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
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