Diagnosing Disseminated Intravascular Coagulopathy in Acute Promyelocytic Leukemia

Beth McCraw, ARNP, ACNS-BC, OCN; Debra E. Lyon, RN, PhD, FNP

Disclosures

Clin J Oncol Nurs. 2008;12(5):717-720. 

In This Article

Treatment and Management

Similarly to the complexity of diagnosing DIC, the treatment and management of DIC is highly complex and individualized. Treatment involves eliminating the etiologic process causing DIC, restoring homeostasis of the coagulation pathway, and maintaining organ function during the acute events. Identifying the underlying pathology is the only definitive treatment for DIC; all other measures are supportive therapies. After treatment of the underlying pathology, patients will require supportive care with blood products, oxygen, and fluid replacement. Depending on the individual patient's initial presentation, they also may require management of intravascular clotting or fibrinolytic inhibitors (Holmes-Gobel, 2002).

Chemotherapy

Patients diagnosed with APL must begin chemotherapy as soon as possible. Induction treatment for the patient with APL consists of cytarabine for seven days, idarubicin or daunorubicin for three days, and all-transretinoic acid. The initiation of chemotherapy causes cytotoxic effects to the promyelocyte blast cells causing DIC. By treating the patient's APL, treatment of the underlying etiologic process of DIC is initiated. During the initiation of chemotherapy, the patient also will require supportive care.

Blood Products

Patients may require platelets, packed red blood cell, fresh frozen plasma (FFP) or cryoprecipitate transfusions. Decision to transfuse depends on the patient's laboratory results. See Table 2 for laboratory results indicative of the need for blood product transfusions. A controversy regarding platelet, FFP, or cryoprecipitate transfusions, continues because they may initiate additional formation of clots (Teal, 2007).

Heparin

The use of heparin in DIC is controversial and contraindicated in patients whose central nervous system is or may be compromised as well as in patients who are moderately thrombocytopenic (< 50,000/mm3) (Holmes-Gobel, 2002). Heparin reduces the production of thrombin, but minimal research evidence supports the use of heparin in patients with DIC (Holmes-Gobel, 2002; Kaplow & Hardin, 2007; Lewis, 2005).

Fibrinolytic Inhibitors

Fibrinolytic inhibitors, such as epsilon aminocaproic acid and tranexamic acid, rarely are initiated (Holmes-Gobel, 2002). Fibrinolysis is required to clear the circulation of thrombi; therefore, the use of fibrinolytic inhibitors can cause fatal disseminated thrombosis and result in multi-organ dysfunction (Holmes-Gobel, 2002; Teal, 2007). The use of fibrinolytic inhibitors only is indicated when other therapies have been unsuccessful.

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