PEMERIKSAAN

DARAH

Dr. NOVI KHILA FIRANI, M.Kes., Sp.PK

Dept. Biologi Oral FKG UB

Langkah-langkah dalam Penatalaksanaan
Pasien

 Anamnesis
 Pemeriksaan Fisik
 Pemeriksaan Laboratorium
 Pemeriksaan Penunjang lain : Radiologi, PA,dll
 Diagnosis
 Terapi
 Evaluasi
MANFAAT PEMERIKSAAN LAB.

• MEMBANTU DIAGNOSA
• MENENTUKAN PROGNOSA
• UNTUK MONITORING
• UNTUK SCREENING

• PENELITIAN
Case : Gum bleeding
Case : Gingival hypertrophy
 Blood
 Urine
 Saliva
 Cerebrospinal Fluid
 Amniotic Fluid Biological Specimens
 Duodenal Aspirate
 Gastric Juice
 Gall stone
 Kidney Stone
 Stools
 Synovial Fluid
 Tissue Specimen
 Laboratory Testing

Clinical Chemistry

Urine & body fluid Biomolecular

Hematology Microbiology Parasitology

Immunology
 Flebotomi (Penyadapan Darah)

• Kapiler : volume darah kurang 0,5 ml

- 3 jari tengah tangan
- tumit, ibu jari kaki

• Vena : volume darah lebih 0,5 ml

- vena superfisial (v. mediana cubiti)

• Arteri : analisa gas darah

- a. Radialis
- a. Femoralis
Kegagalan venapungsi

9
 Blood Composition

Plasma is fluid component of blood.

Plasma Contains proteins, sugars, vit,minerals,
lipids, lipoproteins and clotting factors.
centrifugation 95% of plasma is water

White Blood cells (WBC)

& Platelets Cellular
Components
Red Blood cells (RBC)

Whole Blood + anticoagulant

 PEMERIKSAAN DARAH

- Pemeriksaan Darah Lengkap Manual

(Complete Blood Count)
Hematology
- Pemeriksaan Faal Hemostasis
autoanalyzer
Pemeriksaan Darah Lengkap
Terdiri dari:
 Hemoglobin
 Hematokrit
 Jumlah eritrosit
 Indeks eritrosit :
 Mean corpuscular volume (MCV)
 Mean corpuscular hemoglobin (MCH)
 Mean corpuscular hemoglobin concentration (MCHC)
 Red blood cell distribution width (RDW)
 Jumlah leukosit
 Jumlah trombosit
 Hitung jenis leukosit (Diff. count)

 Evaluasi hapusan darah tepi

 Laju endap darah (LED)
PEMERIKSAAN FAAL HEMOSTASIS

1. Masa perdarahan (BT / Bleeding Time)

2. Masa Pembekuan (CT / Clotting Time)
3. Plasma Prothrombin Time (PPT)
4. Activated Partial Thromboplastin Time (APTT)
PEMERIKSAAN DARAH LENGKAP
Kadar Hemoglobin (Hb)

 Hemoglobin merupakan senyawa kompleks antara

metalloporfirin (heme) dan protein (globin).
 Pemeriksaan kadar Hb  deteksi kelainan anemia, polisitemia
Anemia : Manifestasi Oral
 HEMOGLOBIN (Hb)

Cara manual (Metode Sahli ) :

Hb + HCl 0,1 N  Asam Hematin

HCL

18

16
Kadar Hb normal :
Pria dewasa : 14-18 g/dL 14
13,2
Wanita dewasa : 12-16 g/dL 12
 Hematocrit (Hct)
 Hematokrit : prosentase endapan sel darah merah terhadap
volume darah semula.
 Hematokrit mencerminkan konsentrasi sel darah merah
Hemoglobin x 3 = Hematocrit
Hematocrit
Hematology autoanalyzer
Hematology analyzer
 Indeks Eritrosit

Normal : 80 - 94 fl (normositik), bila > normal = makrositik, < normal = mikrositik

Normal : 26 - 32 pg (normokrom), bila < normal = hipokrom

Normal : 30 - 36 % g/L (normokrom), bila < normal = hipokrom

MCV normal MCV rendah

MCV tinggi
MCH normal MCH rendah

MCH tinggi
 Evaluasi hapusan darah
(eritrosit)

Limfosit

Normositik, normokrom Mikrositik, hipokrom Makrositik, normokrom

Red cell Distribution Width (RDW)

 Menunjukkan variasi pada ukuran/volume eritrosit.

 RDW meningkat  terdapat ukuran eritrosit yang
berbeda-beda = anisositosis.
 Nilai normal:
- RDW-SD 39-46 fL
- RDW-CV 11.6-14.6%
 Meningkat pada: anemia defisiensi besi, anemia
megaloblastik, anemia hemolitik, thalassemia, MDS
 RDW naik

RDW normal
Hematology analyzer
ANEMIA

Anemia : Hb < normal

HARGA NORMAL ♂ ♀
Hb : 14 – 18 12 –16 g / dl
∑ Eri : 4,4 – 5,9 3,8 – 5,2 juta / mm3
HCT : 40 – 52 35 – 37 %
MCV : 80 – 100 80 – 100 fl
MCH : 26 – 34 26 – 34 pg
MCHC : 32 – 36 32 – 36 g / dl

Wintrobe MM. Clinical Hematology

KLASIFIKASI ANEMIA
BERDASARKAN BENTUK ERITROSIT
1. Anemia Normokrom-normositik
- Perdarahan akut
- Anemia Aplastik
- Anemia krn keganasan

2. Anemia Hipokrom-mikrositik
- Anemia defisiensi Besi
- Thalassemia, Hemoglobinopati
- Anemia Penyakit Kronis

3. Anemia Normokrom-makrositik
- Anemia Megaloblastik
- Anemia krn Peny. Hepar
Anemia Defisiensi Besi
Thalassemia
 Autoimmune hemolytic anemia

Normoblast Microspherocyte
Polisitemia
 Hct > normal
 Hb > normal
 Jumlah eritrosit > normal

Klasifikasi :
 Absolute polycythemia : peningkatan total red cell mass
 Relative polycythemia : total red cell mass normal,
peningkatan Hct akibat penurunan volume plasma
(mis. Dehidrasi, syok)
Polycythemia
 Sel-sel darah

 Erythrocytes –
anucleate
 Leukocytes –
complete cells
 Platelets –
cell fragments
 Leukosit
 Sel darah berinti, jenis : eosinofil, basophil, neutrofil, limfosit, monosit
 Jumlah normal : Pria : 4.300 – 10.300/μL
Wanita : 4.700 – 11.300/μL
 Leukositosis : jumlah > normal
- neutrophilia (neutrophilic leukocytosis), lymphocytosis, monocytosis,
eosinophilia (eosinophilic leukocytosis), basophilia (basophilic leukocytosis).
 Leukopenia / agranulocytosis : jumlah < normal
- neutropenia, lymphopenia/lymphocytopenia
Jenis Leukosit
Hapusan darah tepi
Jenis-jenis leukosit

Normal differential
Counting :
Leukocytes physiology

 The life of the granulocytes : 4 - 8 hours circulating in the blood and

another 4-5 days in tissues
 The monocytes : 10 – 20 hours in the blood, before wandering through the
capillary membranes into the tissues  become tissue macrophages 
they can live for months.
 The lymphocytes have life spans of weeks or months, depending on the
body’s need for these cells.
B-Lymphocyte  plasma cell  produce antibodies
Peranan Leukosit

Migration of neutrophil from the blood into inflamed tissue

Interpretasi Hasil Diff.count
Eosinofil / Basofil / stab / segmen / limfosit / monosit
0-4% / 0-1% / 0-5% / 50-70% / 20-40% / 1-6%

Jumlah absolut:
 LEUKOCYTE DISORDER

Neutrophilia : absolute neutrophil count > 10.000/µL

Causes of Neutrophilia
Acute inflammatory – collagen vascular, vasculitis
Acute infectious – bacterial, some viral, fungal, parasitic
Drugs, toxins, metabolic – corticosteroids, growth factors, uremia, ketoacidosis
Tissue necrosis – burns, trauma, myocard infarct, RBC hemolysis
Physiologic – stress, exercise, smoking pregnancy
Neoplastic – carcinomas, sarcomas, myeloproliferative disorders
Neutropenia : absolute neutrophil count < 1.500/µL
Causes of Neutropenia

Drugs – cancer chemotherapy, chloramphenicol, sulfas/other antibiotics,

phenothiazines, benzodiazepine, antithyroids, anticonvulsants, quinine, quinidine,
indometacin, procainamide, thiazides
Radiation
Toxins – alcohol, benzene compounds
Intrinsic defects – Fanconi's, Kostmann's, cyclic neutropenia, Chédiak–Higashi
Immune-mediated – collagen vascular disorders, RA, AIDS
Hematologic – megaloblastic anemia, myelodysplasia, marrow failure, marrow
replacement
Infectious – any overwhelming infection
Others – starvation, hypersplenism
Eosinophilia : absolute eosinophil count > 500/µL

Causes of Eosinophilia

Allergic – urticaria, hay fever, asthma

Inflammatory – eosinophilic fasciitis, Churg–Strauss syndrome
Parasitic – trichinosis, filariasis, schistosomiasis
Nonparasitic infections – systemic fungal, scarlet fever, chlamydial pneumonia of infancy
Respiratory – pulmonary eosinophilic syndromes (Loeffler's, tropical pulmonary
eosinophilia)
Neoplastic – CML, Hodgkin lymphoma, T cell lymphomas
Idiopathic hypereosinophilic syndromes
Others – certain drugs, hematologic and visceral malignancies, GI inflammatory diseases,
sarcoidosis
Basophilia : absolute basophil count > 50/µL

Causes of Basophilia

Myeloproliferative disease
Allergic – food, drugs, foreign proteins
Infectious – variola, varicella
Chronic hemolytic anemia – especially post-splenectomy
Inflammatory – collagen vascular diseases, ulcerative colitis
 Monocytosis : absolute monocyte count > 750/µL
Causes of Monocytosis

Infectious – tuberculosis, subacute bacterial endocarditis, syphilis, protozoan, rickettsial

Recovery from neutropenia
Hematologic – leukemias, myeloproliferative disorders, lymphomas, multiple myeloma
Inflammatory – collagen vascular diseases, chronic ulcerative colitis, sprue, myositis,
polyarteritis, temporal arteritis
Others – solid tumors, immune thrombocytopenic purpura, sarcoidosis
Lymphocytosis : absolute lymphocyte count > 4.000/µL

Causes of Lymphocytosis

Infectious – many viral, pertussis, tuberculosis, toxoplasmosis, rickettsial

Chronic inflammatory – ulcerative colitis, Crohn's
Immune mediated – drug sensitivity, vasculitis, graft rejection, Graves', Sjögren's
Hematologic – ALL, CLL, lymphoma
Stress – acute, transient
Lymphocytopenia/Lymphopenia :
absolute lymphocyte count < 1.500/µL

Causes of Lymphopenia

Destructive – radiation, chemotherapy, corticosteroids

Debilitative – starvation, aplastic anemia, terminal cancer, collagen vascular disease,
renal failure
Infectious – viral hepatitis, influenza, typhoid fever, TB
AIDS associated – HIV cytopathic effect, nutritional imbalance, drug effect
Congenital immunodeficiency – Wiskott–Aldrich
Abnormal lymphatic circulation – intestinal lymphangiectasia, obstruction,
thoracic duct drainage/rupture, CHF
 Leukositosis

Leukopenia
 Platelets / thrombocyte
 Cell fragments from large cells megakaryocytes
 Essential for clotting process
 Degenerate in 9-12 days
 Formation regulated by thrombopoietin (made in liver)
 Normally 150.000-500.000/mm3 blood

Developmental pathway

Hemocytoblast Megakaryoblast Promegakaryocyte Megakaryocyte Platelets

Peran Trombosit pada Hemostasis
Trombositopenia
 Jumlah trombosit < normal
 Penyebab :
 Pseudotrombositopenia : platelet clumping
 Trombositopenia :
Penurunan produksi trombosit :
Obat : kemotx, toxin (alcohol), diuretic thiazide
Radiasi
Aplasia sumsum tulang
Keganasan yg menginfiltrasi sumsum tulang
Defisiensi B12, asam folat
Infeksi virus : HIV, hepatitis
Peningkatan destruksi trombosit :
Autoimun disease, Cancer (CLL, Lymphoma), ITP, Obat (Metildopa,
Heparin, Quinine), Inf. Virus (HIV, hepatitis), Sepsis, DIC
Sekuestrasi trombosit di spleen
Splenomegali
Normal thrombocytes Thrombocytopenia
Platelet clumping
Trombositosis
 Jumlah trombosit > normal
 Penyebab :
 Physiologic thrombocytosis : exercise, stress
 Reactive thrombocytosis
 Essential thrombocytosis
 Thrombocytosis

Giant thrombocytes
Reactive Conditions in Which Elevated Platelet Counts

Transient processes
Acute blood loss
Recover (‘rebound’) from thrombocytopenia
Acute infection or inflammation
Response to exercise
Sustained processes
Iron deficiency
Hemolytic anemia
Asplenia (e.g., after splenectomy)
Cancer
Chronic inflammatory or infectious diseases
Connective tissue disorders
Inflammatory bowel disease
Tuberculosis
Chronic pneumonitis
Drug reactions
Growth factors
Hematology analyzer-Flowsitometri
PEMERIKSAAN HEMOSTASIS

 Hemostasis : proses tubuh yang secara simultan

menghentikan perdarahan dari tempat yang cedera,
sekaligus mempertahankan darah dalam keadaan cair
didalam kompartemen vaskuler.
 Gangguan faktor pembekuan dapat terjadi perdarahan,
dan gangguan faktor fibrinolitik dapat terjadi trombosis
 PEMERIKSAAN HEMOSTASIS

Indikasi :

• Skrining pre-operative
• Dugaan kelainan perdarahan
• Perdarahan akut
• Pasien dengan terapi antikoagulan
• Penyakit dengan potensi disertai kelainan hemostasis:
penyakit hepar, sepsis, DIC, trombositopenia
Bleeding disorder
Yang Berperan pada Hemostasis
– Pembuluh darah : vasokonstriksi
– Trombosit : membentuk sumbat trombosit
– Faktor pembekuan/koagulasi : membentuk bekuan
atau fibrin
Faktor-faktor Koagulasi
Klasifikasi Kelainan Hemostasis

1. Kelainan Perdarahan Vaskular

2. Kelainan trombosit:
1. jumlah trombosit
2. Kelainan fungsi trombosit
3. Kelainan faktor koagulasi
PEMERIKSAAN FAAL HEMOSTASIS

1. Masa perdarahan (BT / Bleeding Time)

2. Masa Pembekuan (CT / Clotting Time)
3. Plasma Prothrombin Time (PPT)
4. Activated Partial Thromboplastin Time (APTT)
 PEMERIKSAAN MASA PERDARAHAN (BT)

Cara :
a. Cara Duke
b. Cara Ivy

Tujuan: Menilai fungsi kapiler dan trombosit

Cara Duke:
 Alat:
- Stopwach
- Kapas alkohol 70%
- Kertas saring
- Lancet steril
Harga normal : 1 – 3 menit
Interpretasi hasil

 Waktu perdarahan
Memanjang pada :
 Penyakit Von Willebrand
 Trombositopeni
 Penyakit mieloproliferatif, mielodisplastik
 Gangguan vaskuler
PEMERIKSAAN MASA PEMBEKUAN (CT)
Cara : Lee & White

 Prinsip: mengukur waktu pembekuan darah,

dimulai saat darah masuk spuit
sampai darah membeku.

Tujuan: Utk menilai faktor koagulasi pada jalur

intrinsik.

 Alat:
- 3 tabung berdiameter 8 mm.
- Stopwatch
- Spuit 5 ml
PEMERIKSAAN MASA PEMBEKUAN

Cara:
 Lakukan flebotomi  Jalankan stopwatch saat
darah masuk spuit  ambil 5 cc darah.
 Masukkan @ 1 ml darah

Tiap 30” tabung 1 diangkat dari rak &

dimiringkan  lihat pembekuan
Setelah darah tabung 1 membeku 
lanjutkan dengan tabung ke 2 & catat
waktunya.
Diamkan 4 menit Lakukan tindakan yg sama thd tabung
ke 3.
Masa pembekuan yang dilaporkan 
darah masuk spuit sampai darah
membeku di tabung ke 3.
1 2 3

Harga normal : 5 – 15 menit

Prothrombin time

 Prothrombin Time (PT): Uji saring laboratorium yang digunakan

untuk mendeteksi kelainan pembekuan darah.
 Pemeriksaan ini mengukur aktifitas faktor-faktor pada jalur
ekstrinsik (II, V, VII, X, dan fibrinogen).
 PT juga untuk memonitor terapi antikoagulan oral seperti
warfarin.
International Normalized Ratio (INR)

 Variasi pada komposisi dan responsifitas reagent PT

memerlukan standarisasi.
 International Normalized Ratio (INR) dikembangkan untuk
tujuan standarisasi monitoring terapi warfarin.
 INR: rasio/perbandingan antara rerata waktu plasma
penderita terhadap log rerata waktu protrombin kontrol
normal.
 INR Normal antara 0,9 – 1,2
Activated partial thromboplastin time
(APTT)
 Salah satu dari pemeriksaan yang digunakan untuk uji
saring penderita dengan bleeding tendency.
 Activated partial thromboplastin time merupakan
pemeriksaan untuk menyaring abnormalitas faktor -
faktor jalur intrinsik.
 Pemeriksaan ini juga digunakan untuk memonitor efek
antikoagulan circulating heparin
HEMOPHILIA A

 Defisiensi Faktor VIII

 Pemeriksaan FH :
 Clotting time memanjang
 APTT memanjang

HEMOPHILIA B

 Defisiensi Faktor IX
 Pemeriksaan FH :
 Clotting time memanjang
 APTT memanjang
Variabel Preanalitik yang mempengaruhi PT
dan APTT

 Pengambilan darah vena

 Hematokrit
 Konsentrasi antikoagulan sitrat: 3.2%
 Plasma: lipemik, hemolisis atau ikterik.
 Sampel harus segera dikirim ke lab  Faktor V
dan VIII mudah rusak
 Laju Endap Darah (LED)
Pemeriksaan utk mengukur kecepatan sedimentasi eritrosit di dalam plasma

Ada 2 cara: 1. Metode Westergren

2. Metode Wintrobe

Nilai normal : P = 0-20 mm/jam

L = 0-15 mm/jam

LED meningkat pada :

- Inflamasi - TBC
- Infeksi - Multiple Myeloma
- Rheumatoid artritis - Kehamilan
ESR analyzer