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TROMBOSIS : DIAGNOSIS & PENATALAKSANAAN

TROMBOSIS : DIAGNOSIS & PENATALAKSANAAN. IRZA WAHID SUBAGIAN HEMATOLOGI & ONKOLOGI MEDIK FK UNAND / RS DR M DJAMIL PADANG. HEMOSTASIS - DIATESIS HEMORAGIS - TROMBOSIS Vaskular Trombosit Koagulasi.

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TROMBOSIS : DIAGNOSIS & PENATALAKSANAAN

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  1. TROMBOSIS : DIAGNOSIS & PENATALAKSANAAN IRZA WAHID SUBAGIAN HEMATOLOGI & ONKOLOGI MEDIK FK UNAND / RS DR M DJAMIL PADANG

  2. HEMOSTASIS - DIATESIS HEMORAGIS - TROMBOSIS VaskularTrombosit Koagulasi

  3. 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

  4. NOMENCLATUR FAKTOR PEMBEKUAN DARAHI FibrinogenII ProtrombinIII Tissue factorIV Ion calsiumV ProaccelerinVI -VII ProconvertinVIII Anti hemophilic factorIX Plasma tromboplastin componentX Stuart factorXI Plasma tromboplastin antecedentXII Hageman factorXIII Fibrin stabilizing factor - High moleculer weight kininogen - Pre kalikrein

  5. Jalur intrinsik Jalur Ekstrinsik XII VII Kontak XIIa Tromboplastin Jaringan Ca HMWK XI XIa IX IXa VIIa PF3, VIII, Ca X Xa V, PF3, Ca Fibrinogen Protrombin Trombin Fibrin Monomer Fibrin Polimer Solubel XIII XIIIa Fibrin Polimer Insoluber Ca

  6. Intrinsik Extrinsik Eksogen XIIa, Kalikrein t-PA Urokinase Aktifator PlasminogenPlasminogen terikat Plasmin terikat Fibrin FDPPlasminogen bebas Plasmin bebas Fibrinogen Fc V, Fc VIII Anti Plasmin

  7. TROMBOSIS

  8. What is thrombosis ? • Thrombosis is the formation or presence of a blood clot inside a blood vessel or cavity of the heart

  9. *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

  10. Pathophysiology thrombosis

  11. Thrombosis • Arterial thrombosis (white thrombus) • Venous thrombosis (red thrombus)

  12. RBCs Platelets Fibrin HIGH FLOW : ARTERIAL CIRCULATION White Thrombus

  13. Fibrin RBCs Platelets Red Thrombus SLOW FLOW : VENOUS CIRCULATION

  14. 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

  15. 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

  16. 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

  17. MANIFESTASI KLINIS & PEMERIKSAAN KLINISARTERI / VENAORGAN

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

  19. DVT >< 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

  20. DVT >< 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- - flebitis:inflamasi ness, poikylothermia - dilatasi v.superfisial - awal: nyeri & parestesia - sianosis (ileofemoral) - palpasi denyut arteri -

  21. PEMERIKSAAN LABORATORIUM • DVT: - D-dimer: - D-dimer < 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

  22. PENATALAKSANAAN - MEDIS - BEDAH

  23. ANTITHROMBOTIC DRUGS: • ANTIPLATELET DRUGS • ANTICOAGULANT DRUGS • THROMBOLYTIC AGENTS

  24. ANTIPLATELET DRUGS • ASPIRIN • DIPYRIDAMOL • CLOPIDOGREL AND TICLOPIDINE

  25. ANTICOAGULANT DRUGS • WARFARIN • HEPARIN • HIRUDIN AND DIRECT THROMBIN INHIBITORS

  26. COMPARATIVECHARACTERISTICSOF ANTICOAGULANTS

  27. 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

  28. Warfarin - Action • Inhibits the synthesis of (in order of potency) • Factor II • Factor X • Factor VII • Factor IX

  29. 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)

  30. THROMBOLYTIC AGENTS • STREPTOKINASE • TISSUE PLASMINOGEN ACTIVATOR

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