Recognition and treatment of intravascular coagulation

The relevance of developmental hemostasis to hemorrhagic disorders of newborns

The hemostatic system is a dynamic evolving process that is age-dependent. Components of the hemostatic system are synthesized in early fetal life and do not cross the placenta from mother to fetus. However, plasma concentrations of proteins involved in hemostasis significantly differ from adults. Physiological reference ranges are available for premature infants, full-term infants and children from ages 1 to 16 years. In the coagulation system, plasma concentrations of the vitamin K-dependent and contact factors are decreased at birth, whereas other factors such as fibrinogen, FV, FVIII, and FXIII are similar or increased compared with adults at birth. In the fibrinolytic system, plasma concentrations of plasminogen are decreased at birth, whereas tissue plasminogen activator and plasminogen activator inhibitor are increased. Clinically, the hemostatic system of the young is effective and healthy infants do not suffer from spontaneous hemorrhagic complications. However, infants are more vulnerable, compared with older patients, for bleeding in the presence of either congenital or acquired haemostatic defects. Severe congenital bleeding disorders, although rare, frequently present in the newborn period. The most common acquired causes of bleeding newborns include disseminated intravascular coagulation, vitamin K deficiency, and liver disease. A description of these disorders and treatment guidelines are provided.

Loxosceles reclusa envenomation

Loxosceles species are widely distributed. People are most at risk for bites when they disturb the nocturnal spider's habitat. The bite sequelae range from insignificant, to disseminated intravascular coagulation and renal failure. Patients most frequently seek care for slow-healing necrotic skin lesions. Early surgical excision is not recommended. Conservative local care usually suffices. Dapsone may benefit some patients. Specific antivenom given early may minimize sequelae.

Cerebral infarction from non-bacterial thrombotic endocarditis. Clinical and pathological study including the effects of anticoagulation

The clinical and pathologic findings in 42 autopsy proved cases of cerebral infarction from cancer-associated non-bacterial thrombotic endocarditis were reviewed. Carcinoma of the lung was the most common malignancy. Most patients had disseminated cancer, but in six patients, the condition was stable or in remission, and six patients had localized cancer; two patients were not known to have cancer until neurologic symptoms developed. Neurologic symptoms were focal, suggesting stroke in 18; diffuse, suggesting metabolic encephalopathy in nine; and mixed in five. Neurologic signs were often the only evidence of thromboembolism. The definitive diagnostic test was cerebral angiography showing multiple arterial occlusions. Anticoagulation with heparin appeared to help some patients and did not promote brain hemorrhage. Early diagnosis and vigorous treatment of non-bacterial endocarditis may prevent severe neurologic disability.

Coagulation disorders in the neonate

A review is presented of those aspects of hemostatic mechanisms that differ between neonates and older children. Practical laboratory tests to evaluate bleeding disorders in the newborn infant are discussed, as are the most frequently encountered primary and secondary conditions that affect hemostasis, both in the otherwise healthy newborn and in the sick low birthweight infant. Pathophysiology and treatment approaches will be briefly reviewed.

Controlled study of treatment for disseminated intravascular coagulation in the neonate

Thirty-three neonates with disseminated intravascular coagulation were assigned randomly to one of three treatment groups: (1) exchange transfusion, (2) administration of fresh-frozen plasma and platelets, and (3) control (no therapy directed specifically at the coagulopathy). The three groups were comparable for degree of abnormality in initial coagulation studies and underlying pathologic processes. Shock was a common accompaniment of DIC and occurred in 85% of all infants. In all cases, underlying disease states and shock were treated aggressively. Resolution of DIC and survival were not different in the three treatment groups. Outcome of DIC was dependent on the success of treatment of the underlying pathologic process and aggressive supportive care, including restoration of blood pressure, but was not altered by therapy specifically directed at the coagulopathy.

Pneumatosis oculi and spontaneous hyphema in association with pneumatosis intestinalis

A premature infant with acute necrotizing enterocolitis, Escherichia coli sepsis, and disseminated intravascular coagulation developed spontaneous bilateral hyphemas at 3 days of age. The necrotizing enterocolitis was associated with gas bubbles in the intestinal walls. The anterior chambers of both eyes also contained bubbles of gas, formed possibly by a mechanism similar to those in the intestine.

Coagulation abnormalities associated with localized hemorrhage in the neonate

Serial coagulation studies were completed on six neonates with apparent or inapparent localized hemorrhage. The sites of the hemorrhages were intracranial (2), gastrointestinal (2), subperiosteal (1), and pulmonary (1). The studies revealed an increased factor VIII level, decreased platelet count, and a short PTT. Since similar findings occur in disseminated intravascular coagulation, it is possible that coagulation abnormalities associated with localized hemorrhage result from similar mechanisms. These observations suggest that occult and clinically unrecognized hemorrhage can be suspected by serial coagulation studies of sick infants.

Non-bacterial thrombotic endocarditis: clinicopathologic correlations

Sixty-five cases of nonbacterial thrombotic endocarditis (NBTE) were discovered at autopsy during a 10 year period--an incidence of 1.6 per cent in the adult autopsy population. In 51 cases, one or more malignant neoplasms were associated; adenocarcinoma represented the most frequent histologic type of related neoplasm. Coagulation abnormalities suggestive of disseminated intravascular coagulation (DIC) were present in 18.5 per cent of the cases. It is possible that both the valvular and peripheral intravascular thromboses in at least some cases of NBTE represent the abnormal coagulation of DIC. Arterial thrombosis with infarction occurred in many peripheral organs. Splenic and renal were most frequent, but cerebral and cardiac consequences were the most significant.

Thrombosis and intravascular coagulation

Stress, including trauma and sepsis, is associated with a state of hypercoagulability. In these circumstances the patient is at risk of generalized or local thrombotic complications. New laboratory investigative procedures facilitate diagnosis and permit improved assessment of therapy, which at present remains of unproven efficacy both in the general and local situation.

Brown recluse spider bites: five cases with a review of the literature

Brown recluse spider bites can cause ulcerations of the skin, intravascular hemolysis and death. Five clinical cases are presented with a summary of known pathological processes, clinical findings, and recommended methods of treatment. The possibility of systemic manifestation make the physician's knowledge of loxoscelism, early diagnosis and adequate treatment necessary.

Outbreake of Marburg virus disease in Johannesburg

The first recognised outbreak of Marburg virus disease in Africa, and the first since the original epidemic in West Germany and Yugoslavia in 1967, occurred in South Africa in February 1975. The primary case was in a young Australian man , who was admitted to the Johannesburg Hospital after having toured Rhodesia. Two secondary cases occurred, one being in the first patient's travelling companion, and the other in a nurse. Features of the illness included high fever, myalgia, vomiting and diarrhoea, hepatitis, a characteristic maculopapular rash, leucopenia, thrombocytopenia, and a bleeding tendency. The first patient died on the seventh day from haemorrhage resulting from a combination of disseminated intravascular coagulation and hepatic failure. The other two patients were given vigorous supportive treatment and prophylactic heparin and recovered after an acute phase lasting about seven days. During this period on developed pancreatitis, the serum amylase remaining raised until the 32nd day after the onset of the illness. The other developed unilateral uveitis after having been asymptomatic for two months. This persisted for several weeks and Marburg virus was cultured from the anterior chamber of the eye.

Peripheral gangrene in hypernatraemic dehydration of infancy

Gangrene of the extremities complicating diarrhoea and severe hypernatraemic dehydration occurred in 6 infants. This is a rare complication of gastroenteritis, and its association with hypernatraemia does not seem to have previously been emphasized. The increased blood viscosity resulting from serum hyperosmolarity may have been responsible for the gangrene, and studies in our patients suggested that disseminated intravascular coagulation was present. In addition to fluid and electrolyte replacement, the infants were treated with heparin with some recovery of the affected extremities.

Diagnosis and management of disseminated intravascular coagulation

Disseminated intravascular coagulation (defibrination syndrome, consumption coagulopathy) is a syndrome which may complicate a number of pathologic states. If clotting factors and platelets are "consumed" more rapidly than the patient can produce them, they may fall to levels which are not adequate for hemostasis. Thus, thrombosis with resulting necrosis and hemorrhage may occur simultaneously in the same patient. Local fibrinolysis (secondary fibrinolysis) may remove or partially remove intravascular thrombi, thus protecting against local tissue necrosis. Diagnosis of the fulminating syndrome is usually simple and depends upon a few relatively easy tests. If the syndrome is low grade, diagnosis is very difficult and may be impossible without sophisticated techniques. Differential diagnosis from coagulation defects secondary to liver disease is extremely difficult. Treatment in the fulminating case before intravascular thrombi can cause irreversible tissue damage is urgent. Treatment depends upon therapy of the underlying disease plus adequate heparinization. It may be necessary to administer platelets and blood fractions after heparinization. Corticosteroids are not contraindicated, particularly when the patient is heparinized. Epsilon-amino-caproic acid (EACA, Amicar) is contraindicated. This drug inhibits local fibrinolysis, which is protective to the patient.

Disseminated intravascular coagulation in newborns. Survey and appraisal as exemplified in two case histories

Abruptio placenta, asphyxia, toxemia of pregnancy, sepsis and gen eralized viral infections are common causes of disseminated intra vascular coagulation in newborn infants. Prolonged prothrombin and partial thromboplastin times, low fibrinogen level, and throm bocytopenia are typical laboratory findings. The decision to give anticoagulation therapy with heparin rests upon bleeding or thrombosis or both, the question of intracranial bleeding, and the duration of the anticoagulation required. Significant bleeding or thrombosis of vessels of vital organs requires heparinization.

Secondary haemorrhagic disease of the newborn

Clinical, laboratory, and necropsy findings are presented in 5 newborn infants who died with a haemorrhagic diathesis developing within 24 hours after birth. 4 babies were born prematurely; 3 suffered birth asphyxia; and 3 became hypothermic. Laboratory studies showed fibrin degradation products, low platelet counts, and deficient coagulation factors. At necropsy extensive subarachnoid haemorrhages of a characteristic type were seen in all cases, and intravascular fibrin deposits in all but one. Haemorrhage in these babies is considered to be due to consumption of platelets and coagulation factors as a consequence of disseminated intravascular coagulation. Predisposing conditions and possible pathogenic mechanisms are discussed. Platelet counts aid early diagnosis of this form of haemorrhagic disease. Treatment by exchange transfusion using fresh heparinized blood is suggested.