ASKEP ALI

Acute Limb Ischemia Definisi, Definisi, Etiologi & Pa P atofis tofisiologi iologi Evalua Evaluasi si K linisDwihasti, & Kelas Kelas Ns. Rambu Inanda SKep

Perawat Pelaksana ICVCU Managemen

Definisi Acute Definisi Acute Limb Ischemia Ischemia

Penurunan perfusi tiba-tiba pd arteri ekstremitas yg menyebabkan ancaman viabilitas ekstremitas

Definisi Acute Definisi Acute Limb Ischemia Ischemia

Penurunan perfusi tiba-tiba pd arteri ekstremitas yg menyebabkan ancaman viabilitas ekstremitas

Etiologi acute limb ischemia

Acute arterial embolism: embolism:

Scr relatif pd cabang arteri sehat tree (arrhythmia, cardiomyopathy, sheath, oklusi Percutaneous Percut aneous Transluminal ranslumina l Artery )

Acute arterial thrombosis: thrombosis:

Seblmnya ada penyakit pd p’cabangan p’cabangan arteri (atherosclerosis)

Acute traumatic ischemia:

Insiden • •Laki-laki > Wanita pd trombosis • Laki-laki = Wanita pd emboli • Ekstremitas atas < Ekstremitas bawah • Mortalitas = 7 - 29%

Iskemik Emboli Akut

Pato-fisiologi

Iskemik Trombosis Akut

Emboli dpt berasal dr jtg (MS dgn atrial fibrillation, MI dgn mural thrombus) atau dilated diseased arteries (aneurisma aorta)

Emboli tiba2 menyumbat percabangan arteri yg sehat

Biasanya menetap pd bifurkasi arteri Aortic bifurcation Iliac bifurcation Femoral bifurcation Popliteal trifurcation

Atherosklerosis menyebabkan penyempitan cabang arteri scr progresif M’stimulus p’bentukan kolateral Aliran melambat & permukaan kasar dpt m’sebabkan trombosis akut

Penting untuk membedakan antara iskemik emboli & trombosis : berbeda management Oklusi embolik harus dicurigai pada pasien dengan corak sebagai berikut: Onset simptom tiba-tiba

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Diketahui sumber emboli

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Tidak terdpt riwayat utama dari klaudikasio intermitten

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Denyut nadi normal pada anggota gerak yang tidak terkena. 

Postgraduates

Severitas iskemik akut tgantung pd: a) Kemampuan dr kolateral yg ada u/ m’bawa drh di sekitar area obstruksi akut (kolateral tumbuh pd psn dgn b) Lokasi obstruksi b.d jmlh p’cabangan arteri preexisting chronic ischemia) Oleh krn itu, emboli arteri cenderung m’sebabkan gejala yg c) Luas obstruksi tiba-tiba & iskemik severe One axial a. with limited collateral pathways Aorta & common iliac Semakin besar obstruksi yg tjd, semakin bykarteri dibanding dgn trombosis d) Lama kolateral yg hilang Internal & external iliac

Superficial & deep femoral

Popliteal artery

Tibial arteries

Two axial aa. With better collateral potentials

Aliran distal pd obstruksi melambat. Jika kolateral tdk dpt me↑ For Example: aliran drh pd area tsb, hambatan aliran drh akan menetap pd Popliteal a occlusion (a area distal p’cabangan arteri. Heparin hrs diberikan sedini Two axial aa. With better collateral potentials single axial a.) results in mungkin severe ischemia, while One axial a. with limited collateral pathways

Three axial aa. with better collateral potentials

posterior tibial occlusion may be asymptomatic if other leg arteries are patent

Definition: Sudden decrease of arterial limb perfusion causing threat to limb viability Etiology: 1-Embolic (Rh.heart w mitral stenosis & AF or Ischemic heart w acute myocardial infarction & mural thrombus or extra-cardiac embolism from aneurismal arteries) 2-Thrombotic

acute ischemia on top of atherosclerotic arterial stenosis

Pathology: onset of symptoms is more acute in embolic ischemia (absent collaterals) Other factors determine the severity of acute ischemia Clinical Picture

Management

Evaluasi Klinik Iskemik Akut (Gambaran Klinik) Gejala iskemik akut: Nyeri: Nyeri hebat pd ekstremitas pd fase akut (more acute in embolic ischemia) Intensitas nyeri dpt me↓ seiring dgn wkt bila ada kolateral yg m’p’baiki s irkulasi, atau jika p’kembangan iskemik m’sebabkan hilangnya sensori iskemik

Dingin adalah gejala awal Baal diikuti oleh hilangnya sensori (late) Kelemahan otot (heavy limb) diikuti oleh paralisis

(late)

Evaluasi Klinis Acute Ischemia (Gambaran Klinis) Riwayat Tujuan pertanyaan 1- U/ mengetahui apakah gejala2 yg muncul sifatnya akut iskemik atau bkn (DD of acute ischemia : acute DVT [phlegmasia] , hypo-perfusion states [e.g. heart failure specially if associated with chronic ischemia]

2- U/ mengetahui tingkat keparahan acut iskemik (ask about symptoms of different classes of acute ischemia –see later )

3- U/ mencari penyebab (ask about Rh. Heart Ds, claudication, recent arterial intervention e.g. cardiac cath ., risk factors for atherosclerosis: hypertension, diabetes, smoking, hyperlipedemia, family history of cardio-vascular disease )

Evaluasi Klinik Iskemik Akut (Gambaran Klinik) Tanda iskemik akut

Inspeksi

5Ps Pain: gejala

+ Pale Pulseless Parathesia Paralysis

warna: Fixed mottling & sianosis

Awal : pale Lanjut : sianosis mottling mottling & sianosis

fixed

An area of Pallor fixed cyanosis surrounded by reversible Reversible mottling mottling Empty veins: bandingkan dgn kanan (iskemik) & kiri (normal)


Palpasi

5Ps Pain: gejala

+

Femoral

Popliteal

Posterior tibial

Dorsalis pedis

Pale Pulseless Parathesia Paralysis

Palpasi pulsasi perifer, bandingkan dgn ekstremitas yg lain & beri tanda Temperatur : ekstremitas teraba dingin dgn (bandingkan diantara ekstremitas kiri & kanan)

Slow capillary refilling setelah tekanan jari


5Ps Pain: gejala

+ Pale Pulseless Parathesia Paralysis

Palpasi Hilangnya fungsi sensori Dr mulai baal s/d anestesia Progress dr kehilangan sensori Sentuhan halus Sensasi Vibrasi proprioreseptor Nyeri dalam

Sensasi tekan

Late


5Ps Pain: gejala

+

Palpasi

Hilangnya fungsi motorik: M’Indicates advanced limb threatening ischemia Late irreversible ischemia: Bengkak otot

Pale Pulseless

Postgraduates

Otot telapak adlh yg pertama kali terkena, di ikuti o/ otot tungkai 

Parathesia

M’deteksi kelemahan otot scr dini adlh sukar krn p’gerakan jari2 dihasilkan yg utama o/ otot tungkai 

Paralysis

Postgraduates

Classes of Acute Ischemia Clinical Findings

Class

Sensory loss

Doppler

Prognosis

Motor

Arterial Venous weakness signals Signals

-ve

-ve

audible

audible

Not immediately threatened

II.a Marginal threat

Minimal sensory loss

No muscle weakness

Often not audible

audible

Salvageable if prompt ttt (there is time for

II.b Immediate threat

Rest pain w sensory loss

III.Irreversible

Severe anesthesia

I. Viable

angiography)

Mild to moderate

more than toes

Usually not audible

audible

Paralysis w Inaudible Inaudible muscle rigor

Salvageable with immediate ttt (no time for angiography)

Not salvageable, permanent N. & muscle damage , needs amputation




The limb is described as having 5 Ps : Pain, Pale, Pulseless, Parathesia, Paralysis

Management

Investigasi acute limb ischemia Severitas dan durasi iskemik m’berikan batasan waktu yg sempit pemeriksaan

Doppler Ultra Sound Penting u/ melihat arteri, m’kaji tingkat obstruksi & itngkat keparahan iskemik

Investigasi acute limb ischemia Arteriografi Patients with high clinical probability of embolic ischemia do NOT need angiography If the differentiation between embolic & thrombotic ischemia is not clear clinically, and if the limb condition permits,

DO ANGIOGRAPHY Value of angiography Localizes the obstruction

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Visualize the arterial tree & distal run-off 

Can diagnose an embolus:

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Sharp cutoff, reversed meniscus or clot silhouette

Popliteal embolism

Lt. iliac embolism

Reversed meniscus sign

Clot silhouette

Treatment of acute limb ischemia A Once diagnosed Immediate anticoagulation with heparin to avoid clot propagation 

Appropriate analgesia

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Simple measures to improve existing perfusion:

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• Keep the foot dependant • Avoid pressure over the heal • Avoid extremes of temperature (cold induces vasospasm, heal raises the metabolic rate)

• Maximum tissue oxygenation (oxygen inhalation) • Correct hypotension Start treatment of other associated cardiac conditions (CHF, AF)

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Treatment of acute limb ischemia B Catheter directed thrombolysis Indications:

Agents used: Streptokinase, Urokinase, tissue plasminogen activator

1. Viable or marginally threatened limb (class I, IIa) 2. Recent acute thrombosis (not suitable for embolism or old thrombi) 3. Avoid patients with contraindications

Contraindications: Absolute: 1. Cerebro-vascular stroke within previous 2 months 2. Active bleeding or recent GI bleeding within previous 10 days 3. Intracranial trauma or neurosurgery within previous 3 months Relative: 1. Cardio-pulmonary resuscitation within previous 10 days 2. Major surgery or trauma within previous 10 days 3. Uncontrolled hypertension

Treatment of acute limb ischemia C Surgery 1- Acute embolism: Catheter embolectomy under local anesthesia

2- Immediate surgical revascularization is indicated in class IIb, or class I, IIa when thrombolysis is not possible or contraindicated

A combination of different procedures can be done: Arterial exploration at different sites

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Arterial thrombectomy

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Bypass surgery based on pre-operative angiography if available or intra-operative angiography 

Embolectomy

Following revascularization: The sudden return of oxygenated blood to the acutely ischemic muscles generates & releases oxygen free radicals that causes cellular injury and severe edema

Compartment syndrome & muscle necrosis

ttt Fasciotomy Longitudinal incision of the skin & deep fascia to release pressure over swollen muscles

Amputation: Done for irreversible ischemia with permanent tissue damage (turgid muscles, fixed cyanosis) The level of amputation is decided according to the level of palpable pulse. Palpable popliteal pulse -------------- Below knee amputation Absent popliteal pulse ---------------- Above knee amputation




The limb is described as having 5 Ps : Pain, Pale, Pulseless, Parathesia, Paralysis Investigations

Doppler to evaluate level & degree of ischemia Conventional angiography in class I & IIa Intraoperative angiography in class IIb

Treatment

Heparin Catheter directed thrombolysis Operative revascularization Amputation in irreversible ischemia

Pengkajian Riwayat Penyakit Tujuan dr pertanyaan 1- U/ mengetahui apakah gejala yg timbul adlh akut iskemik atau bkn 2- U/ mengetahui severitas iskemik akut

3- U mencari etiologi

Pengkajian • Kemunculan penyakit (5P) – Keluhan pain/nyeri: Onset, durasi, intensitas, lokasi – Pallor – Paresthesia – Paralysis – pulselessness

Pengkajian • Riwayat dahulu – Apakah pasien mempunyai nyeri pada kaki sebelumnya (seperti, riwayat klaudikasio) – Apakah telah diintervensi untuk “sirkulasi yang buruk” pada masa lampau – Apakah didiagnosis memiliki penyakit jantung (seperti, atrial fibrilasi) maupun aneurisma (seperti, kemungkinan sumber emboli) – Apakah memiliki penyakit serius yang berbarengan atau faktor resiko aterosklerotik (hipertensi, diabetes, penggunaan tembakau, hiperlipidemia, riwayat keluarga terhadap serangan jantung, stroke, jendalan darah, atau amputasi.)

Pengkajian • Pemeriksaan Fisik – Pulsasi – Warna dan temperatur – Kehilangan fungsi sensoris – Kehilangan fungsi motorik

Diagnosa Keperawatan • Ggn perfusi jaringan b.d tidak adanya suplai darah pd jaringan ekstremitas • Ggn rasa nyaman nyeri b.d penurunan suplai oksigen • Ggn pemenuhan kebutuhan sehari-hari b.d kelemahan anggota gerak

Intervensi Keperawatan • Observasi keluhan nyeri • Observasi TTV • Observasi pulsasi • Hindari penekanan pd area yg sehat • Hindari temperatur yg berlebihan • Kolaborasi: analgesik, atasi penyebab,pemeriksaan dopler-angiografi, terapi trombolitik, tindakan bedah

ASKEP ALI

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