TROMBOSIS : DIAGNOSIS

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TROMBOSIS DIAGNOSIS PENATALAKSANAAN

• IRZA WAHID
• SUBAGIAN HEMATOLOGI ONKOLOGI MEDIK
• FK UNAND / RS DR M DJAMIL PADANG

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HEMOSTASIS - DIATESIS HEMORAGIS -
TROMBOSIS VaskularTrombosit Koagulasi
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A. VASKULAR Vasokonstriksi Aktifasi
trombosit Aktifasi faktor KoagulasiB.
TROMBOSIT Adesi Agregasi RX pelepasan isi
trombosit ? Granula padat ADP, ATP, Ca,
Epinefrin, Norepinefrin, ? Granula alfa
Fibrinogen, vWF, FV, PF 4, bTG,? Lisosom
Enzim asam hidrolaseC. SISTIM KOAGULASI VS
FIBRINOLISIS
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NOMENCLATUR FAKTOR PEMBEKUAN
DARAHI FibrinogenII ProtrombinIII Tissue
factorIV Ion calsiumV ProaccelerinVI -VII Pro
convertinVIII Anti hemophilic factorIX Plasma
tromboplastin componentX Stuart factorXI Plasma
tromboplastin antecedentXII Hageman
factorXIII Fibrin stabilizing factor - High
moleculer weight kininogen - Pre kalikrein
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Jalur intrinsik
Jalur Ekstrinsik
XII
VII
Kontak
XIIa
Tromboplastin Jaringan
Ca
HMWK
XIa
XI
IX
IXa
VIIa
PF3, VIII, Ca
Xa
X
V, PF3, Ca
Fibrinogen
Trombin
Protrombin
Fibrin Monomer
Fibrin Polimer Solubel
XIIIa
XIII
Fibrin Polimer Insoluber
Ca
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Intrinsik Extrinsik
Eksogen XIIa, Kalikrein
t-PA Urokinase Aktifator PlasminogenPlasm
inogen terikat Plasmin terikat Fibrin
FDPPlasminogen bebas
Plasmin bebas Fibrinogen Fc V, Fc
VIII Anti Plasmin
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TROMBOSIS
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What is thrombosis ?

• Thrombosis is the formation or presence of a
  blood clot inside a blood vessel or cavity of the
  heart

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Triad Virchow? Kelainan dinding pembuluh
darah kerusakan endotel hipertensi,
kateterisasi, anoksis , rokok, RX ag ab,
hiperkolesterolemia,
hiperhomosisteinemia ? Perubahan aliran darah ?
kerusakan endotel, perlambatan? Perubahan daya
beku darah Ggn keseimbangan sisitim koagulasi
dan fibrinolisiss
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Pathophysiology thrombosis
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Thrombosis

• Arterial thrombosis (white thrombus)
• Venous thrombosis (red thrombus)

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HIGH FLOW ARTERIAL CIRCULATION
White Thrombus
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SLOW FLOW VENOUS CIRCULATION
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Incidence of thrombosis in United States of
America

• Disease US incidence
  Total in US /year Definable
• /100.000 cases
  reason
• Deep Vein Thrombosis 159/100.000
  398.000 ? 80
  
• Pulmonary Embolus 139/100.000
  347.000 ? 80
• Fatal Pulmonary Emb. 94/100.000
  235.000 ? 80
• Myocardial Infarction 600/100.000
  1.500.000 ? 67
• Fatal MI
  300/100.000 750.000 ? 67
  
• Cerebrovascular thromb. 600/100.000
  1.500.000 ? 30
• Fatal Cereb. Trhromb. 396/100.000
  990.000 ? 30
• Total serious thromb. In US
  1498/100.000 3.742.000 ? 50
• Total deaths from above thrmb. 790/100.000
  1.990.000 ? 50
• Bick RL, Clin Appl Throm Hemos 3, Suppl 1, 1997

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Diagnosis

• Anamnesis ? Riwayat penyakit (Faktor risiko medis
  bedah), Manifestasi klinis
• Pemeriksaan fisik
• Pemeriksaan Laboratorium
• Pemeriksaan lain
• Venografi (Golden Standard)
• USG/ Doppler
• Duplex scan
• Impedance Plethysmography

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FAKTOR RISIKO TROMBOSIS ARTERIHipertensi,
hiperkolesterolemia, hiperlipoproteinemia,
merokok, diabetes melitus, hiperhomosisteinemia,
trombositosis, polisitemiaFAKTOR RISIKO
TROMBOSIS VENAImobilisasi, operasi, trauma
jaringan yang luas, kehamilan, pil kontrasepsi,
defisiensi AT3 / protein C/S / Fc XII, PNH
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MANIFESTASI KLINIS PEMERIKSAAN KLINISARTERI
/ VENAORGAN
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ORGAN

• OTAK
• MATA
• THT
• JANTUNG
• PARU
• ORGAN VISERAL
• EXTREMITAS

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DVT gtlt AILPatogenesis, Perjalanan
Penyakit,Komplikasi, Prognosis

• DVT
  AIL
• Dasar STASIS
  ISKEMIA
• Perjalanan Akut
  Kronik
• penyakit
  (kel. tungkai/tempat lain)
• Kronik
  Akut
• 
  (tromboemboli/trombosis)
• Komplikasi akut PE
  Nekrosis ? amputasi
• Prognosis Baik / fatal
  Fatal lokal / sistemik

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DVT gtlt AILDiagnosis Keluhan dan Tanda

• DVT
  AIL
• Keluhan (stasis)
  (iskemia)
• utama/awal - edema tungkai
  nyeri
• biasanya unilateral
  - tromboemboli onset akut
• - silent DVT
  - trombotik pelan-pelan
• - nyeri dan keras
  (intermittent claudication)
• Keluhan - nyeri
  - 6 Ps pain, pallor, pares-
• tanda - pitting edema
  thesia,paralysis,pulseless-
• -
  flebitisinflamasi ness,
  poikylothermia
• - dilatasi
  v.superfisial - awal nyeri parestesia
• - sianosis
  (ileofemoral) - palpasi denyut arteri -

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PEMERIKSAAN LABORATORIUM

• DVT - D-dimer
• - D-dimer lt 500 ng/ml ?
  menyingkirkan DVT
• 
  atau PE
• - nilai prediktif negatif pada
  DVT PE 98
• - sensitif tetapi tidak spesifik
  pasca bedah,
• DIC, infeksi, dll ? D-dimer ()
• - metoda ELISA cepat dan akurat
• - Pemeriksaan hemostasis lain
  kelainan
• dasar DVT ? ? trombofilia
  herediter/didapat ?
• (defisiensi AT III, Protein C,
  APS, dll)
• ? penentuan lamanya terapi
  antitrombosis

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PENATALAKSANAAN

• - MEDIS
• - BEDAH

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ANTITHROMBOTIC DRUGS

• ANTIPLATELET DRUGS
• ANTICOAGULANT DRUGS
• THROMBOLYTIC AGENTS

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ANTIPLATELET DRUGS

• ASPIRIN
• DIPYRIDAMOL
• CLOPIDOGREL AND TICLOPIDINE

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ANTICOAGULANT DRUGS

• WARFARIN
• HEPARIN
• HIRUDIN AND DIRECT THROMBIN INHIBITORS

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COMPARATIVE CHARACTERISTICS OF ANTICOAGULANTS
Oral administration Fixed dosing Fast onsetand offset Predictive kinetics No coagulation monitoring
Warfarin ?
Heparin ?
LMWH ? ? ? ?
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Dose and administration

• UFH initial dose bolus 75-100 u/kgBB
• followed by continous infusion
• to achieve aPTT between
• 1.5 to 2.5 times control
• LMWH 1 mg/kgBB or 0.1 ml/10kgBB sc
• twice daily
• Fondaparinux 7.5 mg for 50-100 kgBB
• sc daily

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Warfarin - Action

• Inhibits the synthesis of (in order of potency)
• Factor II
• Factor X
• Factor VII
• Factor IX

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Conversion from Heparin to Warfarin

• May begin concomitantly with heparin therapy
• Heparin should be continued for a minimum of four
  days
• Time to peak antithrombotic effect of warfarin is
  delayed 96 hours (despite INR)
• When INR reaches desired therapeutic range,
  discontinue heparin (after a minimum of four days)

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THROMBOLYTIC AGENTS

• STREPTOKINASE
• TISSUE PLASMINOGEN ACTIVATOR