Heri Fadjari

Div. of Hematology Medical Oncology

Dept. of Internal Medicine
Hasan Sadikin General Hospital

CASE
A 46 y.o, 60 kg woman was struck by angkot. She
was transported to hospital and received 1 liter of
crystalloids for blood pressure support.
In the next few hour, patient was noted to be
hypotensive, tachycardic with abdominal distention and
a bloody abdominal tap.
A type and crossmatch for 6 units of packed red blood
cells (PRC) was drawn and she was rushed to the OR
for an exploratory laparotomy.

Laboratories values on admission

Blood type: A+, antibody screen negative
Hct = 18 %
Hgb = 6 g/dL
Platelet = 180,000
PT = 16 sec.
PTT = 50 sec.
Fibrinogen = 240 mg/dL

Given the patient's blood type (ABO/Rh), what

blood groups may she safely be transfused with:

A. Packed red cells

B. FFP
C. Whole blood
D. Washed red cells
E. Cryoprecipitate

A laparotomy showed multiple contusions and

lacerations of the liver and rupture of the spleen.
After an hour, an additional 10 units of whole blood
were ordered and 4 units FFP.
At the end of six hours, the patient had been
transfused with a total of 10 units PRC, 10 unit WB,
4 units FFP and 2 liters of crystalloids.

The surgeon notes diffuse bleeding from

multiple sites in the surgical field.

Repeat labs show:

Hct = 16 %
Hgb = 5 g/dL
Platelet = 20,000
PT = 23 sec (control 17 sec)
PTT = 97 sec (control 32 sec)
Fibrinogen = 65 mg/dL (normal 150-340)
d-Dimers + 2000 ug/mL (normal <500)

What is the etiology of the patient's abnormal

coagulation studies?
A. Dilutional coagulopathy
B. Dilutional thrombocytopenia
C. Coagulation factors deficiency due to liver
damage
D. Primary fibrinolysis
E. Unknown etiology

What should be ordered from UTD to correct the

patient's coagulopathy?

A. Platelets and fresh frozen plasma

B. Platelets, cryoprecipitate, and FFP
C. Whole blood
D. Fresh Whole blood
E. PRC and cryoprecipitate

After transfusion, repeated laboratory testing

shows:
Hct = 26 %
Hgb = 8.6 g/dL
Platelet = 60,000
PT = 19 sec.
PTT = 100 sec.
Fibrinogen = 130 mg/dL
However, the patient is continuing to actively bleed
at a rate of 500 mL/30 min.

Given the most recent laboratory data and the

presence of surgical bleeding, what should you
order?
A. Fresh frozen plasma
B. Stored Whole blood

C. Cryoprecipitate
D. Fresh whole blood
E. Platelets concentrate

CASE
A 30 year-old pregnant woman presents to the
emergency room with third trimester vaginal bleeding
and the sudden onset of marked pelvic pain.
She is quickly admitted to the labor and delivery floor,
where fetal monitoring shows severe fetal distress and
ultrasound reveals placental abruption.
An emergent cesarean section is performed, a few
minutes later the vaginal bleeding increases notably.

Laboratory tests are ordered and the results are

as follows:
PT = 60 seconds (normal = 10.7-15 seconds),
PTT = 95 seconds (normal = 25-40 seconds),
Platelet count = 15 X 109/L (150-450 X 109/L),
Hematocrit = 25% (normal = 37-51%),
Fibrinogen = 30 mg/dL (normal = 150-350
mg/dL), D-Dimer >1000
sGOT = 56 mg/dL, sGPT = 62 mg/dL,
LDH = 868 mg/dL

What process is occurring to cause the increased

bleeding in this case?
1. Dysfibrinogenaemia
2. Disseminated intravascular coagulation
3. Inherited coagulation defect
4. Atonic uterine bleeding

What the best treatment is indicated in this situation?

1.
2.
3.
4.

Cryoprecipitate.
Platelets concentrate
Antithrombin III
Heparin

CASE
A 28-year-old man was admitted to the hospital
because of fever.
The patient had been in excellent health until two weeks
earlier, when fever developed. The next day he had
fatigue, anorexia, and malaise, which waxed and waned.
He frequently had meals at warteg.
On admission, his temperature was 40.6C, with severe
headache. The pulse was 86 bpm, and the respirations
were 24. The blood pressure was 105/80 mm Hg.

On the second hospital day, the patient became

dyspnoe and cyanotic. The urinary volume declined
to 10 ml hour.
Examination revealed hypotension, with petechiae
and purpura on the hands, feet, and chest.
Radiographs of the chest showed bilateral pulmonary
infiltrates.

Peripheral blood smear showed a MAHA (microangiopathic

hemolytic anemia) with marked red cell fragmentation and
severe thrombocytopenia, which is characterized of DIC

Laboratory tests are ordered and the results are as

follows:
Hb = 9.8 g/dL, WBC = 2.2 x 109/L
Platelets = 18 X 109/L (150-450 X 109/L),
PT = 32 seconds (normal = 10.7-15 seconds),
PTT = 46 seconds (normal = 25-40 seconds),
Fibrinogen = 388 mg/dL (normal = 150-350 mg/dL),
d-Dimer = 2000
LDH = 868 mg/dL
Ureum = 112 mg/dL, creatinine = 9.8 mg/dL

What aspects of this patients clinical presentation

suggest a primary source of septicemia?
1.
2.
3.
4.

Gram (+) sepsis

Gram (-) sepsis
Viral infection
Fungal infection

Despite empirical antibiotic treatment, what should we

give to this patients?
1. Platelet concentrate
2. Antithrombin III
3. High dose steroid
4. Heparin

Gram (+)ve can trigger sepsis by

at least two mechanisms:
Exotoxins that acts as superantigen

- Induces T cell activation w/o regard to antigenic

specitivity.
- Interact directly with MHC class II receptors on
macrophages.
Release cell membrane fragments that activate the
sequence of
processes culminating in septic shock,
which trigger the release of
cytokine, the generation
of complement, aggregation of platelets,
and an
increase in cell membrane permeability.

Gram (-)ve in triggering

an inflammatory reaction
LBP

endotoxin
(LPS)

CD14
TNF-
ProIL-1, IL-6
inflammatory
PAF
mediators
MAP-1

Inflamation
Proinflamatory
mediators

Anti-inflamatory
mediators
INFECTION

Endothelial injury

TF

Tissue
factor
Coagulation
cascade
TNF-
IL-1

Tissue
factor

Tissue
factor

Microvascular
thrombosis

Thrombin
TNF-
IL-1
IL-6

Tissue
factor

Inflammation

Endothelial cell
dysfunction

P-selectin

Severe Sepsis:
The Final Common Pathway
Endothelial Dysfunction and
Microvascular Thrombosis

Hypoperfusion/Ischemia

Acute Organ Dysfunction

(Severe Sepsis)
Death

Clinical manifestation
Altered
Consciousness
Confusion
Psychosis

Tachypnea
PaO2 <70 mm Hg
SaO2 <90%
PaO2/FiO2 300
Jaundice
Enzymes
(LDH)
Albumin
PT

Tachycardia
Hypotension
CVP
PAOP
Oliguria
Anuria
Creatinine

Platelets
PT/APTT
Protein C
D-dimer

DIC scoring system

Laboratory Study
PT ratio (INR)
Fibrinogen(g/l)
d-Dimer
Platelet Count(x103/m l)

Symptoms of bleeding
Organ failure due to thrombosis

Values

score

1.25-1.66

>1.67
1.00-1.50
<1.00
500-1000
>1000
80-120
50-80
<50
Positive
Positive

2
1
2
1
2
1
2
3
1
1

The Japanese Ministry of Health and Welfare (1988): DIC 7

A typical findings of laboratory tests

in compensated vs decompensated DIC:
Tests

aPTT
PT
Platelets count

Fibrinogen
AT III
d-Dimer

Compensated

Decompensated

N or
N or
N or

N or

N or