Table 2 Diagnosing the pathophysiology of thrombocytopenia-associated multiple organ failure
Diagnostic criteria | Treatment | |
|---|---|---|
TTP | Fever | Steroids for 24 hours |
Thrombocytopenia | Within 30 hours perform 1 1/2 volume plasma exchange then 1 volume daily until resolution of thrombocytopenia (median 18 days [18]) | |
Increased LDH | ||
Schistocytes >5% | If recalcitrant use cryopreserved supernatant | |
Neurological and renal dysfunction | If continues at 28 days use vincristine | |
DIC | Thrombocytopenia | Reverse shock and underlying disease (increase flow with fluids and consider vasodilators – nitroglycerin, milrinone, pentoxyfilline) |
Decreased factors V and X, and fibrinogen | ||
Decreased antithrombin III and protein C | Replace clotting factors with FFP, cryoprecipitate and platelets via plasma infusion or plasma exchange | |
Increased D-dimers | ||
Prolonged PT/aPTT | Anticoagulate with heparin, protein C, activated protein C, antithrombin III, or prostacyclin | |
Use fibrinolytics for life or limb threatening thrombosis. Remember to keep PT/aPTT and platelets normal when giving fibrinolytics | ||
Give anti-fibrinolytics if life threatening bleeding (rarely needed when PT/aPTT and platelet counts are maintained) | ||
Secondary TMA | Thrombocytopenia | Remove source of secondary TMA |
Increased LDH | Activated protein C for adult severe sepsis [26] | |
Normal or elevated fibrinogen | TTP based plasma exchange (median 9 days [51]; median 12 days for children (Nguyen, 2006, submitted) | |
<5% schistocytes | ||
Multiple organ failure |