experimental and is based on studies that show:
Patients with congenital deficiency are prone to thromboembolic disease. Protein C levels are low in DIC due to sepsis. Levels correlate with outcome. Clinical trials show significantly decreased morbidity and mortality in DIC due to sepsis.

Tissue Factor Pathway Inhibitor

Tissue factor is expressed on endothelial cells and macrophages TFPI complexes with TF, Factor VIIa,and Factor Xa to inhibit generation of thrombin from prothrombin TF inhibition may also have antiinflammatory effects Clinical studies using recombinant TFPI are promising.

Heparin
Use is very controversial. Data is mixed. May be indicated in patients with clinical evidence of fibrin deposition or significant thrombosis. Generally contraindicated in patients with significant bleeding and CNS insults. Dosing and route of administration varies. Requires normal levels of ATIII.

Antifibrinolytic Therapy
Rarely indicated in DIC
Fibrinolysis is needed to clear thrombi from the micro circulation. Use can lead to fatal disseminated thrombosis.

May be indicated for life threatening bleeding under the following conditions:
bleeding has not responded to other therapies and: laboratory evidence of overwhelming fibrinolysis. evidence that the intravascular coagulation has ceased.

Agents: tranexamic acid, EACA