Condensed Case

A 20-year-old woman came through the emergency department with unspecified complaints. A CBC was ordered and her platelet count was recorded as 17.0 X 109/L. A repeat sample was ordered from the emergency department, and with this run, the platelet count was recorded as 6.0 X 109/L. The patient failed to delta check with her CBC history, revealing an admission 3 weeks prior with a platelet count of 250 X 109/L. The technologist called the physician immediately with the report of the thrombocytopenia and inquired as to the patient history.

What additional steps should the technologist take to ensure the accuracy of this result?


The first step that comes to mind is to check the specimen for clots. Improperly mixed specimens are notorious for containing small clots. Emergency department personnel may not be aware that blue-top tubes need to be inverted at least five times for proper mixing. This was done and no clots were observed. Next the technologist queried the physician as to whether or not this was an expected result. Although the physician was less than cooperative, he did reveal that the patient has undergone a cardiac procedure and that the initial consensus was that the thrombocytopenia was medication induced. The patient was admitted and transfused with platelet concentrates, and the platelet count rose to 56 X 109/L. No additional history is known at this time.

Treatment in Acute Disseminated Intravascular Coagulation

If the precipitating event leading to the DIC is discovered, then successful treatment will involve resolution of this pathology. Surgery in the case of obstetrical complications or widespread use of antibiotics in the case of septicemia may stem the bleeding episode. However, because many clinicians are perplexed as to the root cause of the precipitating events, judicious use of blood products will stop the bleeding. Fresh frozen plasma is a source of all of the clotting factors; packed red cells will restore oxygen-carrying capacity; and platelet concentrates will enable clot formation. Heparin has been used in DIC cases when combined with antithrombin. Although controversial, this agent may provide needed antithrombotic activity to delay excessive coagulation.

Summary Points

• Fibrinogen is the key substrate of the coagulation and the fibrinolytic system.

• Fibrinogen has the highest molecular weight of all of the clotting factors.

• Thrombin acts upon fibrinogen to convert it to fibrin.

• Fibrin is stabilized by factor XIII and calcium to become an insoluble clot.

• Plasminogen is converted to plasmin primarily through tissue plasminogen activator and then proceeds to destroy the fibrin clot.

Afibrinogenemia, hypofibrinogenemia, and dysfib-rinogenemia are all inherited disorders of fibrinogen. Each of these may also be acquired disorders. Streptokinase is an exogenous fibrinolytic agent, produced when a bacterial cell product forms a complex with plasminogen. Naturally occurring inhibitors of fibrinolysis are plasminogen activator inhibitor 1 and alpha-2-antiplasmin.

The byproducts of fibrinolysis are fibrin degradation products and D-dimers.

Excess fibrin degradation products provide anticoagulant activity.

D-dimers are produced from a cross-linked and stabilized fibrin clot.

Excess D-dimers are an indication that clots have been formed and are being excessively lysed. Disseminated intravascular coagulation (DIC) is usually triggered by an underlying pathological event.

In DIC patients will excessively clot or excessively bleed, or both.

Laboratory results for a patient with acute DIC will show a prolonged PT and PTT, decreased fibrinogen and platelets, and increased fibrin degradation products and D-dimers.

Treatment for DIC includes investigating and resolving the cause of the disorder and providing blood bank products as needed.

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