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 --> Infark jantung (MCI)

• Arteri serebral --> Infark otak (Stroke)

• Arteri mesenterial --> Akut abdomen

• Arteri/Vena
A t i/V mata
t --> Visus
Vi terganggu/buta
t /b t

• A
Arteri
t i telinga
t li -->
> Sudden
S dd deafness
d f
• DLL
• dapat terjadi pada wanita atau pria
 DVT >< AIL
Di
Diagnosis:
i Keluhan
K l h dan
d Tanda
T d
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 -ppitting
g edema thesia,paralysis,pulseless-
,p y ,p
- flebitis:inflamasi ness, poikylothermia
- dilatasi v.superfisial - awal: nyeri & parestesia
- sianosis (ileofemoral) - palpasi denyut arteri -
 PEMERIKSAAN PENUNJANG

• ANGIOGRAFI: - DVT ((flebografi)

g ) dan AIL (arteriografi)
( g )
- AIL tromboembolik: tidak perlu
• DUPLEX ULTRASOUND:
- DVT:
DVT sensitivitas
iti it 93 % %, spesifisitas
ifi it 98 %
Æ Bila hasil (-): ulangi 1 hari & 1 minggu kemudian
Æ 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)
¾ Tergantung pada : - ukuran embolus
- lokasi/ pembuluh darah yang terkena

¾ Gejala PE : - dispnu (sesak napas)

- nyeri dada difus dan sukar dilokalisir
bertambah dengan napas dalam
- batuk, mula-mula kering hemoptisis
- berkeringat
g (25
( %))

¾ Tanda PE : - Tanda-tanda syok kardiogenik

(Tekanan darah , Denyut jantung )
Diagnosis
g Embolus Paru
1. Pemeriksaan Fisik : Gejala & tanda

2. Pemeriksaan
e e saa Sede
Sederhana
a a : Ro”
o dada, EKGG
Analisa gas darah

3. Pemeriksaan Khusus :

a. Invasive pulmonary angiography

b. Non invasive lungg scanning
g
c. Ventilation scan
Patogenesis Terbentuknya Embolus
 Who is at Risk of Deep Vein Thrombosis
Æ Pulmonary
P l Embolism
E b li ???
FOUR MAJOR RISK GROUP in SURGICAL PROCEDURE:

• Low Risk Patients (< 40 yr, procedure < 30 minutes)

• Medium Risk Patients (> 40 yr

yr, procedure > 30 min
min.))

• High Risk Patients: - Previous history of venous

thrombosis (or strong family history)
- PELVIC or ABDOMINAL SURGERY
for MALIGNANCY
- Lower limb orthopedic
p surgery
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 Æ 1000 – 2000 u/jam

- periksa
ik APTT 6 jam j Æ dosis
d i disesuaikan
di ik
Æ target APTT 1,5 – 2,5 x kontrol
- lama terapi: 4/5 hari = 9/10 hari Æ 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 0,4
4 ml,
ml 50 – 59 kg: 0
0,5
5 ml
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
p (ARIXTRA):-profilaksis:
( ) p 2,5
, mg g 1x/hari,subkutan
,
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:
( ) Æ Th//
- bila kelainan (+)
- risiko (+) Æ pencegahan recurrent
dan trombosis di tempat lain
(otak, jantung, ginjal, mesenterium,
kandungan, dll)
 PROFILAKSIS ANTIKOAGULAN
Faktor Risiko Faktor Pencetus
Trombosis

Usia tua Imobilisasi

Obesitas Plaster gips tungkai
Riwayat DVT / PE + Pembedahan/Pasca PROFILAKSIS
I
Insufiensi
fi i jantung
j t bedah
b d h ANTIKOAGULAN
Kanker Kehamilan /persalinan
Stroke /pasca partus
Varises vena Infark miokard akut
Insufiensi vena Infeksi
Kontrasepsi oral
 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 off DVT to
t PREVENT PE
• 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
- Pneumatic
P ti compression
i stockings
t ki

• High risk patients:

- Enoxaparin 30 mg every 12 hours
- Pneumatic compression stockings
- Warfarin