8/13/2019 14. Dic (Dr.hadianti)
1/41
TROMBOSIS DAN KID/ DIC(Koagulasi Intravascular Diseminata)
HADIANTI
8/13/2019 14. Dic (Dr.hadianti)
2/41
TROMBOSIS
8/13/2019 14. Dic (Dr.hadianti)
3/41
Blood Vessels. A.) The wall of an artery. B.) The wall of a vein
8/13/2019 14. Dic (Dr.hadianti)
4/41
Faktor-faktor penyebab trombosis: Kolesterol
Kompleks imn
!n"otoksin
Sres #emo"inamik
Bakteri "an $irs
Sitokin
!n%im rokok
8/13/2019 14. Dic (Dr.hadianti)
5/41
&ato'enesis
Keti"akseimban'an stimlasi trombo'enik "anmekanisme proteksi
- Stimlasi berlebi#an "' proteksi normal ata
stimlasi normal proteksi berkran'
Hemostasispenyemb#an lka ()* #ari+
#emostasis primer (trombosit "an $essel+
#emostasis sekn"er (faktor koa'lasi "an
antikoa'lan#emostasis tersier (fibrinolisis+
8/13/2019 14. Dic (Dr.hadianti)
6/41
8/13/2019 14. Dic (Dr.hadianti)
7/41
8/13/2019 14. Dic (Dr.hadianti)
8/41
&roteksi trombosis:
&rotein , "' kofaktor protein S #ambat
a "an IIaAT III "an Heparin alfa) antitripsin "an
beta. mikro'lobin#ambat /a "an
trombin t&A #ambat plasmin melisis fibrin
8/13/2019 14. Dic (Dr.hadianti)
9/41
Trombosis Masa abnormal "ari konstiten "ara# melali proses
koa'lasi intralminar sistem $asklar semasa #i"p0
Trombosis $ena a"ala# trombosis "i "alam $ena
&enyakit $ena peri$er terserin' yan' menyebabkan pasien ke"okter a"ala#:1 Trombosis $ena "alam (Deep ein T#rombosis2DT+3
1 Tromboflebitis3
1 &ost T#romboti4 Syn"rome (&TS+ akibat insfisiensi katp $ena"alam kronik berpa:
5 pi'mentasi stasis "an2ata
5 "ermatitis stasis "an2ata
5 lks stasis0
8/13/2019 14. Dic (Dr.hadianti)
10/41
Shears stressShears rate
Turbulence
Pathophysiologic of ThrombosisPathophysiologic of Thrombosis
ArterialThrombosis VenousThrombosis
Abnormality of Abnormality
of vessel wall Abnormality of
Blood flow
abnormality of
blood
Triad of Virchow
Venous
stasisPlatelethyper
activity
Hypercoagulability state
Thrombophilic stateFibrinolysis deficient
Thrombocytosis
Plaqueruptures
EndothelialPerturbation
VenousHypotonia
ArterialThrombosis VenousThrombosis
Hyperviscosity
Hyperfibrinogenemia
ArterialThrombosis
VenousThrombosis
8/13/2019 14. Dic (Dr.hadianti)
11/41
Fa4tor risiko
Berba'ai fa4tor yan' berperan seba'ai penyebabpembentkan saran' trombosit "an kompleks trombin-fibrin seba'ai bakal trombosis $ena tertama a"ala#:1 stasis $ena3
1 #ipotonia $ena3
1 stats #iperkoa'labilitas ole# berba'ai penyebab3
1 stats trombofilik ole# berba'ai penyebab3
1 "efisiensi fibrinolysis ole# berba'ai penyebab3
1 kersakan en"otel $ena ata en"otel $ena teran4am rsak(en"ot#elial pertrbation+3
1 kersakan tnika intima $ena0
8/13/2019 14. Dic (Dr.hadianti)
12/41
Clinical ConditionsDefect of Blood, Protein,
or PlateletArterial Thrombosis Venous Thrombosis
Atherosclerosis
Cigarette smoing
!"#ertension
Dia$etes Mellitus
%o&'ensit"li#o#roteincholesterol
!"#ertrigl"ceriemia
ositive *amil"histor"
%e*t ventricular*ailure
Oral contrace#tives
+strogens
%i#o#rotein(a)
ol"c"themia
!"#erviscosit"s"nromes
General surgery
Orthopaedicsurgery
Arthroscopy
Immobility
alignancy
!epsis
In,ur"
Congestive !eart-ailure
Ne#hrotic s"nromeO$esit"
.aricose veins
ost#hle$itics"nrome
Oral contrace#tives
+strogens
Antiphospholipidsyndrome
!tic"y platelet syndrome
Cancer procoagulant#CP$
rotein S e*ects
rotein C e*ects
AC resistance (*actor .%eien)
Antithrom$in e*ects
!e#arin co*actor II e*ects
lasminogen e*ects
Tissue #lasminogenactivators e*ects
lasminogen activatorinhi$itor e*ects
-actors II e*ects
D"s*i$rinogenemia
Causes of ThrombosisCauses of Thrombosis
8/13/2019 14. Dic (Dr.hadianti)
13/41
8/13/2019 14. Dic (Dr.hadianti)
14/41
8/13/2019 14. Dic (Dr.hadianti)
15/41
8/13/2019 14. Dic (Dr.hadianti)
16/41
VTE: A strong relationship betweenVTE: A strong relationship between
DVT and PEDVT and PE
Almost &, of patients with
pro*imal DVT of the le1
have asymptomatic PE%
DVT (mainly asymptomatic)
is found in around +&,of patients with PE-
1. 6esavento R* et al. -inerva 2ardioan4iol. 199!"#%$!)&(9!%'. Girard 6* et al. 2hest.1999"11($#)&9595
Embolus
2i1ration
Thrombus
8/13/2019 14. Dic (Dr.hadianti)
17/41
T#rombo'enesis DT
Kebanyakan pembentkan trombs $ena "imlai
"ari pembentkan 6arin' "ari saran' trombosit "an
kompleks trombin-fibrin pa"a sins $ena "i"alam
otot ata katp $ena pa"a $ena "alam meskipn
ti"ak a"a kersakan en"otel $ena3 se#in''a sel
"ara# mera# terperan'kap membentk trombs
yan' "isebt seba'ai trombs mera# "ankem"ian men6alar ke proksimal0
8/13/2019 14. Dic (Dr.hadianti)
18/41
8/13/2019 14. Dic (Dr.hadianti)
19/41
7e6ala klinis 7e6ala klinis DT ter'antn' lasnya keterlibatan $ena3
1 "apat asimptomatik ata
1 kombinasi "ari:5 pemben'kakan e8tremitas (tn'kai2len'an+ mlai "ari "istal3
5 otot kak (ti"ak lnak+3
5 nyeri otot tertama pa"a ber"iri "an ber6alan3
5 pittin' e"ema tetapi #an'at3
5 klit kebiran (4yanosis+3
5 $ena sperfi4ial prominent akibat "ilatasi $ena kolateralsperfisial
8/13/2019 14. Dic (Dr.hadianti)
20/41
Stan"ar"i%e" 4lini4al "ia'nosti4s
"e4ision mo"el for sspe4te" DT
Clinical probability parameter !core%
%
%
%
%
%
%%
-&
(@ells et al< %ancet :668 >89 :>=5)
. /o0 probability, % or & . oderate probability, 1 or more . 2igh probability
Acti3e cancer #ongoing or 0ithin pre3ious 4 monthschemotherapy$
Paralysis, paresis or recent plaster immobili5ation of thelo0er e6tremities
Bedridden for more than 1 days or ma7or surgery 0ithin 80ee"s
9ntire leg s0ollen
Calf s0elling of more than 1 cm 0hen compared 0ith the
asymptomatic leg #measured % cm belo0 the tibialtuberosity$
Pitting edema greater in the symptomatic leg
Collateral non3aricose superficial 3eins
/ocali5ed tenderness along distribution of the deep 3einsystem
Alternati3e diagnosis as or more li"ely than DVT
8/13/2019 14. Dic (Dr.hadianti)
21/41
,lini4al "ia'nosti4s "e4ision rle
DVT
Positi3e
:o DVT
:egati3e Positi3e
CCD; at day )
/o0
:egati3eNegative
DVT
Positi3eositive
D-Dimer
oderate 2igh
Clinical probability
:egati3e
Compression
color doppler ;!G
!uspected DVT
8/13/2019 14. Dic (Dr.hadianti)
22/41
8/13/2019 14. Dic (Dr.hadianti)
23/41
8/13/2019 14. Dic (Dr.hadianti)
24/41
8/13/2019 14. Dic (Dr.hadianti)
25/41
8/13/2019 14. Dic (Dr.hadianti)
26/41
8/13/2019 14. Dic (Dr.hadianti)
27/41
Definition Disseminate" intra$as4lar 4oa'lation (DI,+ is a
4lini4opat#olo'i4 syn"rome in >#i4# >i"esprea"
intra$as4lar 4oa'lation is in"4e" by pro4oa'lants
t#at are intro"4e" or pro"4e" in t#e bloo" an"
o$er4ome t#e natral anti4oa'lant me4#anisms
8/13/2019 14. Dic (Dr.hadianti)
28/41
&at#olo'y
- Diffse mltior'an blee"in'
- Hemorr#a'i4 ne4rosis
- Mi4rot#rombi in small bloo" $essels
- T#rombi in me"im an" lar'e bloo" $essels
8/13/2019 14. Dic (Dr.hadianti)
29/41
&at#o'enesis
infection
in7ury
Throm$in generation
8/13/2019 14. Dic (Dr.hadianti)
30/41
atho#h"siolog"
rocoagulantactivation
+?cessive coagulation activit"
DisseminatedThrombosis
Coagulation *actors
consum#tion
Bleeding
Natural anticoagulantconsum#tion
Any causes
Precipitating factors
OD=O
8/13/2019 14. Dic (Dr.hadianti)
31/41
Clinical conditions that may be
associated with overt DIC
se3sis8severe infe+tion $any mi+roor4anism) trauma $e.4. 3olytrauma* neurotrauma* fat em:olism) or4an destru+tion $e.4. severe 3an+reatitis) mali4nan+y
solid tumors
-yelo3roliferative 8 7ym3ho3roliferative mali4nan+ies
o:stetri+al +alamities amnioti+ fluid em:olism a:ru3tio 3la+entae
vas+ular a:normalities 7ar4e vas+ular aneurysms
severe he3ati+ failure severe to;i+ or immunolo4i+ rea+tions
sna
8/13/2019 14. Dic (Dr.hadianti)
32/41
,lini4al Featres
?n"erlyin' "isease Blee"in' manifestations >ere 4ommon
T#romboembolism
Renal3 @i$er an" Respiratory "ysfn4tion ,entral Ner$os System Manifestations
S#o4k
A4ral ,yanosis
8/13/2019 14. Dic (Dr.hadianti)
33/41
@aboratory Featres an" Dia'nosis
Does the patient ha3e an underlying disorder
cause DIC @
:o es
!core ',suggesti3ebut not mono3ert DIC
!core ',o3ertDIC,affirmati3e
Determine score Platelet E %+., %+.% '+ . &
8/13/2019 14. Dic (Dr.hadianti)
34/41
,ertain form of DI,
A+ute 0,2 0,2 develo3s a+utely when sudden e;3osure of :lood to 3ro+oa4ulants
o++urs* in+ludin4 tissue fa+tor $tissue throm:o3lastin)* 4eneratin4intravas+ular +oa4ulation
2hroni+ 0,2 2hroni+ 0,2 refle+ts a +om3ensated state that develo3s when :lood is
+ontinuously or intermittently e;3osed to small amounts of tissue fa+tor
A. 2om3ensated Hi4h level F06 without +oa4ulant fa+tors defi+ient
A. 0e+om3ensated
Hi4h level F06> ,nhi:it 3latelet fun+tion> ,nhi:it +oa4ulation def. +oa4ulation fa+tors
0efi+ien+ies +oa4ulation fa+tors Throm:o+yto3enia
O3ert DIC
:on-o3ert DIC
:o DIC
8/13/2019 14. Dic (Dr.hadianti)
35/41
8/13/2019 14. Dic (Dr.hadianti)
36/41
8/13/2019 14. Dic (Dr.hadianti)
37/41
8/13/2019 14. Dic (Dr.hadianti)
38/41
8/13/2019 14. Dic (Dr.hadianti)
39/41
DI, S4ore ISTH
Ris