equis - Articles
Disseminated intravascular coagulation
Synonym(s): DIC, endotoxemia
Introduction
- A coagulopathy triggered by a primary disease; presents as low grade thrombosis or hemorrhagic diathesis and possibly shock.
- Cause: systemic inflammatory response syndrome is the most common cause.
- Signs: petechiae, ecchymoses of mucous membranes; thrombosis or hematoma following venipuncture; epistaxis, melena; associated primary cause.
- Diagnosis: clinical signs of SIRS and DIC, assessment of hemostatic system.
- Treatment: as for primary disease; fluid therapy Fluid therapy: overview +/- anticoagulants, eg heparin or aspirin; as for sequelae.
- Prognosis: depends on severity and management of primary disorder; potentially catastrophic and can result in multi-organ dysfunction/failure characterized by laminitis Foot: laminitis or respiratory distress, neurological signs or colic.
Presenting signs
- Predisposing cause, eg:
- SIRS Systemic inflammatory response syndrome secondary to gastrointestinal disorders, eg strangulating small intestinal lesions.
- Postpartum complications, eg metritis Metritis-laminitis-septicemia complex .
- Sepsis.
- Severe drug reactions.
- Immune-mediated reaction, eg anaphylaxis Anaphylaxis .
- Hypoxic-ischemic encephalopathy (foals).
- Acute hemorrhage.
- Thrombotic or hemorrhagic lesions, eg petechiae, ecchymoses Blood: petechiae / ecchymoses / bruising .
- Excessive bleeding from venipuncture site.
- Epistaxis, melena (severe cases).
Acute presentation
- DIC always presents acutely secondary to a primary disease which results in SIRS.
- DIC will not present alone so clinical signs usually reflect the primary underlying disease..
Age predisposition
- Foals in septic shock are susceptible to DIC but it can occur at any age.
Cost considerations
- Once a horse/foal has gone into DIC the prognosis is extremely poor and considerable intensive treatment is required to treat them.
- The treatments are often very expensive.
Special risks
- It is not recommended to anesthetize a horse in DIC as they can become profoundly hypotensive.
Pathogenesis
Etiology
- SIRS caused by:
- Colic - eg strangulation or obstruction Colon: small - obstruction Inguinal ring: hernia .
- Enterocolitis Colon: colitis .
- Laminitis Foot: laminitis .
- Acute hemorrhage, eg post-operative.
- Metritis Metritis-laminitis-septicemia complex .
- Peritonitis Abdomen: peritonitis .
- Trauma.
- Anaphylaxis Anaphylaxis .
- Drug reactions.
- Neoplasia.
Pathophysiology
- Primary disease results in SIRS with an overwhelming inflammatory response.
- The inflammatory response (in particular TNF-alpha, IL1 and IL6) → activation of intrinsic coagulation, reduction in fibrinolysis and increased fibrin formation.
- Fibrin deposits in microvasculature = general and visceral microthrombi.
- Primary disease → increase of systemic procoagulant substance(s) or endothelium dysfunction that allows exposure of collagen to platelets
- Decreased perfusion → vascular ischemia (eg digital ischemia → laminitis) → fibrinolysis.
- Fibrin degradation products (anticoagulants) → into circulation → hemorrhage.
Timecourse
- Usually low grade or fulminant.
- Most commonly detected when fulminant.
Diagnosis
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Treatment
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Prevention
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Outcomes
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Further Reading
Publications
Refereed papers
- Recent references from PubMed and VetMedResource.
- Cesarini C et al (2010) Association of admission plasma D-dimer concentration with diagnosis and outcome in horses with colic. J Vet Intern Med 24 (6), 1490-1497 PubMed.
- Dunkel B et al (2010) Association between hypercoagulability and decreased survival in horses with ischemic or inflammatory gastrointestinal disease. J Vet Intern Med 24 (6), 1467-1474 PubMed.
- Monreal L & Cesarini C (2009) Coagulopathies in horses with colic. Vet Clin North Am Eq Pract 25 (2), 247-258 PubMed.
- Dallap B L (2004) Coagulopathy in the equine critical care patient. Vet Clin North Am Eq Pract 20 (1), 231-251 PubMed.
- Jarvis G E & Evans R J (1994) Endotoxin-induced platelet aggregation in heparinised equine whole blood in vitro. Res Vet Sci 57 (3), 317-324 PubMed.
- Welch R D et al (1992) Disseminated intravascular coagulation associated with colic in 23 horses (1984-1989). J Vet Intern Med 6 (1), 29-35 PubMed.
- Morris D D (1988) Recognition and management of disseminated intravascular coagulation in horses. Vet Clin North Am Equine Pract 4, 115-143 PubMed.