TROMBOSIS DAN KID/ DIC (Koagulasi Intravascular Diseminata)

HADIANTI

TROMBOSIS

Blood Vessels. A.) The wall of an artery. B.) The wall of a vein

Faktor-faktor penyebab trombosis: Kolesterol Kompleks im n !n"otoksin Sres #emo"inamik Bakteri "an $ir s Sitokin !n%im rokok

&ato'enesis
Keti"akseimban'an stim lasi trombo'enik "an mekanisme proteksi - Stim lasi berlebi#an "' proteksi normal ata stim lasi normal proteksi berk ran' Hemostasis penyemb #an l ka ()* #ari+ #emostasis primer (trombosit "an $essel+ #emostasis sek n"er (faktor koa' lasi "an antikoa' lan #emostasis tersier (fibrinolisis+

&roteksi trombosis: &rotein , "' kofaktor protein S #ambat -a "an -IIa AT III "an Heparin alfa) antitripsin "an beta. mikro'lobin #ambat /a "an trombin t&A #ambat plasmin melisis fibrin

Trombosis
Masa abnormal "ari konstit en "ara# melal i proses

koa' lasi intral minar sistem $ask lar semasa #i" p0 Trombosis $ena a"ala# trombosis "i "alam $ena &enyakit $ena peri$er terserin' yan' menyebabkan pasien ke "okter a"ala#:
1 Trombosis $ena "alam (Deep -ein T#rombosis2D-T+3 1 Tromboflebitis3 1 &ost T#romboti4 Syn"rome (&TS+ akibat ins fisiensi kat p $ena "alam kronik ber pa:
5 pi'mentasi stasis "an2ata 5 "ermatitis stasis "an2ata 5 lk s stasis0

Pathophysiologic of Thrombosis
Triad of Virchow

Abnormality Abnormality of of vessel wall

Abnormality of Blood flow

abnormality of blood

Plaque ruptures

Venous Hypotonia

Shears stress Shears rate Turbulence

Venous stasis

Platelet hyper activity

Hyper coagulability state Thrombophilic state Fibrinolysis deficient Thrombocytosis

Arterial Thrombosis

Venous Thrombosis

Arterial Thrombosis

Venous Thrombosis

Arterial Thrombosis Venous Thrombosis

Endothelial Perturbation

Hyper viscosity Hyper fibrinogenemia

Fa4tor risiko
Berba'ai fa4tor yan' berperan seba'ai penyebab

pembent kan saran' trombosit "an kompleks trombinfibrin seba'ai bakal trombosis $ena ter tama a"ala#:
1 1 1 1 1 1 stasis $ena3 #ipotonia $ena3 stat s #iperkoa' labilitas ole# berba'ai penyebab3 stat s trombofilik ole# berba'ai penyebab3 "efisiensi fibrinolysis ole# berba'ai penyebab3 ker sakan en"otel $ena ata en"otel $ena teran4am r sak (en"ot#elial pert rbation+3 1 ker sakan t nika intima $ena0

Causes of Thrombosis
Clinical Conditions Arterial Thrombosis Atherosclerosis Cigarette smo ing !"#ertension Dia$etes Mellitus %o&'(ensit" li#o#rotein cholesterol !"#ertrigl"ceri(emia )ositive *amil" histor" %e*t ventricular *ailure Oral contrace#tives +strogens %i#o#rotein(a) )ol"c"themia !"#erviscosit" s"n(romes Venous Thrombosis General surgery Orthopaedic surgery Arthroscopy Immobility alignancy !epsis In,ur" Congestive !eart -ailure Ne#hrotic s"n(rome O$esit" .aricose veins )ost#hle$itic s"n(rome Oral contrace#tives +strogens Defect of Blood, Protein, or Platelet Antiphospholipid syndrome !tic"y platelet syndrome Cancer procoagulant #CP$ )rotein S (e*ects )rotein C (e*ects A)C resistance (*actor . %ei(en) Antithrom$in (e*ects !e#arin co*actor II (e*ects )lasminogen (e*ects Tissue #lasminogen activators (e*ects )lasminogen activator inhi$itor (e*ects -actors /II (e*ects D"s*i$rinogenemia

Dia'nosti4 test t#rombosis

Sensitivit" Occlusive im#e(ance #leth"smogra#h"
%&'

S#eci*icit"

%i elihoo( Ratio #ositive (%R2) :;<57 :7<99 ;<>> :><8; 9;<87 93<87 ()+,,

334 (35'674) 684 (69'684) 694 6:4

I'-i$rinogen %eg Scanning

Do##ler ultrasoun( Du#le? 0S1 Conventional 0S1 Color (o##ler 0S1 Com#ression color (o##ler 0S1

334 (38'6=4) 334 (35'6:4) 684 (36'634) 6>4 (3;'6;4) 684 (6>'6;4) 634 (65'664) 6;4 (68'664) 634 (65'664) ()* ((*

1ol( stan(ar( (iagnostic $" )hle$ogra#h"

In4i"en4e of -T!: T#e t#ir" most 4ommon $as4 lar "isease

Annual incidence (U data) Deep vein thrombosis (DVT) only !%()$%&&'&&& Pulmonary embolism (PE) with or without DVT !"#$%&&'&&&

1. Gillum RF. Am Heart J. 19 !"11#$%)&1'(')1'(# '. Anderson FA Jr* et al. Ar+h ,ntern -ed.1991"1%1$%)& 9..)9. .. /ilverstein -0* et al. Ar+h ,ntern -ed. 199 "1% $()&% %)%9. #. 1,H 2onsensus 0evelo3ment. JA-A. 19 ( Au4 "'%($()&!##)!#9 %. Giuntini 2* et al. 2hest. 199% Jan"15!$1 /u33l)&.)9/

Diagnosis of VTE: VTE often goes undetected until too late

/ver 0&, of fatal PE are detected post mortem%'.

Appro*imately +&, of DVTs are clinically silent-'.

1. /tein 60* et al. 2hest. 199%"15 $#)&9! '. 7ethen H* et al. Am J 2ardiol. 199!" 5&15(() .. /andler 0A* et al. J R /o+ -ed. 19 9" '$%)&'5.

VTE: A strong relationship between DVT and PE

Almost )&, of patients with pro*imal DVT of the le1 have asymptomatic PE% 2i1ration

DVT (mainly asymptomatic) is found in around +&, of patients with PE-

Thrombus

Embolus

1. 6esavento R* et al. -inerva 2ardioan4iol. 199!"#%$!) )&.(9).!% '. Girard 6* et al. 2hest. 1999"11($#)&95.)95

T#rombo'enesis D-T
Kebanyakan pembent kan tromb s $ena "im lai

"ari pembent kan 6arin' "ari saran' trombosit "an kompleks trombin-fibrin pa"a sin s $ena "i"alam otot ata kat p $ena pa"a $ena "alam meskip n ti"ak a"a ker sakan en"otel $ena3 se#in''a sel "ara# mera# terperan'kap membent k tromb s yan' "iseb t seba'ai tromb s mera# "an kem "ian men6alar ke proksimal0

7e6ala klinis
7e6ala klinis D-T ter'ant n' l asnya keterlibatan $ena3

1 "apat asimptomatik ata 1 kombinasi "ari:

5 5 5 5 5 5 pemben'kakan e8tremitas (t n'kai2len'an+ m lai "ari "istal3 otot kak (ti"ak l nak+3 nyeri otot ter tama pa"a ber"iri "an ber6alan3 pittin' e"ema tetapi #an'at3 k lit kebir an (4yanosis+3 $ena s perfi4ial prominent akibat "ilatasi $ena kolateral s perfisial

Stan"ar"i%e" 4lini4al "ia'nosti4s "e4ision mo"el for s spe4te" D-T

(@ells et al< %ancet :668A >89B :>=5) Clinical probability parameter !core

C Acti3e cancer #ongoing or 0ithin pre3ious 4 months % chemotherapy$ % C Paralysis, paresis or recent plaster immobili5ation of the lo0er e6tremities % C Bedridden for more than 1 days or ma7or surgery 0ithin 8 % 0ee"s % C 9ntire leg s0ollen C Calf s0elling of more than 1 cm 0hen compared 0ith the % asymptomatic leg #measured %, cm belo0 the tibial % tuberosity$ % C Pitting edema greater in the symptomatic leg -& C Collateral non3aricose superficial 3eins C /ocali5ed tenderness along distribution of the deep 3ein , . /o0 system probability, % or & . oderate probability, 1 or more . 2igh probability C Alternati3e diagnosis as or more li"ely than DVT

,lini4al "ia'nosti4s "e4ision r le

!uspected DVT Compression color doppler ;!G Positi3e :egati3e Clinical probability /o0 DVT CCD; at day ) :egati3e :o DVT oderate D-Dimer 2igh

Negative :egati3e

Positi3e )ositive

Positi3e DVT

&en'obatan
Mo"alitas pen'obatan trombosis $ena9
1 1 1 1 1 1 T#rombolyses3 T#rombe4tomy3 Anti4oa' lants3 Intermittent &ne mati4 ,ompression3 7ra" ally 4ompression sto4kin'3 &er4 taneo s -al$ loplasty B--:+ (s 44ess rate ;<=+0

Anti4oa' lant are t#e main t#erapy for t#e treatment in

-eno s t#rombosis an" t#romboembolism

D) Nitinol Dou$le Stent Bio#rosthetic .enous .alve

 KID

(Koagulasi Intravascular Diseminata) DIC

Definition
Disseminate" intra$as4 lar 4oa' lation (DI,+ is a

4lini4opat#olo'i4 syn"rome in >#i4# >i"esprea" intra$as4 lar 4oa' lation is in" 4e" by pro4oa' lants t#at are intro" 4e" or pro" 4e" in t#e bloo" an" o$er4ome t#e nat ral anti4oa' lant me4#anisms

&at#olo'y
- Diff se m ltior'an blee"in' - Hemorr#a'i4 ne4rosis - Mi4rot#rombi in small bloo" $essels - T#rombi in me"i m an" lar'e bloo" $essels

&at#o'enesis
infectio n !I> ! in7ur y
96posure of blood to tissue 0ith T<

T:<,I/ induced generation T< Do0n regulation of T Inhibition fibrinolisis by PAI-%

Trigering T< coagulation path0ay

Venom < I? and ?I consentrat Cancer procoagulant Acti3ation platelets,< V dan VIII <ailure of mechanism

Throm$in generation

Consumption Antithrombin,protein C,< V,< VIII,platelet,fibrinogen

DIC
Vessel obstruction fibrinolysis <DP=DDimer

OD

ischemic icroangiopathic hemolytic anemia Vessel patency

bleeding

O<

)atho#h"siolog"
Any causes Precipitating factors )rocoagulant activation
IN-g TN-a I%': !epsis I%'5

+?cessive coagulation activit" Disseminated Thrombosis Coagulation *actors Natural anticoagulant consum#tion consum#tion Ine**ective !emostatic Bleeding s"stem Shoc OD= O< !igh -D)

Clinical conditions that may be associated with overt DIC

se3sis8severe infe+tion $any mi+ro9or4anism) trauma $e.4. 3olytrauma* neurotrauma* fat em:olism) or4an destru+tion $e.4. severe 3an+reatitis) mali4nan+y
) solid tumors ) -yelo3roliferative 8 7ym3ho3roliferative mali4nan+ies

o:stetri+al +alamities ) amnioti+ fluid em:olism ) a:ru3tio 3la+entae vas+ular a:normalities ) 7ar4e vas+ular aneurysms severe he3ati+ failure severe to;i+ or immunolo4i+ rea+tions ) sna<e :ites ) re+reational dru4s ) transfusion rea+tions ) trans3lant re=e+tion

,lini4al Feat res

?n"erlyin' "isease Blee"in' manifestations >ere 4ommon T#romboembolism Renal3 @i$er an" Respiratory "ysf n4tion ,entral Ner$o s System Manifestations S#o4k A4ral ,yanosis

@aboratory Feat res an" Dia'nosis

Does the patient ha3e an underlying disorder cause DIC @
:o Ae s
Performe the follo0ing test Dplatelet count,prothrombine time,fibrinogen le3el,<DP

Discontinue the use of this algoritme

Determine score D Platelet D E %,,+,,,.,,B %,,+,,,.% B ',+,,, . & <ibrin mar"er D no increase . ,, moderate increase .&,strong increse.1 Prolong prothrombin time D B 1 .,, E1 B4 . %, E 4. & <ibrinogen le3el B %g=l . ,, E %g=l .%

!core C ',o3ert DIC,affirmati3e

!core B ',suggesti3e but not mono3ert DIC

,ertain form of DI,

A+ute 0,2 ) 0,2 develo3s a+utely when sudden e;3osure of :lood to 3ro+oa4ulants o++urs* in+ludin4 tissue fa+tor $tissue throm:o3lastin)* 4eneratin4 intravas+ular +oa4ulation 2hroni+ 0,2 ) 2hroni+ 0,2 refle+ts a +om3ensated state that develo3s when :lood is +ontinuously or intermittently e;3osed to small amounts of tissue fa+tor A. 2om3ensated ) Hi4h level F06 without +oa4ulant fa+tors defi+ient A. 0e+om3ensated ) Hi4h level F06 ) 0efi+ien+ies +oa4ulation fa+tors ) Throm:o+yto3enia
> ,nhi:it 3latelet fun+tion > ,nhi:it +oa4ulation def. +oa4ulation fa+tors

O3ert DIC :on-o3ert DIC

:o DIC

Throm$osis (an DIC

Throm$osisB
D'DimerB
Tan#a #er(arahan/ ehamilan E 877 Dengan #er(arahan/ ehamilan E :777

Consum#tion Coaggulo#ath"
)T ratioB E:<=8 )T4B F374 INRB E:<> a)TT E:<=8 ratioB Trom$osit F:=7<7 B 77 -i$rinogen F:87 B

DICB
Throm$osis (isertai consum#tion coaggulo#ath"

Diagnostic Criteria for O3ert DIC by the International !ociety of Thrombosis and 2emostasis #I!T2$ !ubcommittee on DIC, and for DIC by the Fapanese inistry of 2ealth and Gelfare #F 2G$H

I!T2 0n(erl"ing (isease Blee(ing s"m#tom O- (ue to throm$osis )T -i$rinogen -D) In(is#ensa$le 7 #oint 7 #oint )rolongation o* )T I > secA : #oint I 5 secA = #oints J: g/%A : #oint Mil( increase A : #oint Mo(erate increase A = #oints Strong increase A > #oints J :77A : #oint J 87 A = #oints Overt'DIC I 8 #oints : #oint

F 2G !)T(G)B : #ointH !)T(2)B 7 #oint : #oint )T ratio I :<=8B : #oint I :<5;B = #oints J :<8 g/%B : #oint J :<7 g/%B = #oints I :7 mg/m%B : #oint I =7 mg/m%B = #oints I 97 mg/m%B > #oints !T)(2)B 7 #oint !)T(G)B J :=7A : #oint J 37 A = #oints J 87 A > #oints DICB !)T(2) I 9 #oints !)T(G) I ; #oints

)latelet count

Total

DA$$reviationsB O-H organ *ailureA !)T(2)H #atients &ith hemato#oeitic malignanciesA !)T(G)H #atients &ithout hemato#oeitic malignancies<

DI, S4ore ISTH

Ris< assessment 7a:oratory +oa4ulation tests 0oes the 3atient have an underlyin4 disorder +om3ati:le with 0,2? $e4* se3sis* trauma* o:stetri+ emer4en+y* a+tive +an+er* et+). ,f yes* 3ro+eed" if no* do not use this al4orithm.
6latelet +ount 09dimer and F06s 6T and a6TT Fi:rino4en 6latelet +ount& @155 A 5 3oints* B155 A 1 3oint* B%5 A ' 3oints Clevated fi:rin mar<er& 1o elevation A 5 3oints* mild in+rease A 1* moderate

/+orin4

in+rease A ' 3oints* stron4 in+rease A . 3oints 6rolon4ed 6T& B. se+ A 5 3oints* @. B( A 1 3oint* @( A ' 3oints Fi:rino4en level& @1 487 A 5 3oints* B1 A 1 3oint

2al+ulate s+ore

Greater than or eDual to % A +om3ati:le with overt 0,2* re3eat s+orin4 daily 7ess than % su44estive of non9overt 0,2

I* E 8B com#ati$le &ith over t DICA re#eat scoring (ail" Throm$ !aemost< I* F 8B suggestive (not a**irmative) *or non'overt DICA re#eat ne?t :'= (a"sANov =77:A35(8)B:>=;'>7

&en'obatan KID
%an(asan #engo$atan KID a(alah #engo$atan on(isi

"ang men(asarin"a
C C C C

K )engo$atan #en"a it (asar K A ti*asi ontrol hemostasis

!e#arinisasi AT III )rotein C Throm$omo(ulin

K Su$stitusi om#onen (arah

C )RC C -a tor oagulasi (--)H Cr"o) C Trom$osit

K Anti*i$rinoliti )enting untu

mengulangi tes untu memantau secara (inamis $eru$ah s enario "ang (i(asar an #a(a hasil la$oratorium (an #engamatan linis<

ABC D
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