Soedarsono

Department Pulmonolgy & Respiratory Medicine

FK Unair – RSUD Dr. Soetomo
 Sepsis is a clinical syndrome characterized by
systemic inflammation due to infection1
 There is a continuum of severity ranging from
sepsis to septic shock1
 Affects all ages, compromised immune
systems, chronic disease, infants and those
suffering traumatic injury2
 Sepsis remains in the top 10 leading causes of
death2
 Mortality has been estimated to be ≥10 percent and ≥40
percent when shock is present

1. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:801
2. Trauma Surg Acute Care Open 2017;0:1–6.
 Incidence of severe sepsis in Europe
Intensive Care Medicine 2001; 27 (suppl): 581

Annual mortality from the three biggest cancer killers compared

data from www.statistics.gov.uk;sepsis data from Intensive Care with severe sepsis in the United Kingdom1
National Audit Research Centre (2005).
 Epidemiologi

Hospital admissions for sepsis have overtaken those for stroke or

myocardial infarction.

Am J Respir Crit Care Med 2012, 186(12):1264-1271

450
400
350 390
300 (57%)
299
250
200 (43%)
150
100
50
0
Sepsis Non Sepsis
Data Rekam Medik Departemen Paru RSDS, 2016
Daniel and Nutbeam, 2010
250 222
209
200

150 136

100
35 45 42
50

0
Survive Meninggal Pulang Paksa
Sepsis Non Sepsis
Data Rekam Medik Departemen Paru RSDS, 2016
160
140
120 136

100
80
60 65
40
20
7 1
0
Syok Sepsis Gagal Napas Cardiac Event Brain
Metastase
Data Rekam Medik Departemen Paru RSDS, 2016
• Tempereature 
380C or ≤ 36 0C
• HR ≥ 90 beats /min
• RR ≥ 20/min
• WBC ≥12.000/mm 3
or ≤ 4.000/mm 3
Daniel and Nutbeam, 2010
SURGICAL INFECTIONS , Volume 19, Number 2, 2018
SURGICAL INFECTIONS , Volume 19, Number 2, 2018
 The following are the abnormal physiologic SOFA parameters,
each of which receives a score of 2 or higher:

 PaO2: FiO2, < 300 mmHg

 platelets, < 100 × 103/mm3
 bilirubin, ≥ 2 mg/dL
 hypotension requiring vasopressor support
 Glasgow Coma Scale score, ≤ 12
 creatinine, ≥ 2 mg/dL, or urine output < 500 mL/day

 Physiologic parameters are scored from 0 (normal function) to 4

(organ failure).
 Each parameter is scored individually, after which a total score is
derived to suggest severity of illness.
 A score of 2 or higher in any system indicates an elevated risk of
organ dysfunction, poor outcome, or death.
SEPSIS = (qSOFA ≥ 2) + (SOFA  2)
 Early identification of patients with possible
infection and sepsis
 Rapid and aggressive fluid resuscitation (at
least 30 mL/kg within three hours of sepsis-
induced hypoperfusion)
 Frequent hemodynamic reassessment of
patient response to fluids
 Administration of iv antibiotics within one
hour of suspected sepsis or septic shock
SURGICAL INFECTIONS , Volume 19, Number 2, 2018
 Weak recommendation, low quality of evidence

Best practise statement

Strong recommen

Strong recommendation

SURGICAL INFECTIONS , Volume 19, Number 2, 2018

Western Journal of Emergency Medicine, Volume 20, no. 2: March 2019
*Targets for quantitative resuscitation included in the guidelines are CVP
of ≥ 8mm Hg, Scvo2 of ≥70%, and normalization of lactate

SURGICAL INFECTIONS, Volume 19, Number 2, 2018

 Strong recommendation

*Targets for quantitative resuscitation included in the guidelines are CVP

of ≥ 8mm Hg, Scvo2 of ≥70%, and normalization of lactate

SURGICAL INFECTIONS, Volume 19, Number 2, 2018

Western Journal of Emergency Medicine, Volume 20, no. 2: March 2019
1. Deliver high-flow oxygen
2. Take blood cultures prior to antibiotics but do
not delay treatment
3. Administer empirical intravenous antibiotics
4. Measure serum lactate
5. Start intravenous fluid resuscitation with
crystalloids
6. Commence urine output monitoring via either
a catheter
BMJ Quality Improvement Reports 2015
 Penerapan Resusitasi Cairan pada Syok Septik Dewasa

ALI=acute lung injury; CHF=congestive heart failure; CMS= US Centers for Medicare and Medicaid Services; CVP=central
venous pressure; ESRD=end stage renal disease; ScvO2=superior vena cava oxygen saturation
Intensive Care Med (2017) 43: 299-303
 Vasopressin +
consider steroid IV

Epinephrine +
steroid IV

Intensive Care Med (2017) 43:299–303

 Pola
Resusitasi
SEPSIS
Klasik

Update
Mengatasi
hipoperfusi
sesegera
mungkin
  Harus selesai dalam 1 jam :
1. Ukur kadar laktat darah
2. Ambil kultur (sebaiknya sebelum pemberian antibiotik)
Kultur tidak boleh menyebabkan penundaan antibiotik!
3. Berikan antibioik spektrum luas (terapi empirik)
4. Berikan kristaloid s/d 30 mL/kg BB (bila terjadi hipotensi atau bila kadar laktat >4
mmol/L)
5. Berikan vasopressor perifer (hipotensi yang tidak respons terhadap pemberian
cairan awal) untuk mencapai MAP ≥ 65 mmHg

• Harus selesai dalam 3-6 jam :

6. Pasang CVC dan invasive blood pressure (bila memungkinkan)
7. Bila hipotensi refrakter/persisten → nilai responsivitas cairan (fluid
responsiveness)
Gunakan parameter dinamik untuk penentuan terapi selanjutnya →
menambah cairan, atau vasopressin dan/ atau epinefrin dan/ atau steroid
8. Nilai ulang BE, kadar laktat dan/ atau mengukur SvO 2 dan/ atau CO2 gap → untuk
melihat adekwasi resusitasi
 Antibiotic within 1 hour hypotension:
79.9% survival
 Survival decreased 7.6% with each hour
of delay
 Mortality increased by 2nd hour post
hypotension
 Time to initiation of Antibiotics was the
single strongest predictor of outcome
The standard flowchart of the new 6Rs rule for anti-infection tx for sepsis & septic shock

• Right patients: rapid screening

and early diagnosis

• Right time: the appropriate time

to start antibiotic Therapy.

• Right target: identifying the

correct infection source and
Pathogenic microorganism is the
key to successful the

• Right antibiotics: rational

selection of antibiotics

• Right dose: optimized

application of PK/ PD in anti-
infection therapy

• Right source control: controlling

the source of infection is vital to
anti-infection therapy for sepsis

Zhou X et al, Chinese Medical Journal 2019;132(5)

 Early = within 1 hour after
recognition of potential septic shock

 Appropriate = in vitro activity

against pathogen
 Route of administration
 Dose and frequency
 Penetration

Crit Care Clin 2011;27:53-76

Advanced Drug Delivery Reviews. 2014: 77: 3–11
 De Escalation Strategy
 Initial appropriate - adequate therapy through :
Getting it Right the First Time
 Hitting Hard - Fast , Big dose and combination if possible
 antimicrobial selection based on empiric or local ecology
 optimize the antibiotic dose and time of administration

 Adjust antibiotic based on susceptibility test and

administer the shortest possible
 INAPPROPIATE
CAN’T BE
BROAD MORTA
SPECT- SEVERE INFECTION
WRONG DELAYED LITY
HIGH
DOSE

BASED ON: TARGETED

DEDICATED
CULTURE NARROW SP
SUSCEPTIBILITY DE-ESCALATION
CLINICAL COURSE

OPTIMIZING OUTCOME
RESISTANCE MINIMIZING:
TOXICITY RESISTANCE
COST TOXICITY
COST
 Mesurement of procalcitonin levels can be used
to support shortening of duration of
antimicrobial therapy in sepsis patients
 Decisions on initiating, altering, or
discontinuing antimicrobial therapy should
never be made solely on the basis of changes in
any biomarker, including procalcitonin
 Procalcitonin levels can be used to support the
discontinuation of empiric antibiotics in
patients who initially appeared to have sepsis
 Perjalanan klinis sepsis dapat berbeda beda
tergantung jenis patogen dan respons imun
 Pendekatan terapi dapat menjadi sangat individual
 Pro aktif dalam mencari tanda2 sepsis
 Kenali sepsis secara dini
 Resusitasi secara adekuat dan rasional
 Pengobatan sepsis sesuaikan dengan ‘the latest
evidence’
 Antibiotik merupakan terapi kunci pada sepsis,
namun harus diimbangi dengan diagnosis dini
dan resusitasi yang adekuat.