D-DIMER SEBAGAI PREDIKTOR PENGGUNAAN VENTILATOR MEKANIK INVASIF PADA PASIEN COVID-19

Shabrina Dyah Mayangsari, Dr. dr. Usi Sukorini, M.Kes, Sp.PK(K)

2023 | Tesis | S2 Kedokteran Klinik

Latar belakang : Pada bulan Maret 2020 WHO mengumumkan penyakit COVID-19 sebagai pandemi global. Pandemi COVID-19 dengan jumlah kasus terkonfirmasi dan kematian yang tinggi merupakan beban di seluruh negara di dunia. Peningkatan kadar D-dimer pada pasien terkonfirmasi COVID-19 dicurigai berhubungan dengan acute respiratory distress syndrome (ARDS) dan membutuhkan alat bantu respirasi salah satunya dengan ventilator mekanik invasif. Beberapa penelitian telah melaporkan cut off optimal pada D-dimer dalam memprediksi penggunaan ventilator mekanik invasif pada pasien COVID-19 namun terdapat perbedaan nilai cut off D-dimer yang digunakan. Penelitian serupa dengan penelitian ini di Mesir melaporkan nilai cut off D-dimer >1415 ng/mL merupakan prediktor penggunaan ventilator mekanik invasif dengan AUC 0,9 pada pasien COVID-19 derajat berat.

Tujuan: Penelitian ini bertujuan untuk mengetahui kadar D-dimer > 1415 ng/mL dapat menjadi prediktor terhadap penggunaan ventilator mekanik invasif pada pasien COVID-19 yang dirawat di ruang perawatan intensif RSUP Dr. Sardjito.

Metode : Penelitian dilakukan dengan cohort prospective pada pasien COVID-19 yang dirawat di ruang perawatan intensif RSUP Dr. Sardjito. Inception cohort adalah pasien yang dirawat 24 jam pertama di ruang perawatan intensif. Data diambil berdasarkan hasil PCR di laboratorium biomolekular di Instalasi Laboratorium Terpadu. Kriteria inklusi yaitu pasien terkonfirmasi COVID-19 derajat berat, usia ?18 tahun. Pemeriksaan laboratorium yang dilakukan meliputi pemeriksaan PT, APPT, D-dimer, fibrinogen dan darah lengkap. Penggunaan ventilator mekanik invasif sebagai luaran dicatat. Data kategorikal disajikan dalam proporsi, dan hubungan D-dimer dan penggunaan ventilator mekanik invasif dianalisis dengan risiko relatif. Nilai p <0>

Hasil: Sebanyak 70 subjek yang dianalisis dalam penelitian ini dengan 29 pasien (44%) dengan luaran penggunaan ventilator mekanik invasif. Leukosit, netrofil dan D-dimer, secara signifikan berbeda pada kelompok yang menggunakan ventilator mekanik invasif. Dilakukan analisis multivariat D-dimer sebagai prediktor penggunaan ventilator mekanik invasif memiliki kemaknaan secara statistik dengan risiko relatif 4,16 (p=0,004; IK 95% 1,67-7,18)).

Simpulan: D-dimer > 1415 ng/mL dapat memprediksi penggunaan ventilator mekanik invasif 4,16 kali lebih tinggi dibandingkan dengan D-dimer < 1415>

Background: In March 2020 WHO declared COVID-19 as global pandemic. The COVID-19 pandemic with high number of confirmed cases and deaths was burden on all countries in the world. Increased D-dimer levels in patients confirmed COVID-19 were suspected to be related to acute respiratory distress syndrome (ARDS) and require respiratory treatment, one of which was invasive mechanical ventilator. Several studies have reported the optimal cut-off value for D-dimer in predicting the need of invasive mechanical ventilation in COVID-19 patients, but there were differences in the D-dimer cut off value that can be used. Study similar to this study in Egypt reported D-dimer cut off value >1415 ng/mL was predictor of the need of invasive mechanical ventilation usage with AUC of 0.9 in severe COVID-19 patients.

Objective: This study aims to determine whether D-dimer levels > 1415 ng/mL can be predictor of the utilization of invasive mechanical ventilation usage in COVID-19 patients treated in the intensive care unit at RSUP Dr. Sardjito.

Methods: This study was conducted in prospective cohort on COVID-19 patients treated at RSUP Dr. Sardjito. The Inception cohort was patients treated in the first 24 hours in the intensive care unit. Data was taken based on PCR results in the biomolecular laboratory at the Integrated Laboratory Installation. Inclusion criteria were patients with confirmed severe COVID-19, age ?18 years. Laboratory examinations were PT, APPT, D-dimer, fibrinogen and complete blood count tests. Utilization of invasive mechanical ventilation as outcome was recorded. Categorical data were presented in proportions, and the association between D-dimer and utilization of invasive mechanical ventilation was analyzed by relative risk. A p value <0>

Results: A total of 70 subjects were analyzed in this study with 29 patients (44%) with the outcome of utilization of invasive mechanical ventilator. Leukocytes, neutrophils and D-dimer were significantly different in the group using invasive mechanical ventilation. Multivariate analysis of D-dimer as predictor for the use of invasive mechanical ventilation was carried out and had statistical significance with a relative risk of 4.16 (p=0.004; (95% CI 1.67-7.18).

Conclusion: D-dimer > 1415 ng/mL can predict the utilization of an invasive mechanical ventilator 4.16 times higher compared to D-dimer < 

Kata Kunci : COVID-19, D-dimer, ventilator mekanik invasif