HAEMOSTASIS

(VIRCHOWS TRIAD)

Blood vessel (vasoconstriction) Platelets (adhesion and aggregation) Coagulation and Fibrinolysis
Prof. Dr. Adi Koesoema Aman, SpPK (KH)

HAEMORRHAGIC SCREENING TEST

A Global test that may predict what happened with the
Blood vessel (vasoconstriction) Platelets (adhesion and aggregation) Coagulation and Fibrinolysis

BLOOD VESSEL

BLOOD VESSELS MEASUREMENT

TORNIQUET TEST BLEEDING TIME

Tourniquet Test Capillary-fragility-test

Hess test (commonly used): pressure is put midway between systole and diastole for 5 minutes. Reading is done 5 minutes after the release of the cuff Rumple Leed (X): the same pressure as above but for 15 minutes and reading is done straight away after the release of the cuff

Pressure midway between systole and diastole For 5 minutes (Hess test)

Interpretation
(+): small red dots difficult to be seen (++): bigger dots and easily seen (+++): not only easily seen but also quite prominent and sometimes confluent (++++): true bruising

Bleeding Time
As a global test to measure roughly Platelets function Platelets number

Put blood pressure at 40 mmHg

First blood drop is wiped Next, blood is tipped off by filter paper every 30 sec

Normal is less than 5 min

PLATELET

NUMBER (USUALLY SEVERE)

PLATELET

FUNCTION (LESS SEVERE)

Bleeding Time
As a global test to measure roughly Platelets function Platelets number

PLATELET NUMBER IS MEASURED FROM FULL BLOOD COUNT

CELL COUNTER

PLATELET FUNCTION IS TESTED USING PLATELET AGGREGOMETER

PLATELETS
PLATELET ADHESION PLATELET AGGREGATION

Platelet Aggregation
Platelet adhesion is mediated by vWF. This activates platelets causing release of TxA2 During activation, a receptor for fibrinogen becomes exposed on the platelet membrane. Activated platelets release by ADP, Epinephrin, serotonin: Fibrinogen ADP/ATP vWF Serotonin dense core granules Factor V Ca2+ Factor VIII Platelet derived growth factor (PDGF) ~ promotes healing Platelet factor IV prevents formation of active thrombin inhibitor from heparin and anti-thrombin III.

a-granules

AGGREGATION OF PLATELET
IS MEASURED AFTER ADDING THE PLATELET AGONISTS SUH AS ATP EPINEPHRIN SEROTONIN RISTOCETIN

Graph seen in the platelet aggregometer after adding of some agonists

Basic Principle of von Willebrands Factor Test

FUNCTIONAL TEST
Ristocetin co-factor assay dg Plt aggregometer

ANTIGEN TEST (immunoassay)

Radioimmunoassay (RIA) Enzyme-linked immunoassay (ELISA)

Basic Principle of Fibrinogen test

Among other coagulation factors, Fibrinogen has no enzymatic activity and hence there is no functional test but only detection of protein

Intrinsic pathway

XIIa
Extrinsic Pathway XIa

TF Prothrombin
VIII IXa VIIIa VIIa Xa Va Thrombin V
Soft clot

Fibrinogen

Fibrin

XIIIa

Hard clot

Fibrin

FIBRINOGEN ASSAYS
Radial immunodifussion Clauss method (pure clotting-based) Blomback and Blomback (+thrombin Ca++) soluble and unstabilized. The tyrosine content is measured after adding urea. Ratnoff and Menzies: Fibrinogen is clotted into Fibrin in glass beads, washed and bolied +NaOH, tyrosine measured with Fiolin CalcateuPhenol reagent

COAGULATION AND FIBRINOLYSIS

Intrinsic pathway

Extrinsic pathway

Final Common pathway X, V, Prothrombin Thrombin Fibrinogen Fibrin

Intrinsic pathway

Extrinsic pathway

Final Common pathway X, V, Prothrombin Thrombin Fibrinogen Fibrin

Prothrombin Time (PT)

Intrinsic pathway

Extrinsic pathway

Final Common pathway X, V, Prothrombin Thrombin Fibrinogen Fibrin

Activated Partial Thromboplastin Time (APTT)

Intrinsic pathway

Extrinsic pathway

Final Common pathway X, V, Prothrombin Thrombin Fibrinogen Fibrin

Thrombin Time (T.T)

BASIC HAEMORRHAGIC SCREENING TEST MEASURES ROUGHLY

Full Blood Count Torniquet test Bleeding time Prothrombin time Activated partial thromboplastin time Thrombin time

To give a rough idea of what happened in disturbed HAEMOSTASIS

PENGERTIAN TRANSFUSI .
TRANSFUSI DARAH = HEMOTERAPI .
Yang dimaksud hemoterapi adalah pemberian komponen darah serta derivat 2 nya utk terapi dengan cara transfusi . - Komponen Darah : RBC , Trombosit , Lekosit , Plasma , Kriopresipitat . - Derivat : Albumin , F VIII , F IX , Fraksi Protein Plasma .

PEMBAHASAN MELIPUTI :

1. SELEKSI DONOR
2. PEMERIKSAAN PRA TRANSFUSI

3. PENYIMPANAN DARAH
4. KOMPONEN DARAH 5. INDIKASI TRANSFUSI DARAH 6. REAKSI TRANSFUSI DARAH 7. IMMUNO HEMATOLOGI .

1. SELEKSI DONOR .

1.1. Umur : 18 65 THN .

- Umur Donor Pertama Kali Tidak > 60 Thn. - Reguler Donor Umur Bisa sp >

65 thn .

1.2. KADAR HB DAN HT . Darah diambil dari : Ujung jari , daun telinga dan vena
- Wanita : Hb. > 12 ; Ht. > 36% - Pria : Hb. > 13 gr% pria : > 39% . ujung jari & vena .

- Sampel dr earlobe : - Wanita : Hb. > 12,5 gr% , Ht.38% - Pria. : Hb. > 13,5 gr% ,Ht. > 40%

1.3. DENYUT NADI + HAMIL +

BERAT BADAN .

- Nadi : 50 100 /mnt , reguler , tdk patologis . - TD : tdk. > 180 / 100 mmHg , TD > 180/100 mmHg harus dengan seizin dokter . - Wanita hamil diajurkan tdk donor , bila sangat dibutuhkan , dilarang < 6 minggu - BB sebaiknya > 50 kg .

1.4. FREKWENSI DONOR DARAH

- Umumnya : 2 3 x / Thn , pada pria . - Frekwensi Wanita : < dari pria , ok wanita rentan dengan terjadinya deffisiensi Fe.

1.5. VOLUME PENDONORAN

- Tidak lebih 13% dari Perkiraan Volume Darah Misal : BB donor 50 kg , % Vol. darah 6 8 % PVD = 3,0 4,0 l . Vol. donor 13 % = 390 520 ml . - Blood Bag 450 ml Diisi 405 ml dgn. BB 50 kg.

- PVD = Perkiraan Volume Darah .

1.5. VOLUME PENDONORAN

- Tidak lebih 13% dari Perkiraan Volume Darah Misal : BB donor 50 kg , % Vol. darah 6 8 % PVD = 3,0 4,0 l . Vol. donor 13 % = 390 520 ml . - Blood Bag 450 ml Diisi 405 ml dgn. BB 50 kg.

- PVD = Perkiraan Volume Darah .

Components
Whole blood
Cellular components

Fresh plasma

Fresh frozen plasma

Cryoprecipitate

Cryosupernatant Albumin Immunoglobulin etc

Red cells Platelets

Factor VIII Fibrinogen

DAFTAR KOMPONEN DARAH .

No KOMPONEN KOMPOSISI VOLUME

1.
2. 3.

WHOLE BLOOD .
R.B.C RBC + Adenin Saline .

RBC ; PLASMA ;WBC;PLT.

RBC ; REDUCE PLASMA ; WBC ; PLT. RBC ; RED.PLASMA ; WBC ; PLT. 100 ML ADDITIVE SOL

500 ML
25O ML 330 ML

4.

WBC-POOR RBC . Caranya : filtrasi , sentrifugasi atau wash .

Frozen-ThawedDeglycerolized RBC . GRAN. PLT. CONCENT. ( CENTRIFUGATION LEUKOPHRESIS ) .

RBC ; SEDIKIT WBC ; PLT ; MINIMAL PLASMA .

RBC ; MINIMAL WBC ; PLT ; TANPA PLASMA . 1.0 X 10 GRAN. ; LIMP ; PLT. ( PMN > 10 /UNIT ; PLT. > 2 X 1011/UNIT ) ; SDKT. RBC .

200 ML

5. 6.

180 ML 220 ML .

7.

PLATELET - CONCENTR. ( RANDOM DONOR ) . PLATELET-CONCENTR. (SINGLE DONOR , PLATELET-PHRESIS )

8.

PLATELETS ( PLT. > 5,5 X 1010 / UNIT ; SEDIKIT WBC , PLASMA DAN RBC . PLATELETS ( > 3 X 1011 / UNIT ) ; SEDIKIT SKL WBC PLASMA DAN RBC .

50 ML .

300 ML

9.

FRESH FROZEN PLASMA ( FFP ) .

LIQUID PLASMA .

PLASMA ; FAKTOR KOAGULASI ; COMPONENT TANPA PLATELETS .

PLASMA ; STABIL COAGULATION FACTOR ; TANPA PLATELETS . PLASMA ; STABLE CLOTTING FACTOR ; TANPA PLATELETS \. FIBRINOGEN ; F VIII ; F XIII VON WILLIBRAND FAKTOR FIBRINOGEN . F VIII . F. II , F VII ,F IX , F X .

220 ML

10.

220 ML .

11.

CRYOPRECIPITATDEPLETED PLASMA ( MODIFIED PLASMA ) . CRYOPRECIPITAT AHF.

200 ML

12.

15 ML .

13. 14.

LYOPHILIZED F VIII LYOPHILIZED F II ,VII, IX X .

25 ML 25 ML

15.

ANTI-INHIBITOR COAGULATION COMPLEX . ALBUMIN / FRAKSI PLASMA PROTEIN .

F VIII BYPASSING ACTIVITY . ALBUMIN ; a , GLOBULIN

30 ML

17.

5 % ; 25%

18.

IMMUNE SERUM GLOBULIN . Rh. IMMUN GLOBULIN

IgG ANTIBODI

VARIASI

19.

IgG anti D

1 ML

JENIS KOMPONEN DARAH :

1. WHOLE BLOOD ( W.B ) .

- 450 ml Darah + 63 ml Pengawet , Ht : 36 40 % - Pada Suhu 16 C = 21 36 hari . CPD = 21 hari . CPD-A = 35 hari . - CPD : Ph. DARAH , 2,3-DPG tetap . - Kadar 2,3-DPG yg rendah Affinitas Hb. thd 02 . - Adenin CPD agar ATP RBC tetap .

ISTILAH PD WHOLE BLOOD: 1.1. Fresh WB . < 24 jam . - Tidak tersedia di UTD . - Ok pemeriksaan penyaring Lama .

1.2. Stored WB > 24 jam .

INDIKASI :
- SEBAGAI O2-CARRYING CAPACITY & BLOOD VOLUME EXPANSION . - KEHILANGAN DARAH AKUT & BANYAK .

- MENAIKAN MASSA RBC .

- MENAIKAN VOL. PLASMA . - WBC DAN PLT TIDAK BERFUNGSI .

KONTRA INDIKASI :
- Tdk diberikan pada anemi kronik . DOSIS : - Pada dewasa 1 bag 1 gr% , Ht. 3 4 % - Pada anak 8 ml/kg.BB 1 gr% . - Pemberian harus selesai dalam 4 jam .

2. RBC / PRC / SDM .

40 50% PLASMA DIKELUARKAN ( 200-250 ML PD BAG 450 ML PLASMA ATAU 100 25 ML PD BAG 250 ML ) .

- Ht. 70 80 % . - STORED RBC : PLT. & WBC ( - ) .

- STORED RBC 1 6 0C TAHAN 35 HARI .

Packed red blood cells

Indications
Symptomatic deficit of oxygen-carrying capacity Exchange transfusion
Hemolytic disease of new born Acute chest syndrome in sickle cell crisis

Contraindications
Anemias that can be corrected with specific medications such as iron, vitamin B12, folic acid, or erythropoietin Coagulation deficiency Volume expansion To improve oncotic pressure, wound healing and sense of well being

INDIKASI :
ANEMI DEFF. BERAT . ANEMI CHRONIK DISEASE . ANEMI GGK . ANEMI GAGAL SUMSUM TULNG . PASIEN DGN REGULER TRANSFUSI . HDN . AIHA .

CARA & DOSIS .

- TRANSFUSI HARUS MENGGUNAKAN FILTER . - ALIRAN TRANSFUSI HRS DIPERHATIKAN TINGGI . - UTK MENGURANGI VISKOSITI BISA DITAMBAH LAR. SALINE ATAU KOMPATIBLE HUMAN PLASMA ATAU ALBUMIN .

REAKSI / EFFEK SAMPING TRANSFUSI

A . REAKSI JANGKA PENDEK / AKUT : 1. GANGGUAN FUNGSI JANTUNG OK TRANSFUSI TERLALU CEPAT DISTRIBUSI CAIRAN CEPAT CVP GAGAL VENTRIKEL KIRI . 2. PENYIMPANAN YG LAMA K.ION . HATI2 UTK GGK . 3. TRANSFUSI MASIF HIPOTERMIA , INTOKSIKASI SITRAT , BERKURANGNYA TROMBOSIT DAN F.KOAGULASI . 4. REAKSI HEMOLITIK : dengan tanda2 sbb :

Tanda2 Reaksi Hemolitik :

4.1. DEMAM . 4.2.TACHIKARDI . 4.3. NYERI SELANGKAAN . 4.4. SULIT TIDUR , RIGOR ,MUNTAH , DIARRHE. 4.5. NYERI KEPALA , HIPOTENSI , SYOK . 4.6. GAGAL GINJAL AKUT . 4.7. PERDARAHAN OK DIC .

B. KOMPLIKASI JANGKA MENENGAH :

1. PHLEBITIS LOKAL . - OK JARUM TERLALU LAMA DIPASANG . - INFEKSI OLEH STAFILOKOKKUS . 2. HIPERTENSI . - REGULAR TRANSFUSI . - LEPASNYA ZAT VASOAKTIF SELAMA PENYIMPANAN DARAH . 3. INFEKSI .

C. MASALAH JANGKA PANJANG

1. HEMOSIDEROSIS . - PENUMPUKAN ZAT BESI . - TERUTAMA PADA REGULER TRANSFUSI - 1 BAG = 250 mg Fe. YG TDK DPT DIEKSRESIKAN TUBUH . - DAPAT MENYEBABKAN : SIROSIS , DM , HIPOPARATHIROID , GAGAL JANTUNG .

3. PLATELET CONCENTRATES .
3.1. RANDOM DONOR . - DARI BERBAGAI INDIVIDU .

- TIAP BAG = 5,5 X 1010 / 50 70 ML PLASMA .

- DPT DISIMPAN 5 HARI PD 20 240C DAN 48 JAM PADA 1 60C .

3.2. SINGLE DONOR ( S.D ) .

- DENGAN MENGGUNAKAN ALAT APHRESIS ATAU CELL- SEPARATOR . - BIAYA MAHAL . - MENGANDUNG 3 X 1011 PLATELET/BAG - 1 BAG SINGLE DONOR = 6 8 BAG MULTIPLE DONOR . - 1 UNIT SD 30.00060.000 / mm3 / 70 KG BB.

Platelet Incubator

Stored with constant agitation

INDIKASI :
1. ANEMIA APLASTIK . 2. KELAINAN FUNGSI TROMBOSIT . - PENY. GLANZMANN . - PENY. BERNARD-SOULIER . 3. SEK. TROMBOPATI . - MM , PARAPROTEINEMIA . - UREMIA . 4. DILUTION TROMBOSITOPENIA OK TRANSFUSI MASIF ( PLT. < 50 X 103/MM3 . ) . 5. PENGGUNAAN ALAT KARDIPULMONAIR ( HEART LUNG MACHINE ) . TROMBOSITOPENIA 6. PENDERITA ITP . - TERUTAMA TROMBOSITOPENIA BERAT .

7. DILUTION TROMBOSITOPENIA OK TRANSFUSI MASIF ( PLT.< 50 x103/mm3 ) 8. PENGGUNAAN ALAT KARDIO-PULMONAIR ( HEART LUNG MACHINE ) . TROMBOSITOPENIA . 9. PENDERITA ITP . TERUTAMA TROMBOSITOPENIA BERAT

KONTRA INDIKASI .
PEMBERIAN TDK EFFEKTIP PADA KEADAAN : 1. Ps. DGN RAPID PLATELETS DESTRUCTION . 2. IDIOPATIK AUTOIMMUN TROMBOSITOPENIA PURPURA ( ITP ) . 3. DIC . 4. SEPTIKEMIA . 5. HYPERSPLENISME .

4. GRANULACYTES.
- CENTRIFUGATION LEUKOPHRESIS - 1 BAG = >1,0 X 1010 GRANULACYTES . - JUMLAH LIMFOSIT ,TROMBOSIT,RBC BERVARIASI . - SUSPENSI 200 300 PLASMA .

- HARUS SEGERA DITRANSFUSIKAN PALING LAMA 24 SETELAH PENGUMPULAN .

INDIKASI .
1. BONE MARROW HYPOPLASIA . 2. NETROPENIA < 500 PMN / MM3 . 3. FEVER 24 48 JAM , TDK RESPONS THD ANTI BIOTIK TERAPI .

5. FRESH FROZEN PLASMA ( FFP ) .

- PEMISAHAN PLASMA < 6 JAM PHLEBOTOMY - PADA ( 18 oC) ATAU LEBIH RENDAH TAHAN 1 THN - VOLUME 200 250 ML .

FRESH FROZEN PLASMA

Fresh Frozen Plasma

Frozen Plasma 24

6. LIQUID PLASMA .

- Dibuat pemisahan plasma dari wholeblood . - Volume 200 250 ml ( bag 450 ) atau 100 125 ml ( bag 250 ml ) . - Mengandung stabil faktor yang cukup , labil faktor sedikit kurang ( FV dan F VIII ) . - Penyimpan < ( -18oC ) tahan 5 tahun

INDIKASI .
MULTIPLE F.KOAGULASI DEFFISIENSI SEK.

- LIVER DISEASE .
- DIC . - DILUTION COAGULOPATHY OK MASSIVE BLOOD REPLACEMENT .

- MILD HEMOFILIA B .

INDIKASI .
1. DEFFISIENSI STABIL FAKTOR .

2. LIQUID PLASMA DAPAT DISUBSTITUSI FFP

3. LP TIDAK DIGUNAKAN UTK VOLUME EXPANSION OK RESIKO : TRANSMITED DISEASE , ALLERGIC REACTION ANAPHYLAXIS 4. TIDAK UTK F.V , F.VIII DEFF. , DIC .

Cryoprecipitate

7. CRYOPRECIPITATED AHF .
- FFP THAWING 40C SUPERNATANT + PRICIPITATE .

- SUPERNATANT DIKELUARKAN COLD PRECIPTATE PROTEIN + 10 15 ML PLASMA = CRYOPRECIPITATE REFROZEN PADA ( 180C ) TAHAN 1 TAHUN .
-MENGANDUNG : F.VIII:C ( PROKOAGULANT ACTIVITY ) F.VIII , Vwf , FIBRINOGEN , F.XIII FIBRONECTIN . - 1 BAG = 80 120 UNIT F.VIII ; C , 250 mg FIBRINOGEN , 20-30% F.XIII .

 Cryoprecipitate is prepared by thawing fresh frozen plasma at a temperature between 1C and 6C. After centrifugation, the supernatant plasma is removed and the insoluble cryoprecipitate is refrozen. On average, each unit of cryoprecipitate contains 80 IU or more Factor VIII (FVIII:C) and at least 150 mg of fibrinogen in 5-15 mL of plasma. Cryoprecipitate provides a source of coagulation factors. Factor VIII, Factor XIII and von Willebrand Factor. Fibrinogen and fibronectin are present.

INDIKASI .
1. HEMOFILIA A .
2. Von WILLIBRAND DISEASE . 3. DEFF. FIBRINOGEN CONGENITAL / AQUIRED . 4. DIC .

TRANSFUSI PLATELETS & GRANULOSIT .

1. ANEMIA APLASTIK . 2. KELAINAN FUNGSI TROMBOSIT . - PENY. GLANZMANN . - PENY. BERNARD-SOULIER . 3. SEK. TROMBOPATI . - MM , PARAPROTEINEMIA . - UREMIA . 4. DILUTION TROMBOSITOPENIA OK TRANSFUSI MASIF ( PLT. < 50 X 103/MM3 ) 5. PENGGUNAAN ALAT KARDIPULMONAIR ( HEART LUNG MACHINE ) TROMBOSITOPENIA .

6. PENDERITA ITP . - TERUTAMA TROMBOSITOPENIA BERAT . - SELALU TDK EFFEKTIP OK AKAN LISIS OLEH PROSES IMMUN .

CARA PEMBERIANNYA :
- 1 UNIT KONSTR. / 10 KGBB RESIPIEN . - SINGLE DONOR = 6 UNIT KONSTR. PLT.

- GUNAKAN PERANGKAT PEMBERIAN TROMBOSIT - GUNAKAN KONSTR. TROMB. SPESIFIK ABO & Rh.

KOMPLIKASI . 1. TROMBOSITOPENI REFRAKTER TRANSF. TROMB. BERULANG . ANTIBODI HLA . 2. GRAFT VERSUS HOST DISEASE ( GVHD ) . - JARANG TERJADI .

THANK YOU