Prevensi DVT pada Pasien Non Bedah

7/21/2019 Prevensi DVT pada Pasien Non Bedah

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PREVENTION OF VENOUS

THROMBOEMBOLISM IN

MEDICALLY ILL PATIENTS

Pembimbing: dr. Kartika Widayati, SpPD-KHOM

Presentan: dr. Levina Prima Rosalia


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Venous

Thromboembolism

(VTE)

PulmonaryEmbolism

(PE)

Deep VeinThrombosis

(DVT)


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Strong risk factor

(odds ratio >10)

Fraktur

(panggul/kaki)

Penggantian sendi

panggul/lutut

Operasi mayor

Trauma mayor

Cedera spinal cord

Moderate risk factor

(odds ratio 2-10)

Arthroscopic knee surgery

Kateter vena sentral

Kemoterapi

CHF

Gagal nafas

Terapi pengganti hormon

Keganasan

Terapi kontraseptif oral

Stroke paralitik

Kehamilan/post-partum

Riwayat VTE

Trombofilia

Weak risk factor

(odds ratio


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VTE pada Pasien Medically ill

Pasien yang dirawat di RSresiko VTE lebih tinggi 100X

Tanpa tromboprofilaksis, insidensi DVT pada pasien RS :

16-55% dan pasien bedah ortopedi mayor: 50-60%. PE5-10% kematian di RS150-200 ribu kematian

per tahun di AS

Sebagian besar (78%) pasien memiliki 1 faktor resiko

VTEmenetap sampai beberapa minggu setelah pulang

Profilaksis VTE keselamatan pasien


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VTE pada Pasien Critically ill (ICU)

Perubahan koagulasi darah, inflamasi, & respons imun

Imobilisasi, ventilator, sedasigejalanya terkaburkan

silent VTE

Insidensi VTE tanpa profilaksis : 15-60%:

DVT: 28-32%, bisa sampai 60% pada pasien trauma &

70% pada stroke iskemik akut

PE fatal: pada hemiplegi: 1-2% 40-50% pasien DVT simtomatikdidapatkan PE

asimtomatik saat skrining


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Pasien rawat inap dengan sakit akut & peningkatan resiko

trombosis tromboprofilaksis antikoagulan: LMWH, UFH

dosis kecil 2-3x/hari, atau fondaparinux (Grade 1B)

Pasien rawat inap dengan sakit akut & resiko trombosis

rendah profilaksis tidak direkomendasikan (Grade 1B)

Pasien rawat inap dengan sakit akut & perdarahan/resiko

perdarahan tinggi tromboprofilaksis antikoagulan tidak

direkomendasikan (Grade 1B)

ACCP Guideline (2012)


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Pasien rawat inap dengan sakit akut & resiko trombosis

& perdarahan/resiko tinggi tromboprofilaksis mekanik:

graduated compression stocking(Grade 2C)/

intermittent pneumatic compression (IPC) (Grade 2C).

Bila resiko perdarahan & resiko VTE menetap gantidengan obat (Grade 2B)

Pasien rawat inap dengan sakit akut yang diberitromboprofilaksis direkomendasikan diberikan sampai

imobilisasi selesai/sampai saat pulang (Grade 2B)



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Pasien sakit kritis tidak direkomendasikan skrining DVT

rutin dengan USG Dopler (Grade 2C)

Pasien sakit kritis direkomendasikan pemberian LMWH

/UFH low dose dibandingkan tanpa profilaksis (Grade 2C)

Pasien sakit kritis dengan perdarahan/resiko tinggi

tromboprofilaksis mekanik dengan GCS/IPC (Grade 2C)

sampai resiko perdarahan ganti obat (Grade 2C)



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1

Nilai faktor resiko VTE dasar pasien

2

Nilai faktor resiko VTE tambahan pada pasien alasan

hospitalisasi, operasi, trauma, penyakit

3 Nilai resiko perdarahan & kontraindikasi profilaksis VTE

4 Formulasikan keseluruhan penilaian (risk-benefit)

5 Tentukan cara dan jenis profilaksis VTE


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CAPRINI SCORE

Total Score Incident of DVT Risk Level

0-1


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Penilaian Resiko Perdarahan

Perdarahan mayor (butuh transfusi 2 unit produk darah

dalam 24 jam)

Perdarahan kronis yang signifikan >48 jam

Bleeding disorder (misal: hemofilia) Lesi intrakranial/spinal

Perdarahan sistem saraf pusat

Koagulasi darah abnormal

Trombositopenia (AT < 50,000/l)

Disfungsi trombosit berat (uremia, obat-obatan, MDS)


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Penyakit gastrointestinal ulseratif/ulkus peptikum aktif

Obstructive jaundice/kolestasis

Prosedur operasi mayor dengan resiko perdarahan tinggi

Penggunaan obat-obatan yang mempengaruhi proses

pembekuan darah (antikoagulan, antiplatelet, NSAID,

agen trombolitik)

Anestesi aksial regional atau pungsi lumbal Resiko jatuh yang tinggi


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The IMPROVE VTE Risk Modelprobabilitas VTE akut sejak

admisi sampai dengan pulang

The IMPROVE Bleeding Risk Modelprobabilitasperdarahan mayor sejak admisi sampai 14 hari kemudian


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Profilaksis VTE

Primary prophylaxisobat/metode fisik yang

efektif mencegah VTE

Secondary preventiondeteksi dini dengan

skrining dan terapi VTE subklinismahaljarang

dilakukan


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Profilaksis VTE - Farmakoterapi

Unfractionated heparin (UFH) atau low molecular weight

heparin(LMWH) subkutan

Fondaparinux subkutaninhibitor activated Factor X (Xa) Rivaroxaban oralinhibitor langsung faktor Xa

Dabigatran etexilate oralinhibitor trombin

Warfarin oral

antagonis vitamin K


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Profilaksis VTE - Mekanik

aliran darah vena dengan kompresi eksternal

stasis vena dan stagnasi darah

Intermittent pneumatic compression devices (IPCs)

Kontraindikasi: iskemi kaki karena PAD Segera dimulai secepat mungkin

Resiko perdarahan kombinasi atau ganti dengan

farmakoterapi


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Profilaksis VTE - Mekanik

Graduated compression stockings

(GCS)

Meta-analysistidak efektif

dalam prevensi VTE pada pasien

stroke iskemik

resiko ulkus kulit dan nekrose

Venous foot pumps (VFP)

Data tentang efikasi terbatas


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PenelitianPenelitian HASIL

Tapson et

al, 2005

Tromboprofilaksis masih underused di RS di Amerika

3778 rekam medis pasien dipilih secara random di 38 RS

Pasien AF dengan resiko tinggi stroke: 54.7% dapat warfarin, 20%

tidak mendapat aspirin/warfarin

Operasi ortopeditromboprofilaksis 85%

Bergmann et al,

2010

ENDORSE global surveyn = 37,356 pasien di 32 negara

Resiko VTE bervariasi tergantung diagnosis medis (global rate 41.5%)

Profilaksis VTE diberikan pada hanya 39.5% pasien beresiko

Samama et al,

1999

MEDENOX studyn = 1102

Pasien >40 tahun, hospitalisasi 6 hari, imobilisasi sebelumnya 3 hari

Enoxaparin 20 mg atau 40 mg/hari vs placebo, 1-14 hari

Skrining DVT dengan venografi/USG pada hari 6-14

DVT: Enoxaparin 20 mg 15%, 40 mg 5.5%, placebo 014.9%, RR 463% (p


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Cohen AT et

al,2006

ARTEMIS studyn = 849

Pasien rawat inap >60 thn dengan CHF, PPOK eksaserbasi

akut, infeksi akut, kemungkinan akan immobile 4 hari

Fondaparinux 2,5 mg/hari vs placebo, 6-14 hari

Skrining DVT dengan venografi pada hari 6-15

DVT: Fondaparinux 5,6%, placebo 0, 5%, RR 46,7% (p = 0.029)

Perdarahan mayor masing-masing kelompok: 1 orang

Penelitian HASIL

Leizorovicz et

al, 2004

PREVENT studyn = 3706

Pasien rawat inap >40 thn dengan penyakit akut, membutuhkan

rawat inap 4 hari, imobilisasi sebelumnya 3 hari

Dalteparin 5000 IU/hari vs placebo, 14 hari

Skrining DVT dengan USG pada hari 21

DVT: Dalteparin 2,77%, placebo 4.96%, RR 45% (p = 0.0015) Perdarahan mayor: Dalteparin 0.49%, placebo 0.16%


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Glynn RJ et

al, 2007

39,876 perempuanaspirin dosis rendah 100 mg setiap 48 jam

vs placebo selama 10 tahun

Insidensi VTE pada kelompok aspirin 1.18 vs 1.25 per 1000

orang tahun pada kelompok placebo

Aspirin meningkatkan resiko perdarahan

Penelitian HASIL

Li Wang et al,

2011

11,135 rekam medis pasien

Kejadian VTE lebih rendah pada pasien yang mendapat

profilaksis dibanding yang tidak (1,3% vs 2.99%, HR 0.37)

Penggunaan profilaksis berhubungan dengan biaya healthcare

lebih rendah

PRINCE

study, 2003

Enoxaparin (40 mg/hari) vs UFH (5000 IU 3x/hari) selama 10 hari

pada 665 pasien kardiopulmoner beratsama efektifnya

PRIME study,

2006

RCT double blind Enoxaparin (40 mg/hari) vs UFH (5000 IU

3x/hari) pada 959 pasien resiko tinggi VTE seimbang, namun

efek samping Enoxaparin lebih sedikit


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Alex C Spyropoulos, Charles Mahan. 2009. Venous Thromboembolysm Prophylaxis in The Medical

Patients: Controversies and Perspectives. The American Journal of Medicines. Amir Qaseem, Roger Chou, Linda L. Humphrey,Melissa Starkey, Paul Shekelle.2011.Venous

Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the

American College of Physicians.American College of Physicians

Caprini, J A.2005.Update on Risk Factors for Venous Thromboembolism.Elsevier

Chee M. Chan, Andrew F. Shorr. 2010. Venous Thromboembolic Disease in the Intensive Care Unit.

Seminars in Respiratory and Critical Care Medicine

Deborah J. Cook, James Douketis, Donald Arnolda, Mark A. Crowther. 2009. Bleeding and venous

thromboembolism in the critically ill with emphasis on patients with renal insufficiency. Current Opinion

in Pulmonary Medicine

Frederick A. Anderson, Frederick A. Spencer.2003.Risk Factors for Venous

Thromboembolism.Circulation.American Heart Association

Deborah Cook , Maureen Meade, Gordon Guyatt, Stephen D. Walter, Diane Heels-Ansdell, William

Geerts, Theodore E. W, D. Jamie Cooper, Nicole Zytaruk, Shirley Vallance, Otavio Berwanger, Marcelo

Rocha, Ismael Qushmaqi, Mark Crowther. 2011. Prophylaxis for Thromboembolism in Critical Care

Trial Protocol and Analysis Plan.Journal of Critical Care 26, 223.e1223.e9.

Graham F P Lawrence LK Leung, Jess Mandel, Stephen A L. 2011. Prevention of venous

thromboembolic disease in medical patients.UpToDate.

Referensi


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Li Wang, Nishan Sengupta, Onur Baser.2011.Risk of venous thromboembolism and benefits of

prophylaxis use in hospitalized medically ill US patients up to 180 days post-hospital discharge.

Thrombosis Journal

Jean-Francois Bergmann, Alexander T. Cohen, Victor F. Tapson, Samuel Z. Goldhaber, Ajay K.Kakkar, Bruno Deslandes, Wei Huang, Frederick A. Anderson. 2010. Venous thromboembolism risk

and prophylaxis in hospitalised medically ill patients: The ENDORSE Global Survey. Blood

Coagulation, Fibrinolysis and Cellular Haemostasis

National Health and Medical Research Council. 2009. Clinical practice guideline for the prevention of

venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to

Australian hospitals. Melbourne: National Health and Medical Research Council

Sarah M Adriance, Claire V Murphy.2013.Prophylaxis and treatment of venous thromboembolism in the

critically ill.International Journal of Critical Illness and Injury Science

Susan R. Kahn, Wendy Lim, Andrew S. Dunn, Mary Cushman, Francesco Dentali, Elie A. Akl ,

Deborah J. Cook, Alex A. Balekian , Russell C. Klein, Hoang Le , Sam Schulman, M. Hassan Murad.

2012. Prevention of VTE in Nonsurgical Patients Antithrombotic Therapy and Prevention ofThrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice

Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th Edition: ACCP Guidelines

Scott M Stevens, James D Douketis. 2010. Deep Vein Thrombosis Prophylaxis in Hospitalized Medical

Patients: Current Recommendations, General Rates of Implementation, and Initiatives for

Improvement.Chestmed.

Wheeler A.2005.Venous thromboembolism in medically ill patients: identifying risk and strategies for


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FAKTOR RESIKO

STASIS HIPERKOAGULABILITAS CEDERA ENDOTELUsia >40 tahun

Imobilitas

CHF

StrokeParalisis

Cedera spinal cord

Hiperviskositas

Polisitemia

PPOK berat

Anestesi

Obesitas

Vena varikosa

Kanker

Kadar estrogen tinggi

Inflammatory Bowel

DiseaseSindrom Nefrotik

Sepsis

Merokok

Kehamilan

Trombofilia

Operasi

Riwayat VTE

Kateter vena

sentralTrauma


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Inherited thrombophilia:

Factor V Leiden mutation

Prothrombin gene mutation

Protein S deficiency

Protein C deficiency

Antithrombin (AT) deficiency

Rare disorders: Dysfibrinogenemia


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1. Assess level of mobility, VTE and bleeding risk for every adult patient

admitted to SUHT, including ambulatory patients: (1) Complete national risk

assessment tool, and (2) document assessment in the relevant section on

the patients drug chart. Medical patients who are NOT expected to have

significantly reduced mobility relative to normal state are not regarded atincreased VTE risk and do not need to be risk assessed further

2. Balance risks of VTE and bleeding

If any VTE risk factors identified, offer VTE prophylaxis, ensuring that there

are no contraindications. Do not offer pharmacological prophylaxis if bleeding

risk outweighs risk of VTE.3. Reassess VTE & bleeding risk within 24 hours of admission and whenever the

clinical situation changes. If the VTE or bleeding risk changes during the

admission the VTE prophylaxis must be reviewed and adjusted as

appropriate


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Guideline ACP

Recommendation 1: ACP recommends assessment of the risk forthromboembolism and bleeding in medical (including stroke)

patients prior to initiation of prophylaxis of venous

thromboembolism (Grade: strong recommendation,

moderatequality evidence). Risk factors for bleeding with anticoagulant therapy include older

age; female sex; diabetes; hypertension; presence of cancer;

acute or chronic alcoholism; liver disease; severe chronic kidney

disease; peptic ulcer disease; anemia; poor treatment adherence;

prior stroke or intracerebral hemorrhage; presence of bleeding

lesions; bleeding disorder; and concomitant use of aspirin,

nonsteroidal anti-inflammatory drugs, antiplatelet agents,

antibiotics, statins, fibrates, and steroids.


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Guideline ACP

Recommendation 2: ACP recommends pharmacologicprophylaxis with heparin or a related drug for venous

thromboembolism in medical (including stroke) patients

unless the assessed risk for bleeding outweighs the likely

benefits (Grade:strong recommendation, moderate-qualityevidence).

Recommendation 3: ACP recommends against the use of

mechanical prophylaxis with graduated compression

stockings for prevention of venous thromboembolism (Grade:strong recommendation, moderate-quality evidence).


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Guideline Australia


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Guideline Australia


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Guideline Australia


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Guideline Australia


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Pasien critically ill di ICUresiko perdarahan

Sebuah penelitian RCT di ICU223 pasien on

ventilatorperdarahan mayor pada kelompok terapi

nadroparin 6.5% vs placebo 2.7%

Penelitian prospektif 100 pasien di ICU90% pasien

mengalami perdarahan (70% minor, 20% mayor)


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ACCP Guideline

In outpatients with cancer who have no additional risk

factors for VTE, we suggest against routine prophylaxis with

LMWH or LDUH (Grade 2B) and recommend against the

prophylactic use of vitamin K antagonists (Grade 1B).

Remarks: Additional risk factors for VTE in cancer outpatientsinclude previous VTE, immobilization, hormonal therapy,

angiogenesis inhibitors, thalidomide, & lenalidomide.

In outpatients with cancer and indwelling central venous

catheters, we suggest against routine prophylaxis withLMWH or LDUH (Grade 2B) and suggest against the

prophylactic use of vitamin K antagonists (Grade 2C).


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ACCP Guideline

In outpatients with solid tumors who have additional risk

factors for VTE and who are at low risk of bleeding, we

suggest prophylactic dose LMWH or LDUH over no

prophylaxis (Grade 2B).

In chronically immobilized persons residing at home or at a

nursing home, we suggest against the routine use of

thromboprophylaxis (Grade 2C)

For long-distance travelers, we suggest against the use ofaspirin or anticoagulants to prevent VTE (Grade 2C).


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ACCP Guideline For long-distance travelers at increased risk of VTE (including

previous VTE, recent surgery or trauma, active malignancy,

pregnancy, estrogen use, advanced age, limited mobility, severe

obesity, or known thrombophilic disorder), we suggest frequent

ambulation, calf muscle exercise, or sitting in an aisle seat if

feasible(Grade 2C). For long-distance travelers at increased risk of VTE (including

previous VTE, recent surgery or trauma, active malignancy,

pregnancy, estrogen use, advanced age, limited mobility, severe

obesity, or known thrombophilic disorder), we suggest use of

properly fitted, below-knee GCS providing 15 to 30 mmHg ofpressure at the ankle during travel (Grade 2C). For all other long-

distance travelers, we suggest against the use of GCS(Grade 2C).


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Vitamin K Antagonist

Warfarin, coumarin, tecarfarin

Inhibition of the vitamin K-dependent gamma-carboxylation

of coagulation factors II, VII, IX, and X

Efeknya delayed sampai faktor pembekuan normal

(protrombin) hilang dari sirkulasi36-72 jam setelah

pemberian

Parenteral anticoagulants and warfarin should OVERLAP by

four to five days when warfarin is initiated in patients with

acute thrombotic disease

Use of the INR The INR is the PT ratio obtained by testing a

given sample using the WHO reference thromboplastin.


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Prevensi DVT pada Pasien Non Bedah

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