PEMERIKSAAN HEMOSTASIS

dr.Agustyas Tjiptaningrum

Evaluasi Klinik Pasien dgn Perdarahan

Bila ada perdarahan tentukan hemostasis normal atau abnormal,

apakah perdarahan berlebihan setelah ekstraksi gigi atau luka kecil

(small cuts), perdarahan otot spontan atau hematom (bruisin), apakah

pernah ditransfusi

Tentukan apakah

Perdarahan akibat kelainan koagulasi atau

Kelainan pembuluh darah dan platelet (purpura karena perdarahan

kulit atau mukosa)

Test untuk kelainan vaskuler dan trombosit:

1. Bleeding time (waktu perdarahan)

2. Jumlah dan morfologi trombosit

3. MPV trombosit muda, >> produksinya msh bagus, bila tr-peni

MPV kelainan destruksi, produksi msh bagus

4. Fungsi trombosit agregasi trombosit

5. Reaksi Pelepasan dan marker aktivasi trombosit (p-selectin, PF4,

betaTG, CD40L)

6. Retraksi bekuan

7. Aktivitas PF3

EVALUASI PERDARAHAN

Test Kelainan Koagulasi:

1. Activated Partial Thromboplastin Time (aPTT)

2. Plasma Prothrombin Time (PT)

3. Thromboplastin generation test (TGT)

4. Prothrombin consumption test (PCT)

5. Fibrinogen plasma

6. Thrombin time

7. D-Dimer

8. Test untuk Fibrinolisis

Skrening Awal (primer)

1. Percobaan pembendungan

2. Masa perdarahan

3. Hitung trombosit

4. PT

5. aPTT

6. Masa Thrombin

Laboratory Monitoring

Prothrombin Time (PT)

test of extrinsic pathway activity

measures vitamin K - dependent factors activity (factors II,

VII, IX, X)

thromboplastin + Ca+2 to plasma = clotting time

normal values: 12-14 seconds

International Normalized Ratio (INR) tdk menggunakan

nilai normal karena untuk memonitor antikoagulan oral,

diharapkan adalah target valuenya bukan nilai normalnya

▪ standardizes PT reporting

normal values: 0.8 -1.2 seconds

Laboratory Monitoring

Prothrombin Time (PT)

monitors coumadin therapy

most sensitive to alteration in F VII levels

prolonged: 55 % ↓ of normal F VII activity bila F VII

aktivitasnya menurun hingga 55% maka akan prolonged

antithrombotic activity: reduction of factor II and factor X

activity (after several days)

Merupakan fungsi hati yang paling sensitif terutama fungsi

sintesis karena F VII half life paling pendek (dibandingkan

albumin dan CHE)

Activated Partial Prothrombin Time (aPTT)

test for intrinsic and common pathways

dependent on activity of all coagulation factors,

except VII and XIII

normal values: 25 -35 seconds

monitors heparin tx & screen for hemophilia

Activated Prothrombin Time (aPTT)

prolonged: heparin, thrombin inhibitors,

fibrin degradation products (FDP) FDP menghambat

polimerisasi fibrin menghambat koagulasi

citrated plasma + surface activators + phospholipid

prinsip pemeriksaan

prolonged only if coagulation factors reduced to < 30

% of normal

Activated Clotting Time (ACT)

monitors heparin anticoagulation in the OR

(cardiac and vascular surgeries)

normal values: 90 - 120 seconds

Menggunakan whole blood diberikan

aktivator clotting timenya ?

Laboratory Monitoring

Thromboelastography (TEG)

continuous profiles during all phases of

clot formation

provides more accurate picture of in vivo

coagulation process

to evaluate:

• hypo / hypercoagulable state

• hemophilia

• dilutional coagulopathy

• rare coagulation disorders anticoagulation tx

• coagulation problems with liver transplantation

Thromboelastogram (TEG)

Bleeding time

monitors platelet function

not specific indicator of platelet function

not very reliable

very operator - dependent

variable from each institution

Bleeding time

other factors: degree of venostasis, depth

and direction of incision

no evidence as

• a predictor of risk of hemorrhage

• useful indicator of efficacy of antiplatelet therapy

insensitive to mild platelet defects

LABORATORY

TEST

COMPONENT

MEASUREMET

NORMAL

VALUES

Bleeding time platelet function

vascular integrity

3 - 10 mins

PT I, II, V, VII, IX, X 12 - 14 secs

PTT I, II, V, VIII, IX, X, XI, XII 24 - 35 secs

Thrombin time

I, II 12 - 20 secs

Pemeriksaan Trombosit

JUMLAH TROMBOSIT

HITUNG CARA MANUAL

HITUNG AUTOMATIK

HAPUSAN DARAH

FUNGSI TROMBOSIT

BLEEDING TIME

MORFOLOGI –

HAPUSAN DARAH

AGREGASI TROMBOSIT

ANALISIS

GLIKOPROTEIN

TROMBOSIT – FLOW

SITOMETRI

CD41, 42, 61

HITUNG TROMBOSIT

• Larutan : Rees Ecker atau amonium oksalat

• Pipet automatik, pengenceran 100x atau 200x Pengenceran rendah untuk trombositopenia, pengenceran tinggi untuk trombositosis

• Hitung seluruh trombosit dlm 1 bidang besar ditengah (1 mm2)

• Konversi: Jml Trombosit / mm3 darah (pengenceran 200x): Y x 2000

17

Neubauer Chamber Improved

http://homepages.gac.edu/~cellab/chpts/chpt1/Images/fig1_8.gif

Cutaneus bleeding

Platelet Count Normal

Pemeriksaan Laborotorium Dx VWD dan Disfungsi Trombosit

DIAGNOSIS LABORATORIUM KELAINAN KOAGULASI DITURUNKAN

Prolonged aPTT

Normal PT

DIAGNOSIS LABORATORIUM PERDARAHAN DGN aPTT MEMANJANG

DIAGNOSIS LABORATORIUM KELAINAN LABORATORIUM YG DIDAPAT

Tes Skrening Pasien dg Perdarahan

aPTT