A 70-year-old intensive care unit patient complains of fever and shaking chills. The patient develops hypotension, and blood cultures are positive for gram-negative bacilli. The patient begins bleeding from venipuncture sites and around his Foley catheter. Laboratory studies are as follows:Hct: 38%WBC: 15,000/mLPlatelet count: 40,000/mL (normal 150,000-400,000)Peripheral blood smear: fragmented RBCsPT: elevated PTT: elevatedPlasma fibrinogen: 70 mg/dL (normal 200-400)Which of the following is the best course of therapy in this patient?
This patient with gram-negative bacteremia has developed disseminated intravascular coagulation (DIC), as evidenced by multiple-site bleeding, thrombocytopenia, fragmented red blood cells on peripheral smear, prolonged PT and PTT, and reduced fibrinogen levels from depletion of coagulation proteins. Initial treatment is directed at correcting the underlying disorder-in this case, infection. Although heparin was formerly recommended for the treatment of DIC, it is now used rarely and only in unusual circumstances (such as acute promyelocytic leukemia). For the patient who continues to bleed, supplementation of platelets and clotting factors (with fresh frozen plasma or cryoprecipitate) may help control life-threatening bleeding. Red cell fragmentation and low platelet count can be seen in microangiopathic disorders such as thrombotic thrombocytopenic purpura (TTP), but in these disorders the coagulation pathway is not activated. Therefore, in TTP the prothrombin time, partial thromboplastin time, and plasma fibrinogen levels will be normal. Plasmapheresis, vitamin K therapy, and RBC transfusion will not correct the underlying cause.
Begin heparin
Treat underlying disease
Begin plasmapheresis
Give vitamin K
Oncology