CCCSIRS, ARDS and DIC following

ischemic stroke in a patient with SLE

LeeChuy, KatherineLee, Sidney Abert

Lerma, Daniel JosephLegaspi, Roberto Jose

Li, Henry WinstonLi, Kingbherly

Lichauco, RafaelLim, Imee Loren

Lim, Jason MorvenLim, John Harold

Lim, MaryLim, Phoebe RuthLim, Syndel Raina

Lipana, Kirk AndrewLiu, Johanna

Llamas, Camilla Alay

1. What are the risk factors for thrombosis in SLE?

• Demographic characteristics– Age, gender, ethnicity

• Increased prevalence of traditional cardiovascular risk factors– Hypertension, diabetes mellitus, proatherogenic lipid

profile, elevated homocysteine levels, obesity, sedentary lifestyle, early menopause

• Acquired thrombosis triggers– Smoking, oral contraceptives, hormone replacement

therapy, pregnancy, prolonged hospitalization, immobilization, surgical procedures

• Genetic hypercoagulable states

Erkan, Doruk.(2006) Editorial: Lupus and thrombosis, The Journal of Rheumatology 2006; 33:9, retrieved on September 28, 2010 from: http://www.jrheum.com/subscribers/06/09/1715.html

• Acquired lupus-specific risk factors– Chronic inflammation, renal disease,

corticosteroid use (controversial), vasculitis, Libman-Sacks endocarditis, anti-oxidized LDL antibodies, elevated C-reactive protein and proatherogenic cytokines

• Persistent antiphospholipid antibodies– Positive lupus anticoagulant test, moderate-

to-high titer anticardiolipin and anti-ß2-glycoprotein-I antibodies

Erkan, Doruk.(2006) Editorial: Lupus and thrombosis, The Journal of Rheumatology 2006; 33:9, retrieved on September 28, 2010 from: http://www.jrheum.com/subscribers/06/09/1715.html

2. Describe the pathophysiology of SIRS

Mark S. Klempnernetal. Case 25-2010: A 24-Year-Old Woman with Abdominal Pain and Shock. new england journal of medicine 363;8 august 19, 2010

3. Define ARDS

Acute Respiratory Distress Syndrome

• A clinical syndrome of severe dyspnea of rapid onset, hypoxemia, and diffuse pulmonary infiltrates leading to respiratory failure.

http://www.harrisonspractice.com/practice/ub/view/Harrisons%20Practice/141281/all/Acute_Respiratory_Distress_Syndrome

4. Describe the pathomechanisms in DIC

Pathomechanisms in DIC• acute, subacute, or chronic

thrombohemorrhagic disorder characterized by the excessive activation of coagulation, which leads to the formation of thrombi in the microvasculature of the body

• Two major mechanisms: (1) release of tissue factor or thromboplastic substances into the circulation, and (2) widespread injury to the endothelial cells

Robbins and Cotran Pathologic Basis of Disease, 8th ed.

Pathomechanisms in DICEndothelial Injury

• Exposure of subendothelial matrix leads to activation of platelets & both coagulation pathways

• Increased TNF in sepsis– induces endothelial cells to express tissue factor on their cell

surfaces & to decrease the expression of thrombomodulin– upregulates expression of adhesion molecules on endothelial

cells, promoting the adhesion of leukocytes (ROS & preformed proteases)

Robbins and Cotran Pathologic Basis of Disease, 8th ed.

Pathomechanisms in DICEndothelial Injury

• Deposition of antigen-antibody complexes (e.g., systemic lupus erythematosus), temperature extremes (e.g., heat stroke, burns), or microorganisms (e.g., meningococci, rickettsiae)

• Subtle endothelial injury causes coagulation by enhancing membrane expression of tissue factor

Robbins and Cotran Pathologic Basis of Disease, 8th ed.

Pathomechanisms in DICConsequences of DIC

• Widespread deposition of fibrin – ischemia – microangiopathic hemolytic anemia

• Consumption of platelets & clotting factors, & activation of plasminogen

– Plasmin cleaves fibrin & digests factors V and VIII– Fibrin degradation products resulting from fibrinolysis inhibit

platelet aggregation, fibrin polymerization, and thrombin– hemorrhagic diathesis

Robbins and Cotran Pathologic Basis of Disease, 8th ed.

Pathophysiology of DIC

Robbins and Cotran Pathologic Basis of Disease, 8th ed.

5. Enumerate the risk factors for SIRS, ARDS and DIC and cite those that are

present in the patient

Risk factors for ARDS

• The risk of developing ARDS are increased in patients suffering from more than one predisposing medical or surgical condition

• OTHERS– older age– chronic alcohol abuse,

metabolic acidosis– Use of mechanical ventilator– Heavy drinker– severity of critical illness

Risk factors for SIRS

• young and elderly people• Severe trauma• Complication of Surgery• Burns• Immunodeficiency (Treatment with chemotherapy drugs or radiation) • Transplantation• People with long-standing diabetes, AIDS, or cirrhosis • Infection such as:

– Pneumonia– Meningitis– Cellulitis – Urinary tract infection – Ruptured appendix– Acute pancreatitis

Risk factors for DIC

Risk factors present in the patient

Brain Injury (infarct in Left MCA)

Respiratory Distress Syndrome

Pneumonia

Metabolic Acidosis

Altered Mental StatusGCS9, aphasia

Use of mechanical Ventilator

6. Outline the management of febrile neutropenia