ISTH International Society

on

Thrombosis and Haemostasis

ISTH

Russian Association on Thrombosis

Haemostasis and Vascular Pathology

n.a. A.A.Schmidt-B.A.Kudryashov

First Moscow State Medical University

n.a. I.M.Setchenov

RUSSIAN ASSOCIATION ON THROMBOSIS,

HEMORRAGE AND VASCULAR PATHOLOGY

named after А. А. SCHMIDT - B.А.KUDRYASHOV

ISTH International Society on

Thrombosis and Haemostasis EDUCATIONAL COURSE

Thrombosis, Thrombophilias, DIC and Thrombolytic Therapy.

Moscow17-19 September 2014

YOU

ARE

WELCOME !!!

DICand

HOW WE UNDERSTAND

it in RUSSIA

I.N.BokarevMoscow

ISTH EDUCATIONAL COURSE

17.09.2014

TFPITFPI

AT AT

APC

APC

XIIa XII

Kallikrein Prekallikrein

HMWK

Tissue factor molecule

НАРУШЕНИЯ ГЕМОКОАГУЛЯЦИИ

ВЫЗЫВАЮТ:

ГЕМОРРАГИИ

ТРОМБОЗЫ

ДВС-СИНДРОМ

ИНТЕНСИВНОСТЬ ВНУТРИСОСУДИСТОГО

МИКРОСВЕРТЫВАНИЯ КРОВИ

МОЖНО ОПРЕДЕЛИТЬ

на основании измерения

фибринопептида А

D-димера

b - тромбоглобулина

4-го фактора тромбоцитов

DIC

Syndrom

Волтер Сиггерс 1910-1996

The reasons of my presentation:

1. To restrict the unnecessary use

the DIC expression, to remind how it

was originated.

2. To resolve debatable questions on

definitions and detection of DIC

by introducing the conception of the

Constant Intravascular Microcoagulation.

3. Stop to use the term

“hypercoagulability”

The reasons of my presentation:

1. To restrict the unnecessary use

the DIC expression, to remind

how it was originated. 2. To resolve debatable questions on

definitions and detection of DIC

by introducing the conception of the

Constant Intravascular Microcoagulation.

3. Stop to use the term

“hypercoagulability”

DIC - is a very dangerous state.

For the Doctor the DIC diagnosis requires

a very quick actions, because the patient

can die during several hours .

Prevalence of DIC

• People who arrive to hospital 1 in 1000

G. Мuller-Веrghaus

1 in 867 J.Zilbut

• Acute leukemia - 15-20%

• Septicemia (if it is Gram-negative or Gram-positive microbes) - 30-50%

• Severe injury - 50-70 %M. Levi

D. McKay

Term of DIC was proposed in USA by young American pathologist Donald МсКау in 1950 , when he made the autopsy. D. МсКау discovered a lot of thrombus in the vessels in the body of woman, who had died in obstetric hospital because of bleeding disorders. He proposed the term-Disseminated Intravascular Coagulation which was coined.

The senior collegues of D.McKay - С.Schneider and W. Siggers made public this term. The term DIC - syndrome got wide use in medicine after 4th American congress of obstetricians in 1951 where С.Schneider and W. Siggers reported the case of D.McKay.

Walter Siggers 1910-1996

Schneider CL. “Fibrin embolism”(disseminated intravascular coagulation) with defibrination as one of the end results during placenta abruptio.

Surg.Gynec.Obstet.92:27-34. Jan 1951

Schneider CL: Fibrin embolism (disseminated intravascular coagulation) and the etiology of eclampsia. J. Obst. Gynaec. Brit Emp. 58: 538-554.Aug.1951

DIC attracted high attention of the medicine

By :

1. Its dangerous to the life

2. Unusual way of development-

thrombosis induced bleeding

- Н. Lasch - consumption coagulopathy

- H. Selye and М.Machabeli - thrombo-hemorragic syndrom

- С. Оwen and W. Воwie - Intravascular blood coagulation and fibrinolysis

С. Оwen in his experimental works with the animals, when he infused thromboplastin to the dogs, had got not the bleeding, but increase some of the procoagulant in their blood. Those data allowed him to say, that the DIC may be the chronic- and from those time appeared new term- the “Chronic DIC-syndrome”. It was done in 1970-th.

The reasons of my presentation:

1. To restrict the unnecessary use

the DIC expression, to remind how it

was originated.

2. To resolve debatable questions on

definitions and detection of DIC

by introducing the conception of the

Constant Intravascular Microcoagulation.

3. Stop to use the term “hypercoagulability”

Types of the DIC- syndrome

• Compensated and decompensated DIC G. Мuller-Веrghaus

• Chronic, subacute, Acute DIC С. Оwen

• Evident and latent DIC F.Тауlor

• Pre-DIC• Consumption Coagulopathy - Н. Lasch • Thrombo-hemorragic syndrom - H. Selye and М.Machabeli ,

The finding of D.McKay and C.Owen very much stimulated the investigation of the process of fibrin formation.

By B. Blomback, M. Blomback, B. Lipinsky and V. Gurevich, U. Abildgaard, P. Gaffney, S. Niewiarovsky, K.Rucinski and others. was proposed the methods to detect FDP, soluble fibrin-monomer, D-dimer, β-thromboglobulin, the platelets factor - 4 and at last TPP, for the investigation of the fibrin formation.

And the investigations in this area began to be done.

The possibility of determination the markers of fibrin-formation and the activity of platelets component of blood coagulation made it possible to found out the difference in their intensity and to suggest that they are relatively independent from each other.

Investigations, that we had done on the large body of patients with chronic pathology, gave us the information about the fibrin formation and platelet activity as the parts of intravascular microcoagulation at patients with different diseases.

We studied the state of intravascular fibrin

formation with the help of TPP( thrombus protein precursor), which detect the fibrin-monomer without fibrinopeptids А and В. We took the patient with the opposite clinical picture- thrombosis and bleeding. The level of TPP was measured at the patients with acute coronary syndrome and at the hemophiliac.

In the blood of people, who had the hemophilia, the level of TPP was higher, than it was at the healthy people

INTENSITY OF INTRAVASCULAR MICROCOAGULATION MAY BE

MEASURED BY the level of:

Fibrinopeptide- A

D-dimer

b - thromboglobulin

Platelet factor- 4

Constant intravascular microcoagulation

Constant presence of the markers of intravascular coagulation in plasma of healthy and sick people gave us the reason to think, that the intravascular microcoagulation of the blood is going permanently, and there is need to show its existence by the term “Constant intravascular microcoagulation”- CIMC .

Grades OF the CONSTANT INTRAVASCULAR MICROCOAGULATION

of BLOOD

1-st grade

NORMAL CIMC

Levels of CIMC markers are “ normal” .

2-nd grade

TRANSIENT

INCREASED CIMC

Levels of CIMC markers increased, but it is unstable and does not produce special clinical changes in the main disease picture.

3-d grade

SUSTAINED

INCREASED CIMC

Levels of CIMC-markers is increased. This state is stable, but does not have special clinical manifestations. There is hope,that Its regulation may be important and may increase the positive outcome of the disease.

4th grade

CIMC-

DIC-SYNDROM

Increase of the constant intravascular coagulation is going sharply and produce the impact on the organs function, threatening to the life of the patients ( DIC-syndrom)

DEFINITION of DIC

DIC is the phenomena of acute and intensive formation of intravascular microclots, that are generated in the microvessels level. They can get different morphologic structure, different forms of clinical manifestation and lead to acute dysfunction of organs and

tissues is the threat to life.

Constant intravascular microcoagulation

DIC-syndrome is only the highest stage of CIMC, where the increase of its intensity is an independent cause of the damage of body-organs and body-tissues and may manifest itself by the bleeding, multiple organ damage, hypotony, micro- and macro- thrombosis and its different combinations.

It may be used by the doctor in the following way:

- He will know, that the blood in the body is clotting constantly, and that the patients with the chronic disease every time have the permanent increase of the blood clotting. The term “ hypercoagulation” is unnecessary.

- Doctor must know, that the possibility of thrombosis depends from the main disease and from the ability of the patients blood to coagulate

(thrombophilia).

CIMC conception

resolves all debatable questions on definition and get the practicaly useful information about DIC

There is no need to look for the chronic DIC, as the clotting of blood is going constantly.

The reasons of my presentation:

1. To restrict the unnecessary use

the DIC expression, to remind how it

was originated.

2. To resolve debatable questions on

definitions and detection of DIC

by introducing the conception of the

Constant Intravascular Microcoagulation.

3. Stop to use the term

“hypercoagulability”

Identification of the level of the markers of the intravascular blood microcoagulation couldn’t help to the doctor to predict the speed of progress of increasing of intravascular microcoagulation for reaching the 4-th stage of CIMC, which is the synonym of the acute DIC.

At each morbid events which characterized by high risk of DIC’s development, such as sepsis and other infections, neoplasms, traumatic and surgical tissue damage, obstetrical pathology, vascular lesions and vessels anomaly, autoimmune diseases, allergic reactions, the expectation of the development of DIC by the doctors must be constant. Only than it will be possible to do the right and early recognition of DIC.

Diagnosis of DIC

• Level of fibrinogen • Level of platelets

Progressive reduction of their level in combination with the clinical picture should be the reason for diagnosis of DIC and for the beginning of therapy.

We HOPE, that the use of the conception of Constant Intravascular Micro Coagulation will help You to treat Your patients.

Thank You

For Your Attention !