DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood...
Transcript of DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood...
![Page 1: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/1.jpg)
DIC dan VTE padainfeksi COVID.19
Rahajuningsih DharmaPDSPatKLIn
Webinar3Juni 2020
![Page 2: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/2.jpg)
Garis besar
• Kelainan hemostasispada COVID.19• Patofisiologi DICpada infeksi COVID.19• Pemeriksaan labuntuk deteksi DICpadaCOVID.19
• VTEpada COVID.19• Patofisiologi VTEpada COVID.19• RiskAssessmentModel
![Page 3: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/3.jpg)
Pendahuluan• COVID.19pertama kalidiidentifikasi diWuhanpada
Desember 2019.Penyakit ini telah menyebabkan tingginyamortalitas dibeberapa negara.
• Diseluruh dunia jumlah kasus yangterinfeksi meningkatsecara eksponensial, sehingga melampaui kapasitas tenagamedik,rumah sakit maupun pendukung kesehatan.
• Pada mulanya pasien yangberat menunjukkan kegagalansatu organyaitu gangguan respirasi,tetapi beberapa kasusberkembang menjadi penyakit sistemik disertai kegagalanmultiorgan.
• Gambaran prognostik yangpalingparah pada COVID.19adalah berkembangnya koagulopati.
![Page 4: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/4.jpg)
ProminentchangesinbloodcoagulationofpatientswithSARS-CoV-2infection
• KadarDdimer,FDPdan fibrinogenlebih tinggibermakna pada pasien 94SARS-Cov-2dibandingkankontrol (40orangsehat)sebaliknya ATlebih rendahsecara bermakna
• Ddimerdan FDPmeningkat dengan makin beratpenyakit
• Tidak ada perbedaan bermakna pada parameterPT,APTT,TT.
Hanetal.Clin Chem LabMed2020
![Page 5: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/5.jpg)
Thrombocytopeniaisassociatedwithseverecoronavirusdisease.(COVID.19)infection.
Ametaanalysis
• Jumlah trombosit lebih rendah pada kasus yangberat
• Pada kasus COVID.19yangberat weightmeandifference-31x109/L(CI-35sp -29x109/L)
• Pada kasus yangmeninggal -48x109/L(CI-57sp-39x109/L)
Lippietal,Clinica Chimica Acta 506(2020)145- 148
![Page 6: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/6.jpg)
Abnormalcoagulationparametersareassociatedwithpoorprognosisinpatientswith
novelcoronaviruspneumonia
• DIC(menurut kriteria ISTH)ditemukan pada 71,4%pasien yangmeninggal,tetapi pada yanghiduphanya 0,6%
• KadarDdimeryangtinggi saat masuk rumah sakitdan peningkatan sangat tinggi selama dirawat (3-4x)dihubungkan dengan kematian
TangNetal.JThromb Hemost.Feb2020
![Page 7: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/7.jpg)
• Lebih dari 50%pasien COVID.19mengalami sepsis.• Faktor risiko terjadinya kematian pada COVID.19adalah :usia lanjut (OR1,1),Ddimer>1µg/mLsaatmasuk rumah sakit (OR18,54)dan SOFAscoreyangtinggi (OR5,65)
• Pada pasien COVID.19yangberat juga dijumpaipeningkatan IL-6,troponin,LDH,dan lymphopenia
ZhouFetal.Lancet2020;395:1054-62
![Page 8: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/8.jpg)
Basedoncurrentlyavailableliterature,ISTHrecommendformeasuring:Ddimer,PT,plateletcountandfibrinogeninallpatientswithCOVID.19TheseparametersshouldbemonitoredtodetermineprognosisofCOVID.19patients.Ifthereisworseningoftheseparameters,moreaggressivetreatmentiswarranted.Iftheseparametersisstableorimproving,stepdown oftreatment
Tachil etal.Doi.10.1111/JTH.14810
![Page 9: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/9.jpg)
Disseminatedintravascularcoagulation
![Page 10: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/10.jpg)
DefinitionofDICbySSCofISTH
• DICisanacquiredsyndromecharacterizedbyintravascularactivationofcoagulationarisingfromdifferentcauses.
• Itcanoriginatefromandcausedamagethemicrovasculaturewhichifsufficientlyseverecanproduceorgandysfunction.
![Page 11: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/11.jpg)
Disseminatedintravascularcoagulation(DIC)
• DICisnotadiseaseorsymptombutasyndrome
• Alwayssecondarytoanunderlyingdisease
• Characterizedbysystemiccoagulationactivation
• MinimalclinicalcriteriaforDIC:
– Bleedingorthrombosisorboth
– Underlyingdisease
Bick,1998
![Page 12: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/12.jpg)
![Page 13: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/13.jpg)
Kondisi klinis yangdikaitkan dengan DIC
• Sepsis• Trauma/burn/surgery• Malignancy:
– Solidtumors– Acuteleukemia
• Severeallergic/toxicreaction:– snakebites– transfusionraction
• Obstetricalcalamities– Amnioticembolism– Abruptio placentae
• Vascularabnormalities– Kasabach Merittsyndrome
– Aorticaneurysma
Levi et al Thromb Haemost 1999;82(2):695-705
![Page 14: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/14.jpg)
Kriteria labminimaluntuk DIC
1. Bukti adanya aktivasi koagulasi
2. Bukti adanya aktivasi fibrinolisis
3. Bukti adaya konsumsi inhibitor
4. Bukti adanya kerusakan endorgan
Bick,1998
![Page 15: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/15.jpg)
Bukti aktivasi koagulasi
• Peningkatan prothrombin fragment1+2
• Peningkatan thrombin-antithrombin complex(TAT)
• Peningkatan fibrinopeptide A
• Peningkatan D-dimer
Bick,1998
![Page 16: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/16.jpg)
+F1.2
AT--- TAT
Ddimer
+
FPA+FPB
![Page 17: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/17.jpg)
Bukti aktivasi fibrinolitik
• Peningkatan D-dimer
• Peningkatan FDP
• Peningkatan plasmin
• Peningkatan plasmin-antiplasmin complex(PAP)
Bick,1998
![Page 18: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/18.jpg)
Ddimer
PAPcomplex
![Page 19: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/19.jpg)
Klasifikasi DIC
Fibrinolitik tertekan
Fibrinolitik meningkat
Fibrinolitik seimbang
Asakura J Intensive Care 2014 ;2:20
![Page 20: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/20.jpg)
DICdengan fibrinolitik tertekan
• TF sedangkan ATdan PC¯ sehingga faktorkoagulasi yg aktif tidak dapat dihambat
• Peningkatan PAI-1menghambat aktivasiplasminogen® produksi plasminrendah ®aktivitas fibrinolisis rendah
• Trombosis dimikrovaskuler® multiorganfailure/dysfunction
• Sepsis• Late– phaseoftrauma
Asakura JIntensiveCare2014;2:20
![Page 21: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/21.jpg)
![Page 22: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/22.jpg)
DICdengan fibrinolitik meningkat
• Peningkatan aktivitas fibrinolisis sehingga terjadifibrinolisis primerdan sekunder
• TAT,PAP,FDP,Ddimer,PT>,APTT>,TT>,fibrinogen¯,Trombosit¯
• Perdarahan berat• AcuteLeukemia(M3)• Aorticaneurysma• MetastaticprostateCa
Asakura JIntensiveCare2014;2:20
![Page 23: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/23.jpg)
DICdengan fibrinolitik seimbang• Terjadi keseimbangan antara fibrinolisis dankoagulasi
• Jarang perdarahan maupun kegagalan multiorgan
• Solidtumor• Pada beberapa tumordapat berkembang menjadiDICdengan fibrinolitik meningkat
Asakura J Intensive Care 2014 ;2:20
![Page 24: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/24.jpg)
Patofisiologi DICpada COVID.19
Covid.19
Sepsis
DIC
![Page 25: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/25.jpg)
Sepsis-3(2016)
• Sepsisadalah disfungsi organyangmengancam jiwa disebabkan disregulasirespon tubuh terhadap infeksi.
• Kriteria klinis sepsis:infeksi (documentedorsuspected)dengan peningkatan SOFAscore≥2
• PositiveqSOFA harus dipertimbangkansebagai kemungkinan infeksi pada orangyangsebelumnya tidak infeksi.
Gyawali.B etal.Journals.Sagepub.com/home/smo 2019;7:1-13
![Page 26: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/26.jpg)
SOFA-score• Fungsi respirasi: PaO2/FiO2• Fungsi koagulasi:jumlah trombosit• Fungsi hati :kadar bilirubin• Fungsi kardiovaskular :meanarterialpressure• Fungsi neurologi:Glasgowcomascale• Fungsi ginjal :kadar kreatinin dan urineoutput
![Page 27: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/27.jpg)
Gyawali.B etal.Journals.Sagepub.com/home/smo 2019;7:1-13
![Page 28: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/28.jpg)
QuickSOFA
• Perubahan statusmental(GCS<15)• Tekanan darah sistolik <100mmHg• Laju nafas >22/menit
Gyawali.B etal.Journals.Sagepub.com/home/smo 2019;7:1-13
![Page 29: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/29.jpg)
Sepsispada COVID.19
• Hasil penelitian Zhouetalmenunjukkan lebih dari50%pasien COVID.19mengalami sepsis (Lancet2020,395:1054-62)
• Menurut HuiLietal.pada COVID.19terjadi viralsepsis(Lancet2020,395:1517-20)
• GlobalSepsisAlliancemenyatakan bahwa COVID.19menyebabkan terjadinya sepsis.
![Page 30: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/30.jpg)
PathogenesisofDICinsepsis
InflamasiAktivasikoagulasi
![Page 31: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/31.jpg)
Lowdoseendotoxin
TNFa
IL6 F1,2
TAT
90min. 2hours
![Page 32: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/32.jpg)
Cytokines
Endotoxin Complementactivation
CRP
Tissuefactor
Monocyte
![Page 33: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/33.jpg)
Efek sitokin proinflamasi
BekuanFibrin
ATdanPC¯
EkspresiTF
PAI-1
![Page 34: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/34.jpg)
Kaskade koagulasi
XIIa
IIa
Intrinsicsystem(surfacecontact)
XII
XI XIa
Tissuefactor
IX IXa VIIa VIIVIII VIIIa
Extrinsicsystem(tissuedamage)
X
V Va
II
Fibrinogen Fibrin(Thrombin)
Xa AT
PC+PS
![Page 35: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/35.jpg)
Konsumsi (thrombingeneration)
Penurunan sintesis(negativeAPR)
Proteolytic olehneutrophilelastase
Penurunan Antithrombin pada Inflamasi
![Page 36: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/36.jpg)
gangguansintesis Aktivasi
menurun Degradasiolehelastase
PenurunanProteinCpada
Inflamasi
![Page 37: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/37.jpg)
![Page 38: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/38.jpg)
Sepsis
cytokine
TFmediatedcoagulatonactivation
DepressionofInhibitorysystem
PAI-1 mediated inhibition of fibrinolysis
Fibrinformation inadequate fibrin removal
Fibrindeposition
Organfailure
Decreasedperfusion
![Page 39: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/39.jpg)
DiagnosisalgorithmforthediagnosisofovertDICaccordingtoISTH
1. Riskassessment:doesthepatienthaveanunderlyingdisorderknowntobeassociatedwithovertDIC?Ifyesproceedifnodonotusethisalgorithm
2.Orderlaboratorytests3.Scorethelabresults• Plateletcount(>100=0;<100=1;<50=2)• Elevatedfibrinrelatedmarkers(eg fibrinmonomer,FDP)
(noincrease=0moderateincrease=2trong increase=3)• ProlongedPT(<3sec=0,3– 6sec=1;>6sec=2)• Fibrinogenlevel(>1g=0;<1g=1)4.Calculatescore• If³5=overtDICrepeatscoringdaily• If<5=nonovertDICrepeatnext1-2days
![Page 40: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/40.jpg)
Pemeriksaan laboratorium untuk DIC
• Sesuai dengan rekomendasi ISTH:– Ddimersejak dirawat ,meskipun tanpa gejalaberat.Kadar yangtinggi >2xULNprediktorkematian
– PT,hanya sedikit memanjang– Jumlah trombosit akan menurun pada yangberat– Fibrinogen,mula mula kadar meningkat karenamerupakan proteinfase akut.
![Page 41: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/41.jpg)
VTEpada COVID.19• Wangetal.yangmelakukan penilaian risiko TEVpada 1026pasien COVID.19,ternyata 40%mempunyai risiko tinggi TEVdengan scorePADUA>4,selanjutnya 11%dari yangberisiko tinggimengalami trombosis venadalam
• Middeldorp etal.mendapatkan insidens TEVsebesar17%dari 198pasien COVID.19yangdirawat diAmsterdam.Insidens TEVlebih besar pada pasienyangdirawat diICU(25%)dari pada yangdirawat dibangsal (6,5%).
Middeldorp Setal.doi:1020944/preprints202004.0345.v1
Wangetal.LancetHematol 2020,April9.doi.org/10.1016/S2352-3026(20)30109-5
![Page 42: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/42.jpg)
Emboliparu pada COVID.19• Bompard etal.yangmelakukan pemeriksaanComputerizedTomography(CT)pada 135pasienCOVID.19diParis,mendapatkan emboliparu pada37pasien atau 24%.
• Hasil otopsi yangdilakukan oleh Wichman etal.pada12pasien COVID.19yangmeninggal diHamburgJerman,mendapatkan emboliparu sebagaipenyebab kematian pada 4pasien dan trombosisvenadalam pada 7pasien.
Wichmannetal.AnnInternMeddoi:10.7326/M20-2003
Bompard etal.Eur Respir J2020;inpress.Doi.org/10.1183/13993003.01365-2020)
![Page 43: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/43.jpg)
Patofisiologi Trombosis
![Page 44: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/44.jpg)
Trias Virchow
Kelainan dindingvaskuler
Perubahan alirandarah
Hiperkoagulabilitas
![Page 45: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/45.jpg)
Trombosis vena
Hiperkoagulabilitas
Aliran darah stasis
![Page 46: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/46.jpg)
Patofisiologi VTEpada COVID.19
Hiperkoagulabilitas
Disfungsiendotel
inflamasi
Stasis
Tirah baring
Hypoxia
![Page 47: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/47.jpg)
WellsScoreItem Point
• Activecancer +1• Paralysisorimmobilization +1• Bedridden>3daysorpostsurgery<4weeks +1• Painordeeppainpalpation +1• Legedema +1• Calfedema>3cmcontralateral +1• Pittingedemaonipsilateral +1• Superficialveindilatationipsilateral +1• Alternativediagnosis -2Low 0Intermediate 1-2High ≥3
![Page 48: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/48.jpg)
PaduaPredictionScoreItem Score
• Activecancer +3• PreviousVTE +3• Reducedmobility +3• Knownthrombophilia +3• Recenttrauma/surgery +2• Age>70years +1• Heartorrespiratoryfailure +1• AMIorischemicstroke +1• Acuteinfectionorrheumaticdisorders +1• Obesity +1• Hormonaltherapy +1• Paduascore<4lowrisk• Paduascore³ 4highrisk
![Page 49: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/49.jpg)
IMPROVEInternationalMedicalPreventionon
VenousThromboembolismItem Score
• PreviousVTE 3• Malignancy 1• Thrombophilia 3• Age>60years 1
Score0-1lowScore2-3moderateScore³ 4high
![Page 50: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/50.jpg)
Pemeriksaan labpada VTE• Diagnosis:
– Ddimer>1,5µg/mL(normal<0,5µg/mL)dapatmemprediksi VTEdengan sensitivitas 85%specificitas88,5%dan negativepredictivevalue94,7%
• Monitoringterapi antikoagulan:– UFHdengan APTTtarget1,5– 2,5kalicontrol,denganantiXa 0,3– 0,7IU
– LMWHdan DOACtidak perlu pemantauan kecualikondisi tertentu
– VKAdengan INRtarget2-3• Deteksi faktor risiko :
– ACA,antib2GP1,LA,Antitrombin,ProteinC,ProteinS,penyebab trombofilia lain
![Page 51: DIC dan VTE pada - PDSPATKLIN...adalah berkembangnya koagulopati . Prominent changes in blood coagulation of patients with SARS-CoV-2 infection • Kadar D dimer, FDP danfibrinogen](https://reader034.fdocument.pub/reader034/viewer/2022052614/607248383aa13007366c6a40/html5/thumbnails/51.jpg)
Ringkasan
• Pada infeksi COVID.19yangberat dapat dijumpai DICmaupun VTE.
• DICpada COVID.19terjadi karena sepsis,diklasifikasikan sebagai DICdengan fibrinolisistertekan yangmengakibatkan multiorganfailure
• Ddimersaat masuk rumah sakit merupakanprediktor kematian
• VTEpada COVID.19terjadi karena hiperkoagulabilitasdan aliran darah stasisakibat tirah baringyanglama