On her third day of hospitalization. a 70-year-old woman who is being treated with antibiotics for acute cholecystitis develops increased pain and tenderness in the right upper quadrant with a palpable mass. Her temperature rises to 40°C (104°F) and her blood pressure falls to 80/60 mmHg. Hematemesis and melena ensue and patchier are noted. Laboratory studies reveal thrombocytopenia, prolonged prothrombin time, and a decreased fibrinogen level. The most important step in the correction of this patient's coagulopathy is
|A||Administration of heparin|
|B||Administration of fresh frozen plasma|
|C||Administration of whole blood|
a. The majority of patients with acquired hypofibrinogenemia suffer from intravascular coagulation, more properly known as defibrination syndrome or consumptive coagulopathy, and it is to this group of patients that the term disseminated intravascular coagulation (DIC. has been applied.
b. This syndrome is caused by the introduction of thromboplastic materials into the circulation. Because this material is found in most tissues, many disease processes may activate the coagulation system.
c. Evidence of the thrombotic process includes patchy necrosis of the skin, hematuria and oliguria, confusion caused by cerebral ischemia, gastrointestinal bleeding, and hemorrhage into the adrenal cortex causing acute onset of hypotension.
ii. Maintaining adequate capillary flow.
iii. The use of intravenous fluids to maintain volume, and sometimes vasodilators to open the arterioles, is indicated.
iv. If insufficient blood flow is related to the inability of a damaged heart to pump, the use of drugs such as dobutamine may be indicated.
v. Viscosity may be affected by an increased hematocrit concentration, and therefore a plasma expander may be beneficial.
vi. If there is active bleeding, hemostatic factors should be replaced with FFP, which is usually sufficient to correct the hypofibrinogenemia; cryoprecipitate, which also provides fibrinogen (250 mg/10 mL); and platelet concentrates.
vii. Heparin is not helpful in acute forms of DIC, but the drug is indicated for purpura fulminans or venous thromboembolism.
viii. Fibrinolytic inhibitors such as EACA may be used to block the accumulation of degradation products but are dangerous if the thrombotic process is still active. They should not be used without prior effective antithrombotic treatment with heparin.