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dr. Reno Rudiman,MSc., Sp.

B-KBD
Alamat kantor : RSHS, Jl. Pasteur No 38
Bandung
Tlp / Fax : 022 2034574
Alamat Rumah : Apartemen Setia Budi 1310
Bandung
No HP : 0811 222 074
Email : renorudiman@gmail.com
TTL : Bandung, 10 Juli 1965
Profesi : Dokter Spesialis Bedah
Jabatan : Ka Program Studi Bedah
Digestif
Reno Rudiman, MD, MSc, PhD, FCSI, FICS
Consultant in Digestive Surgery

CURRENT UPDATE ON
SEPSIS AND SEPTIC SHOCK

Hasan Sadikin General Hospital, Bandung, Indonesia


Importance

Definitions of sepsis and septic shock were


last revised in 2001.
Considerable advances have since been made
into the pathobiology (changes in organ
function, morphology, cell biology,
biochemistry, immunology, and circulation),
management, and epidemiology of sepsis,
suggesting the need for reexamination.
Sepsis Definition

Sepsis is defined as the presence (probable or


documented) of infection together with systemic
manifestations of infection.

Severe sepsis is defined as sepsis plus sepsis-induced


organ dysfunction or tissue hypoperfusion

Singer, et al. The Third International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3). JAMA February 23, 2016 Volume 315, Number 8
Sepsis Definition

Septic shock is defined as sepsis-induced hypotension


persisting despite adequate fluid resuscitation.

Sepsis-induced tissue hypoperfusion is defined as


infection-induced hypotension, elevated lactate, or
oliguria.

Singer, et al. The Third International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3). JAMA February 23, 2016 Volume 315, Number 8
SIRS (Systemic Inflammatory Response Syndrome)
Two or more of:

Temperature >38C or <36C

Heart rate >90/min

Respiratory rate >20/min or PaCO2 <32 mm Hg (4.3 kPa)

White blood cell count >12000/mm3 or <4000/mm3 or


>10% immature bands

Singer, et al. The Third International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3). JAMA February 23, 2016 Volume 315, Number 8
Key Concepts of Sepsis

Sepsis is the primary cause of death from infection,


especially if not recognized and treated promptly. Its
recognition mandates urgent attention.

Sepsis is a syndrome shaped by pathogen factors and


host factors (eg, sex, race and other genetic
determinants, age, comorbidities, environment) with
characteristics that evolve over time.

What differentiates sepsis from infection is an aberrant


or dysregulated host response and the presence of
organ dysfunction.
Key Concepts of Sepsis

Sepsis-induced organ dysfunction may be occult;


therefore, its presence should be considered in any
patient presenting with infection.

Conversely, unrecognized infection may be the cause


of new-onset organ dysfunction.

Any unexplained organ dysfunction should thus raise


the possibility of underlying infection.

Singer, et al. The Third International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3). JAMA February 23, 2016 Volume 315, Number 8
Key Concepts of Sepsis

The clinical and biological phenotype of sepsis can be


modified by preexisting acute illness, long-standing
comorbidities, medication, and interventions.

Specific infections may result in local organ dysfunction


without generating a dysregulated systemic host
response.

Singer, et al. The Third International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3). JAMA February 23, 2016 Volume 315, Number 8
New Terms and Definitions

Sepsis is defined as life-threatening organ dysfunction


caused by a dysregulated host response to infection.

Organ dysfunction can be identified as an acute change in


total SOFA score >2 points consequent to the infection.

The baseline SOFA score can be assumed to be zero in


patients not known to have preexisting organ dysfunction.

A SOFA score >2 reflects an overall mortality risk of


approximately 10% in a general hospital population with
suspected infection.
qSOFA

Respiratory rate 22/min

Altered mentation

Systolic blood pressure 100 mm Hg

Singer, et al. The Third International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3). JAMA February 23, 2016 Volume 315, Number 8
SOFA score
Managing Infection

Antibiotics: Administer broad-spectrum intravenous


antimicrobials for all likely pathogens within 1 hour after
sepsis recognition (strong recommendation; moderate
quality of evidence

Source control: Obtain anatomic source control as rapidly as


is practical (best practice statement [BPS]).

Antibiotic stewardship: Assess patients daily for


deescalation of antimicrobials; narrow therapy based on
cultures and/or clinical improvement
Howell, MD, Davis, M. Management of Sepsis and Septic Shock.
JAMA Published online January 19, 2017
Managing Resuscitation

Fluids: For patients with sepsis-induced hypoperfusion,


provide 30 mL/kg of intravenous crystalloid within 3 hours
(strong recommendation; low QOE) with additional fluid
based on frequent reassessment (BPS), preferentially using
dynamic variables to assess fluid responsiveness

Howell, MD, Davis, M. Management of Sepsis and Septic Shock.


JAMA Published online January 19, 2017
Managing Resuscitation

Resuscitation targets: For patients with septic shock


requiring vasopressors, target a mean arterial pressure
(MAP) 65 mmHg (strong recommendation; moderate QOE).

Vasopressors: Use norepinephrine as a first-choice


vasopressor (strong recommendation; moderate QOE)

Howell, MD, Davis, M. Management of Sepsis and Septic Shock.


JAMA Published online January 19, 2017
Mechanical ventilation in patients with sepsis-
related ARDS:

Target a tidal volume of 6 mL/kg of predicted body weight


(strong recommendation; high QOE) and a plateau pressure
of 30 cm H2O (strong recommendation; moderate QOE).

Howell, MD, Davis, M. Management of Sepsis and Septic Shock.


JAMA Published online January 19, 2017
Formal improvement programs

Hospitals and health systems should implement programs


to improve sepsis care that include sepsis screening (BPS).

Howell, MD, Davis, M. Management of Sepsis and Septic Shock.


JAMA Published online January 19, 2017