DAFTAR ISI

1. Pembukaan.......................................................................................................................6
2. Pendahuluan.....................................................................................................................8
2.1........................................................................................ Mengapa butuh pedoman baru
.......................................................................................................................................8
2.2.............................................................................. Apa yang baru dalam pedoman baru
.......................................................................................................................................8
2.2.1. Konsep baru/revisi pada tahun 2019..............................................................9
2.2.2. Perubahan dalam rekomendasi 2014-2019...................................................10
2.2.3. Rekomendasi baru utama 2019....................................................................10
3. Pertimbangan Umum......................................................................................................12
3.1................................................................................................................... Epidemiologi
.....................................................................................................................................12
3.2.......................................................................................................... Faktor predisposisi
.....................................................................................................................................13
3.3....................................................................................... Patofisiologi dan penentu hasil
.....................................................................................................................................15
4. Diagnosis........................................................................................................................18
4.1.............................................................................................................. Presentasi klinis
.....................................................................................................................................18
4.2......................................................................... Penilaian kemungkinan klinis (pre-test)
.....................................................................................................................................19
4.3........ Menghindari penggunaan yang berlebihan dari tes diagnostik untuk emboli paru
.....................................................................................................................................20
4.4.......................................................................................................... Pengujian D-dimer
.....................................................................................................................................20
4.4.1. Cut-off D-dimer yang disesuaikan usia........................................................21
4.4.2. Cut-off D-dimer disesuaikan dengan kemungkinan klinis...........................21
4.4.3. Pemeriksaan D-dimer titik perawatan..........................................................21
4.5........................................................................ Angiografi paru tomografi terkomputasi
.....................................................................................................................................22
4.6.................................................................................................... Scintigraphy paru-paru
.....................................................................................................................................23
 4.7............................................................................................................... Angiografi Paru
.....................................................................................................................................25
4.8....................................................................................... Angiografi resonansi magnetik
.....................................................................................................................................25
4.9........................................................................................................... Echocardiography
.....................................................................................................................................25
4.10. Kompresi Ultasonografi..........................................................................................27
4.11. Venografi tomografi terkomputasi..........................................................................30
5. Penilaian keparahan emboli paru dan risiko kematian dini............................................30
5.1......................................................................... Parameter klinis keparahan emboli paru
.....................................................................................................................................30
5.2................................................................ Gambaran ukuran dan fungsi ventrikel kanan
.....................................................................................................................................30
5.2.1. Echocardiography.........................................................................................30
5.2.2. Angiografi paru paru terkomputasi..............................................................31
5.3.................................................................................................. Biomarker laboratorium
.....................................................................................................................................31
5.3.1. Tanda cedera myocardial..............................................................................31
5.3.2. Penanda disfungsi ventrikel kanan...............................................................32
5.3.3. Biomarker laboratorium lainnya..................................................................33
5.4.............. Parameter dan skor gabungan untuk penilaian tingkat keparahan emboli paru
.....................................................................................................................................33
5.5................................................. Integrasi kondisi yang memperburuk dan komorbiditas
.....................................................................................................................................33
5.6....................................................................... Rekomendasi untuk penilaian prognostik
.....................................................................................................................................35
6. Perawatan dalam fase akut.............................................................................................37
6.1....................................................................... Dukungan hemodinamik dan pernapasan
.....................................................................................................................................37
6.1.1. Terapi oksigen dan ventilasi.........................................................................37
6.1.2. Pengobatan farmakologis dari kegagalan ventrikel kanan akut...................38
6.1.3. Dukungan peredaran darah mekanis dan oksigenasi....................................40
6.1.4. Dukungan kehidupan tingkat lanjut.............................................................40
 6.2......................................................................................................... Anticoagulasi Awal
.....................................................................................................................................40
6.2.1. Antikoagulasi parenteral...............................................................................40
6.2.2. Antikoagulan oral non-vitamin K ................................................................40
6.2.3. Vitamin K antagonists..................................................................................41
6.3......................................................................................................... Perawatan reperfusi
.....................................................................................................................................42
6.3.1. Trombolisis sistemik....................................................................................42
6.3.2. Pengobatan yang diarahkan kateter perkutan...............................................43
6.3.3. Embolektomi bedah......................................................................................44
6.4........................................................................................ Tim emboli paru multidisiplin
.....................................................................................................................................45
6.5.............................................................................................................. Filter Vena cava
.....................................................................................................................................45
6.6......................... Rekomendasi untuk pengobatan fase akut emboli paru berisiko tinggi
.....................................................................................................................................46
6.7.................... Rekomendasi untuk pengobatan fase akut emboli paru menengah/rendah
.....................................................................................................................................47
6.8......................................................... Rekomendasi untuk tim emboli paru multidisiplin
.....................................................................................................................................48
6.9................................................................. Rekomendasi untuk Filter vena cava inferior
.....................................................................................................................................48
6.10. Rekomendasi untuk pemulangan dini dan perawatan di rumah............................. 48
7. Diagnosis dan manajemen yang disesuaikan dengan risiko terintegrasi........................48
7.1....................................................................................................... Diagnostic strategies
.....................................................................................................................................48
7.1.1. Emboli paru yang dicurigai dengan ketidakstabilan hemodinamik.............51
7.1.2. Emboli paru yang dicurigai tanpa ketidakstabilan hemodinamik................51
7.1.2.1............................ Strategi berdasarkan angiografi paru paru terkomputasi
................................................................................................................51
7.1.2.2.................................... Strategi berdasarkan ventilasi/perfusi scintigraphy
................................................................................................................51
7.2......................................................................................................... Strategis Perawatan
.....................................................................................................................................52
 7.2.1. Perawatan darurat dari emboli paru berisiko tinggi.....................................52
7.2.2. Pengobatan emboli paru risiko menengah....................................................52
7.2.3. Manajemen emboli paru berisiko rendah.....................................................53
8. Perawatan kronis dan pencegahan kekambuhan............................................................56
8.1............................................................................. Tujuan antikoagulasi setelah PE akut
.....................................................................................................................................56
8.2................................................................ Resiko berdarah terkait dengan Antikoagulan
.....................................................................................................................................58
8.3..................................................................................... Regimen dan durasi pengobatan
.....................................................................................................................................59
8.4.................................................... Rekomendasi untuk rejimen dan durasi antikoagulasi
.....................................................................................................................................60
8.5..................................................... Manajemen emboli paru pada pasien dengan kanker
.....................................................................................................................................61
8.6. Rekomendasi untuk rejimen dan durasi antikoagulasi setelah emboli paru pada pasien
dengan kanker aktif.....................................................................................................63
9. Emboli paru dan kehamilan............................................................................................64
9.1............................... Epidemiologi dan faktor risiko untuk emboli paru pada kehamilan
.....................................................................................................................................64
9.2.......................................................................... Diagnosis emboli paru pada kehamilan
.....................................................................................................................................64
9.2.1. Aturan prediksi klinis dan D-dimer..............................................................64
9.2.2. Tes Gambaran...............................................................................................65
9.3....................................................................... Pengobatan emboli paru pada kehamilan
.....................................................................................................................................67
9.4.................................................................................................... Emboli cairan ketuban
.....................................................................................................................................69
9.5.......................................................... Rekomendasi untuk emboli paru pada kehamilan
.....................................................................................................................................70
10. Gejala Sisa jangka panjang dari pulmonary embolism.................................................70
10.1. Gejala dan keterbatasan fungsional yang menetap setelah emboli paru.................. 71
10.2. Faktor risiko dan kondisi untuk hipertensi paru tromboemboli kronis................... 72
10.2.1. Epidemiologi, patofisiologi, dan riwayat..................................................... 72
10.2.2. Presentasi dan diagnosis klinis..................................................................... 73
 10.2.3. Perawatan Bedah.......................................................................................... 74
10.2.4. Angioplasti paru balon................................................................................. 75
10.2.5. Perawatan Pharmacological......................................................................... 76
10.3. Strategi untuk tindak lanjut pasien setelah emboli paru.......................................... 77
10.4. Rekomendasi untuk tindak lanjut setelah emboli paru akut................................... 79
11. Pesan kunci.....................................................................................................................80
12. Kesenjangan dalam bukti...............................................................................................81
13. ‘Apa yang harus dilakukan ’dan‘ pesan yang tidak boleh dilakukan ’dari Pedoman....83
14. Data Tambahan...............................................................................................................85