TROMBOSIS DAN EMBOLI PARU

Dairion Gatot, Soegiarto Gani, Savita Handayani, Lily S Hidayatullah

Hematology-Medical Oncology Division, Dept of Internal Medicine School of Medicine, Sumatera Utara Unversity 2009

DAMPAK TROMBOSIS ARTERI Arteri koroner Arteri serebral --> Infark jantung (MCI) --> Infark otak (Stroke)

Arteri mesenterial --> Akut abdomen A t i/V Arteri/Vena mata --> Vi t Visus terganggu/buta t /b t A t i telinga Arteri t li --> Sudden deafness > S dd d f DLL dapat terjadi pada wanita atau pria

DVT >< AIL Diagnosis: Keluhan dan Tanda Di i K l h d T d DVT Keluhan (stasis) utama/awal - edema tungkai biasanya unilateral - silent DVT - nyeri dan keras Keluhan & tanda - nyeri - pitting edema p g - flebitis:inflamasi - dilatasi v.superfisial - sianosis (ileofemoral) AIL (iskemia) nyeri: - tromboemboli: onset akut - trombotik: pelan-pelan (intermittent claudication) - 6 Ps: pain, pallor, paresthesia,paralysis,pulseless,p y ,p ness, poikylothermia - awal: nyeri & parestesia - palpasi denyut arteri -

PEMERIKSAAN PENUNJANG ANGIOGRAFI: - DVT (flebografi) dan AIL (arteriografi) ( g ) ( g ) - AIL tromboembolik: tidak perlu DUPLEX ULTRASOUND: - DVT sensitivitas 93 % spesifisitas 98 % DVT: iti it %, ifi it Bila hasil (-): ulangi 1 hari & 1 minggu kemudian Calf venous thrombosis: sensitivitas 60 % - AIL : - stratifikasi derajat iskemia & prediksi hasil terapi - Ankle-brachial index (ABI): Normal ABI > 1,0 ABI berat < 0,5

Gejala dan Tanda Embolus Paru (PE)Tergantung pada : - ukuran embolus - lokasi/ pembuluh darah yang terkena Gejala PE : - dispnu (sesak napas) - nyeri dada difus dan sukar dilokalisir bertambah dengan napas dalam - batuk, mula-mula kering hemoptisis - berkeringat (25 %) g ( ) Tanda PE : - Tanda-tanda syok kardiogenik (Tekanan darah , Denyut jantung

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Diagnosis Embolus Paru g1. Pemeriksaan Fisik : Gejala & tanda 2. Pemeriksaan Sede a a : Ro dada, EKG e e saa Sederhana o G Analisa gas darah 3. Pemeriksaan Khusus : a. Invasive pulmonary angiography b. Non invasive lung scanning g g c. Ventilation scan

Patogenesis Terbentuknya Embolus

Who is at Risk of Deep Vein Thrombosis Pulmonary Embolism ??? P l E b liFOUR MAJOR RISK GROUP in SURGICAL PROCEDURE: Low Risk Patients (< 40 yr, procedure < 30 minutes) Medium Risk Patients (> 40 yr procedure > 30 min ) yr, min.) High Risk Patients: - Previous history of venous thrombosis (or strong family history) - PELVIC or ABDOMINAL SURGERY for MALIGNANCY - Lower limb orthopedic surgery p g y Very High Risk Patients: - Lower limb trauma and surgery - Surgery in other risk factors (previous PE,CHF, cancer, etc)

PENGOBATAN SEGERA pada DVT/PE Heparin: - bolus 5000 u/10.000 u 1000 2000 u/jam - periksa APTT 6 jam ik j dosis di d i disesuaikan ik target APTT 1,5 2,5 x kontrol - lama terapi: 4/5 hari = 9/10 hari 7 hari Warfarin: pada hari diagnosis/ 24 jam kemudian/48 jam Enoxaparin (LOVENOX) : 1 mg/kg bb/12 jam Nadroparin (FRAXIPARINE) : - 2 x/hari, setiap 12 jam - BB < 50 kg: 0 4 ml, 50 59 kg: 0 5 ml 0,4 ml 0,5 ml, 60 69 kg: 0,6 ml, 70 79 kg: 0,7 ml 80 89 kg: 0,8 ml, > 90 kg: 0,9 ml Fondaparinux (ARIXTRA):-profilaksis: 2,5 mg 1x/hari,subkutan p ( ) p , g , 6 jam pasca penutupan luka operasi - pengobatan: BB 50 kg: 5 mg, BB > 75 kg: 7,5 mg Dalteparin: 100 unit/kg bb/12 jam

PENCEGAHAN PRIMER / SEKUNDER IDENTIFIKASI FAKTOR RISIKO DVT dan AIL PENCEGAHAN PRIMER: bila kelainan (-), risiko (+) PENCEGAHAN SEKUNDER: - bila kelainan ( ) (+) Th/ / - risiko (+) pencegahan recurrent dan trombosis di tempat lain (otak, jantung, ginjal, mesenterium, kandungan, dll)

PROFILAKSIS ANTIKOAGULANFaktor Risiko Trombosis Usia tua Obesitas Riwayat DVT / PE Insufiensi jantung I fi ij t Kanker Stroke Varises vena Insufiensi vena Faktor Pencetus

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Imobilisasi Plaster gips tungkai Pembedahan/Pasca bedah b d h Kehamilan /persalinan /pasca partus Infark miokard akut Infeksi Kontrasepsi oral

PROFILAKSIS ANTIKOAGULAN

PROPHYLACTIC REGIMENS Compression stockings Standard heparin: 5000 units BTD TID Two steps warfarin: warfarin started 2 weeks befor operations to achieve INR 1.5, then increase post operatively to INR 2 - 3 One step warfarin: start warfarin night of surgery to achieve goal INR of 2 3 Dalteparin: - low risk surgery 2500 u every day, - high risk abdominal surgery 5000 u every day Enoxaparin: - abdominal surgery 40 mg/day - orthopedic indications 30 mg/day g y

SPECIFIC RECOMMENDATIONS for PROPHYLAXIS of DVT to PREVENT PE f t Low risk patients: early ambulation Medium risk patients: - low dose heparin 5000 units bid - Dalteparin 2500 5000 units every day - Enoxaparin 40 mg every day -P Pneumatic compression stockings ti i t ki High risk patients: - Enoxaparin 30 mg every 12 hours - Pneumatic compression stockings - Warfarin