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PENATALAKSANAAN
IRZA WAHID
SUBAGIAN HEMATOLOGI & ONKOLOGI MEDIK
FK UNAND / RS DR M DJAMIL PADANG
HEMOSTASIS - DIATESIS HEMORAGIS
- TROMBOSIS
Vaskular
Trombosit Koagulasi
A. VASKULAR
* Vasokonstriksi
* Aktifasi trombosit
* Aktifasi faktor Koagulasi
B. TROMBOSIT
* Adesi
* Agregasi
* RX pelepasan isi trombosit
Granula padat : ADP, ATP, Ca, Epinefrin, Norepinefrin,
Granula alfa : Fibrinogen, vWF, FV, PF 4, TG,
Lisosom : Enzim asam hidrolase
I Fibrinogen
II Protrombin
III Tissue factor
IV Ion calsium
V Proaccelerin
VI -
VII Proconvertin
VIII Anti hemophilic factor
IX Plasma tromboplastin component
X Stuart factor
XI Plasma tromboplastin antecedent
XII Hageman factor
XIII Fibrin stabilizing factor
- High moleculer weight kininogen
- Pre kalikrein
Jalur Jalur
intrinsik Ekstrinsik
XII VII
Kontak
XIIa Tromboplastin
Ca
HMWK Jaringan
XI XIa
IX IXa
VIIa
PF3, VIII, Ca
X Xa
V, PF3, Ca
Fibrinogen
Protrombin Trombin
Fibrin Monomer
Fibrin Polimer
Solubel
XIII XIIIa
Ca Fibrin Polimer
Insoluber
Intrinsik Extrinsik Eksogen
FDP
Anti Plasmin
TROMBOSIS
What is thrombosis ?
• Thrombosis is the formation or presence
of a blood clot inside a blood vessel or
cavity of the heart
* Triad Virchow
Kelainan dinding pembuluh darah
* kerusakan endotel : hipertensi,
kateterisasi, anoksis , rokok,
RX ag – ab, hiperkolesterolemia,
hiperhomosisteinemia
White Thrombus
SLOW FLOW : VENOUS CIRCULATION
Red Thrombus
Incidence of thrombosis in United
States of America
Disease US incidence Total in US /year Definable
/100.000 cases reason
ARTERI / VENA
ORGAN
ORGAN
• OTAK
• MATA
• THT
• JANTUNG
• PARU
• ORGAN VISERAL
• EXTREMITAS
DVT >< AIL
Patogenesis, Perjalanan Penyakit,
Komplikasi, Prognosis
DVT AIL
Kronik Akut
(tromboemboli/trombosis)
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)
• 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
PENATALAKSANAAN
- MEDIS
- BEDAH
ANTITHROMBOTIC DRUGS:
• ANTIPLATELET DRUGS
• ANTICOAGULANT DRUGS
• THROMBOLYTIC AGENTS
ANTIPLATELET DRUGS
• ASPIRIN
• DIPYRIDAMOL
• CLOPIDOGREL AND TICLOPIDINE
ANTICOAGULANT DRUGS
• WARFARIN
• HEPARIN
• HIRUDIN AND DIRECT THROMBIN INHIBITORS
COMPARATIVE CHARACTERISTICS
OF ANTICOAGULANTS
Warfarin
Heparin
LMWH
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
Warfarin - Action
• Inhibits the synthesis of (in order of potency)
– Factor II
– Factor X
– Factor VII
– Factor IX
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)
THROMBOLYTIC AGENTS
• STREPTOKINASE
• TISSUE PLASMINOGEN ACTIVATOR