Disseminated intravascular coagulation (DIC)
results from a series of complex changes in the haemostatic and coagulation function within the blood. It occurs in numerous clinical settings, I though a review of the literature suggests that it is a rare complication of total hip replacement. 2 -4 This case study describes a patient who developed DIC in the immediate postoperative period following bilateral total hip replacement.
Disseminated intravascular coagulation (DIC)
CASE HISTORY An 82-year-old male, weight 66 kg, was admitted for elective bilateral total hip arthroplasty to treat severe osteoarthritis. The disease process was confined to the hip joints. The patient had never previously been anaesthetised, was receiving no drug therapy, had no drug allergy and had no serious health problem. Postoperative epidural analgesia was explained and the patient premedicated with temazepam 20 mg orally. General anaesthesia was induced with thiopentone 200 mg and suxamethonium 75 mg was given to aid tracheal intubation. Anaesthesia was maintained with nitrous oxide 70%, oxygen 30% and enflurane 0.8% with pancuronium 6 mg given to facilitate intermittent positive pressure ventilation. A lumbar epidural catheter was inserted using a lossof-resistance technique, though no drugs were administered through it during the procedure. Intra-operative monitoring included ECG, automatic indirect blood pressure recording, pulse oximetry and capnography.
Disseminated intravascular coagulation (DIC)
Fifty-five minutes after induction of anaesthesia, acrylic cement (polymethyl methacrylate) was inserted into the acetabulum of the first hip. This resulted in a transient decrease in systolic BP to 80 mmHg from its peroperative stable range of 105-110 mmHg. This was not associated with any change in either the arterial oxygen saturation or end-tidal carbon dioxide concentration. The hypotension responded to a rapid infusion of 500 ml compound sodium lactate solution within five minutes. Hypotension was not associated with the three further implantations of cement at 85, 140 and 160 minutes. The total measured blood loss was 2600 ml and intraoperative replacement was with 1500 ml crystalloid and six units of whole blood.
Disseminated intravascular coagulation (DIC)
Following discontinuation of the anaesthetic and reversal of residual neuromuscular blockade with glycopyrrolate 0.5 mg and neostigmine 2.5 mg IV, spontaneous respiration returned and the patient regained consciousness. He was extubated and transferred to the recovery ward breathing air enriched with oxygen 4 l/min via a Hudson mask.
Disseminated intravascular coagulation (DIC)
On arrival in the recovery ward it was noted that the Redivac drain bottles needed replacement, representing a blood loss of 700 ml in twenty niinutes. There was no hypotension but a marked tachycardia of 120 beats/min was noted. Two further units of blood were transfused following blood sampling for haemoglobin estimation, clotting studies and further cross-matching. The patient's condition deteriorated with a fall in blood pressure to 65 mmHg systolic and he was transferred to the Intensive Care Vnit (ICV) for further management.
Disseminated intravascular coagulation (DIC)
On arrival in the ICV he was conscious but confused, cold, and poorly perfused peripherally with a sinus tachycardia of 120 beats/minute and blood pressure of 65/40 mmHg. The Redivac bottles were draining approximately 600 ml per twenty-minute period. He was transfused a further six units of blood, 4.5 litres of colloid and five units of fresh frozen plasma. Results of clotting studies, haemoglobin and platelet count at this time, two hours postoperatively, are shown in respiratory effort and reduced arterial oxygen saturation. Central venous pressure and direct intra-arterial monitoring were instituted. Sedation was provided with an intravenous infusion of papaveretum commenced at 5 mglhr. The infusion of whole blood and colloid restored arterial pressure initially to a systolic of 100 mmHg. Renal protection was instituted with low-dose dopamine, 2.5 ~glkglmin and mannitol 20 g. Following consultation with a senior haematologist twelve units of cryoprecipitate, six units of fresh frozen plasma and four units of pooled platelet concentrate were administered, along with whole blood to maintain a systolic arterial pressure greater than 100 mmHg. Further measurements of haemoglobin, platelets and clotting studies were made three hours following the completion of the replacement therapy (Table I) at which time the wound bleeding had decreased to an acceptable rate of less than 50 ml/hr.
Disseminated intravascular coagulation (DIC)
A dobutamine infusion (1 0 ~glkglmin) was started twelve hours postoperatively as arterial pressure fell to 80 mmHg systolic despite a central venous pressure of 20 cm of water.
Disseminated intravascular coagulation (DIC)
In the subsequent postoperative period, the patient required a further transfusion of three units of blood to maintain a haemoglobin of 100 gllitre, though there were no further coagulation problems. The postoperative period was further complicated by the onset of acute renal failure and several episodes of sepsis. Despite aggressive therapeutic and supportive measures, the patient died seventeen days postoperatively.
DISCUSSION
Disseminated intravascular coagulation is a disorder characterised by a pathological activation of the coagulation system with formation of fibrin. Clotting factors and platelets are consumed and there is a secondary activation of fibrinolysis. There is often an associated bleeding diathesis, circulatory collapse and ischaemic tissue damage to one or more organs. Excellent classifications and reviews may be found in the literature. I , 5, 6 There are many clinical conditions associated with DIC,I amongst them surgery, trauma/,s fat embolism, transfusion reaction and massive blood transfusion. 9 The common triggering factor is the release of tissue thromboplastins into the circulation. I Despite the release oflarge amounts of thromboplastin during reaming of the femur 2 and impaction of the femoral prosthesis,lo this syndrome has rarely been reported as a complication of total hip replacement. [2] [3] [4] In two cases there were associated pathological abnormalities, namely, metastatic carcinoma ofthe proximal femur and massive ectopic bone formation. In the third case DIC complicated a total hip replacement in a fit patient who had previously undergone a replacement of the opposite hip. The immunological mechanism has previously been implicated as a provoking factor l and in this case 2 the author postulated that the DIC was triggered by an immune response to the acrylic cement. The specific association between an immune response to acrylic cement as a trigger for DIC is not proven.
DISCUSSION
The patient had received six units of whole blood prior to the onset of circulatory collapse and increased clinical bleeding. On rechecking none of the transfused blood was found to be incompatible, nor was the amount transfused usually associated with the activation of DIC9 or with haemorrhage due to clotting factor deficiency in a previously healthy patient. ll No clinical evidence of significant fat embolism was detected, with stable arterial oxygen saturation and end-tidal carbon dioxide concentration throughout the perioperative period. However, in a prospective study, fat embolism was detected in all cases of hip arthroplasty studied. 12 Despite the severe derangements of the clotting studies, the level of fibrin degradation products (FDP) were at no time greater than 40 ~glml. Initial 6 In these cases the prognosis is much worse, usually due to irreversible organ failure.
DISCUSSION
The management of this episode ofDIC followed conventional lines ofreplacement of the consumed platelets and clotting factors, 6 but was not treated with heparin. CONCLUSION DIC is a rare complication of total hip replacement, even though the known trigger events of tissue damage and fat embolism l2 are unavoidable.
DISCUSSION
Tissue thromboplastins are released during hip surgery and may be detected in venous blood. 10 The release of excessive amounts of tissue thromboplastin secondary to the trauma of bilateral hip replacement surgery is the most likely feature to have triggered the syndrome in this case.
DISCUSSION
It is hoped that the report will raise awareness of the connection between this operation and DIC, and thus allow early recognition and treatment of the condition.
DISCUSSION
virulence of invasive group A beta-haemolytic streptococci,2 The unpredictable rapidity and severity of an underlying streptococcal infection with disastrous consequences only just avoided are illustrated in this case.
CASE HISTORY
A 25-year-old previously healthy primigravida was admitted to our ICU tachypnoeic, cyanosed with very poor peripheral circulation and hypotension four days after an uneventful vaginal delivery with episiotomy. During the last two days she was depressed in mood and had vague

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