Acute Limb Ischemia

Definisi, Etiologi & Patofisiologi Evaluasi Klinis & Kelas Ns. Rambu Inanda Dwihasti, SKep

Perawat Pelaksana ICVCU

Managemen

Definisi Acute Limb Ischemia

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

Etiologi acute limb ischemia

Acute arterial embolism:

Scr relatif pd cabang arteri sehat tree (arrhythmia, cardiomyopathy, sheath, oklusi Percutaneous Transluminal Artery )
Seblmnya ada penyakit pd pcabangan arteri (atherosclerosis)

Acute arterial thrombosis:

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 Atherosklerosis menyebabkan penyempitan cabang arteri scr progresif Mstimulus pbentukan kolateral Aliran melambat & permukaan kasar dpt msebabkan 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

Penting untuk membedakan antara iskemik emboli & trombosis : berbeda

management Oklusi embolik harus dicurigai pada pasien dengan corak sebagai berikut:
Onset simptom tiba-tiba
Diketahui sumber emboli Tidak terdpt riwayat utama dari klaudikasio intermitten

Denyut nadi normal pada anggota gerak yang tidak terkena.

Postgraduates

Severitas iskemik akut tgantung pd:

a) Kemampuan dr kolateral yg ada u/ mbawa drh di sekitar area obstruksi akut
(kolateral tumbuh pd psn dgn b) Lokasi obstruksi b.d jmlh pcabangan arteri preexisting chronic ischemia) Oleh krn itu, emboli arteri cenderung msebabkan 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 byk dibanding dgn trombosis arteri d) Lama kolateral yg hilang
Internal & external iliac

Superficial & deep femoral

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

Two axial aa. With better collateral potentials

Popliteal artery

Tibial arteries

Three axial aa. with better collateral potentials

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 mpbaiki sirkulasi, atau jika pkembangan iskemik msebabkan 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 warna: Fixed mottling & sianosis Awal: pale Lanjut: sianosis mottling mottling & sianosis fixed

5Ps
Pain: gejala

+
Pale Pulseless Parathesia Paralysis

An area of Pallor fixed cyanosis surrounded by reversible Reversible mottling mottling

Empty veins: bandingkan dgn kanan (iskemik) & kiri (normal)

Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut

Palpasi

5Ps
Pain: gejala

+
Pale Pulseless Parathesia Paralysis

Femoral

Popliteal

Posterior tibial

Dorsalis pedis

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

Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut

Palpasi Hilangnya fungsi sensori

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

5Ps
Pain: gejala

+
Pale Pulseless Parathesia Paralysis

Sensasi tekan

Late

Evaluasi Klinik Iskemik Akut (Gambaran Klinik)

Tanda iskemik akut Palpasi

5Ps
Pain: gejala

Hilangnya fungsi motorik:

MIndicates advanced limb threatening ischemia Late irreversible ischemia: Bengkak otot

+
Pale Pulseless Parathesia Paralysis

Postgraduates

Otot telapak adlh yg pertama kali terkena, di ikuti o/ otot tungkai Mdeteksi kelemahan otot scr dini adlh sukar krn pgerakan jari2 dihasilkan yg utama o/ otot tungkai

Postgraduates

Classes of Acute Ischemia

Clinical Findings Class
I. Viable II.a Marginal threat II.b Immediate threat III.Irreversible

Doppler
Arterial Venous signals Signals
audible
Often not audible Usually not audible

Prognosis

Sensory loss
-ve
Minimal sensory loss Rest pain w sensory loss
more than toes

Motor
weakness
-ve
No muscle weakness Mild to moderate

audible
audible

Not immediately threatened

Salvageable if prompt ttt (there is time for
angiography)

audible

Salvageable with immediate ttt (no time

for angiography)

Severe anesthesia

Paralysis w Inaudible Inaudible

muscle rigor

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

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

The limb is described as having 5 Ps :

Pain, Pale, Pulseless, Parathesia, Paralysis

Management

Investigasi acute limb ischemia

Severitas dan durasi iskemik mberikan batasan waktu yg sempit pemeriksaan

Doppler Ultra Sound

Penting u/ melihat arteri, mkaji 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 Visualize the arterial tree & distal run-off Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot silhouette

Popliteal embolism
Reversed meniscus sign

Lt. iliac embolism

Clot silhouette

Treatment of acute limb ischemia

A Once diagnosed Immediate anticoagulation with heparin to avoid clot propagation
Appropriate analgesia Simple measures to improve existing perfusion:

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)

Treatment of acute limb ischemia

B Catheter directed thrombolysis
Indications:
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 Agents used: Streptokinase, Urokinase, tissue plasminogen activator

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 Arterial thrombectomy

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

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

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 Heparin Catheter directed thrombolysis Operative revascularization Amputation in irreversible ischemia

Treatment

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