14. dic (dr.hadianti)

8/13/2019 14. Dic (Dr.hadianti)

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TROMBOSIS DAN KID/ DIC(Koagulasi Intravascular Diseminata)

HADIANTI


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TROMBOSIS


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


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Faktor-faktor penyebab trombosis: Kolesterol

Kompleks imn

!n"otoksin

Sres #emo"inamik

Bakteri "an $irs

Sitokin

!n%im rokok


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&ato'enesis

Keti"akseimban'an stimlasi trombo'enik "anmekanisme proteksi

- Stimlasi berlebi#an "' proteksi normal ata

stimlasi normal proteksi berkran'

Hemostasispenyemb#an lka ()* #ari+

#emostasis primer (trombosit "an $essel+

#emostasis sekn"er (faktor koa'lasi "an

antikoa'lan#emostasis tersier (fibrinolisis+


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&roteksi trombosis:

&rotein , "' kofaktor protein S #ambat

a "an IIaAT III "an Heparin alfa) antitripsin "an

beta. mikro'lobin#ambat /a "an

trombin t&A #ambat plasmin melisis fibrin


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Trombosis Masa abnormal "ari konstiten "ara# melali proses

koa'lasi intralminar sistem $asklar 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#rombosis2DT+3

1 Tromboflebitis3

1 &ost T#romboti4 Syn"rome (&TS+ akibat insfisiensi katp $ena"alam kronik berpa:

5 pi'mentasi stasis "an2ata

5 "ermatitis stasis "an2ata

5 lks stasis0


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Shears stressShears rate

Turbulence

Pathophysiologic of ThrombosisPathophysiologic of Thrombosis

ArterialThrombosis VenousThrombosis

Abnormality of Abnormality

of vessel wall Abnormality of

Blood flow

abnormality of

blood

Triad of Virchow

Venous

stasisPlatelethyper

activity

Hypercoagulability state

Thrombophilic stateFibrinolysis deficient

Thrombocytosis

Plaqueruptures

EndothelialPerturbation

VenousHypotonia

ArterialThrombosis VenousThrombosis

Hyperviscosity

Hyperfibrinogenemia

ArterialThrombosis

VenousThrombosis


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Fa4tor risiko

Berba'ai fa4tor yan' berperan seba'ai penyebabpembentkan saran' trombosit "an kompleks trombin-fibrin seba'ai bakal trombosis $ena tertama a"ala#:1 stasis $ena3

1 #ipotonia $ena3

1 stats #iperkoa'labilitas ole# berba'ai penyebab3

1 stats trombofilik ole# berba'ai penyebab3

1 "efisiensi fibrinolysis ole# berba'ai penyebab3

1 kersakan en"otel $ena ata en"otel $ena teran4am rsak(en"ot#elial pertrbation+3

1 kersakan tnika intima $ena0


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Clinical ConditionsDefect of Blood, Protein,

or PlateletArterial Thrombosis Venous Thrombosis

Atherosclerosis

Cigarette smoing

!"#ertension

Dia$etes Mellitus

%o&'ensit"li#o#roteincholesterol

!"#ertrigl"ceriemia

ositive *amil"histor"

%e*t ventricular*ailure

Oral contrace#tives

+strogens

%i#o#rotein(a)

ol"c"themia

!"#erviscosit"s"nromes

General surgery

Orthopaedicsurgery

Arthroscopy

Immobility

alignancy

!epsis

In,ur"

Congestive !eart-ailure

Ne#hrotic s"nromeO$esit"

.aricose veins

ost#hle$itics"nrome

Oral contrace#tives

+strogens

Antiphospholipidsyndrome

!tic"y platelet syndrome

Cancer procoagulant#CP$

rotein S e*ects

rotein C e*ects

AC resistance (*actor .%eien)

Antithrom$in e*ects

!e#arin co*actor II e*ects

lasminogen e*ects

Tissue #lasminogenactivators e*ects

lasminogen activatorinhi$itor e*ects

-actors II e*ects

D"s*i$rinogenemia

Causes of ThrombosisCauses of Thrombosis


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VTE: A strong relationship betweenVTE: A strong relationship between

DVT and PEDVT and PE

Almost &, of patients with

pro*imal DVT of the le1

have asymptomatic PE%

DVT (mainly asymptomatic)

is found in around +&,of patients with PE-

1. 6esavento R* et al. -inerva 2ardioan4iol. 199!"#%$!)&(9!%'. Girard 6* et al. 2hest.1999"11($#)&9595

Embolus

2i1ration

Thrombus


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T#rombo'enesis DT

Kebanyakan pembentkan trombs $ena "imlai

"ari pembentkan 6arin' "ari saran' trombosit "an

kompleks trombin-fibrin pa"a sins $ena "i"alam

otot ata katp $ena pa"a $ena "alam meskipn

ti"ak a"a kersakan en"otel $ena3 se#in''a sel

"ara# mera# terperan'kap membentk trombs

yan' "isebt seba'ai trombs mera# "ankem"ian men6alar ke proksimal0


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7e6ala klinis 7e6ala klinis DT ter'antn' lasnya keterlibatan $ena3

1 "apat asimptomatik ata

1 kombinasi "ari:5 pemben'kakan e8tremitas (tn'kai2len'an+ mlai "ari "istal3

5 otot kak (ti"ak lnak+3

5 nyeri otot tertama pa"a ber"iri "an ber6alan3

5 pittin' e"ema tetapi #an'at3

5 klit kebiran (4yanosis+3

5 $ena sperfi4ial prominent akibat "ilatasi $ena kolateralsperfisial


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Stan"ar"i%e" 4lini4al "ia'nosti4s

"e4ision mo"el for sspe4te" DT

Clinical probability parameter !core%

%

%

%

%

%

%%

-&

(@ells et al< %ancet :668 >89 :>=5)

. /o0 probability, % or & . oderate probability, 1 or more . 2igh probability

Acti3e cancer #ongoing or 0ithin pre3ious 4 monthschemotherapy$

Paralysis, paresis or recent plaster immobili5ation of thelo0er e6tremities

Bedridden for more than 1 days or ma7or surgery 0ithin 80ee"s

9ntire leg s0ollen

Calf s0elling of more than 1 cm 0hen compared 0ith the

asymptomatic leg #measured % cm belo0 the tibialtuberosity$

Pitting edema greater in the symptomatic leg

Collateral non3aricose superficial 3eins

/ocali5ed tenderness along distribution of the deep 3einsystem

Alternati3e diagnosis as or more li"ely than DVT


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,lini4al "ia'nosti4s "e4ision rle

DVT

Positi3e

:o DVT

:egati3e Positi3e

CCD; at day )

/o0

:egati3eNegative

DVT

Positi3eositive

D-Dimer

oderate 2igh

Clinical probability

:egati3e

Compression

color doppler ;!G

!uspected DVT


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Definition Disseminate" intra$as4lar 4oa'lation (DI,+ is a

4lini4opat#olo'i4 syn"rome in >#i4# >i"esprea"

intra$as4lar 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 natral anti4oa'lant me4#anisms


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&at#olo'y

- Diffse mltior'an blee"in'

- Hemorr#a'i4 ne4rosis

- Mi4rot#rombi in small bloo" $essels

- T#rombi in me"im an" lar'e bloo" $essels


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&at#o'enesis

infection

in7ury

Throm$in generation


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atho#h"siolog"

rocoagulantactivation

+?cessive coagulation activit"

DisseminatedThrombosis

Coagulation *actors

consum#tion

Bleeding

Natural anticoagulantconsum#tion

Any causes

Precipitating factors

OD=O


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Clinical conditions that may be

associated with overt DIC

se3sis8severe infe+tion $any mi+roor4anism) 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


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,lini4al Featres

?n"erlyin' "isease Blee"in' manifestations >ere 4ommon

T#romboembolism

Renal3 @i$er an" Respiratory "ysfn4tion ,entral Ner$os System Manifestations

S#o4k

A4ral ,yanosis


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@aboratory Featres an" Dia'nosis

Does the patient ha3e an underlying disorder

cause DIC @

:o es

!core ',suggesti3ebut not mono3ert DIC

!core ',o3ertDIC,affirmati3e

Determine score Platelet E %+., %+.% '+ . &


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,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)* 4eneratin4intravas+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> ,nhi:it 3latelet fun+tion> ,nhi:it +oa4ulation def. +oa4ulation fa+tors

0efi+ien+ies +oa4ulation fa+tors Throm:o+yto3enia

O3ert DIC

:on-o3ert DIC

:o DIC


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DI, S4ore ISTH

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14. dic (dr.hadianti)

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