Infection

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SEPSIS
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Penyebab Sepsis pada Kehamilan

• Chorioamnionitis
• Endometritis
• Pyelonefritis
• Abortus septik
• Luka operasi
• Necrotizing fascitis
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Sepsis =
infection plus systemic inflammatory
response syndrome (SIRS)
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INFLAMASI
Respon awal
tubuh

Tujuan :
menghancurkan
dan
menetralisasi
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1. Perubahan sirkulasi darah

2. Perubahan pada
permeabilitas pembuluh
darah
3. Perpindahan leukosit

1. Mengisolasi
2. Mendilusi
3. Menghancurkan
4. membersihkan
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 Infection
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PEMBULUH
DARAH
BEKUAN

O2

ALBUMIN →

PEMBULUH INTERST. SEL

DARAH SPACE

PLASMA →

CO2

MENGGANGGU PERTUKARAN O2
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JENIS SEPSIS Sepsis

T> 38o or < 36o
Sepsis +
PR > 90 bpm
+ Hypotension and
RR > 20/min or hypoperfusion
Invasion of Infection Organ
PaCO2 < 32 despite adequate
microorganisms dysfunction,
+
L > 12,000/uL hypoperfusion or volume
or < 4,000/uL SIRS hypotension replacement
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Bacteremia
Other
Infection
SIRS
Fungemia Sepsis Trauma
Parasite

Virus Burns
other
Pancreatitis

Crit Care Med 1992; 20:864

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Severe Sepsis
• Sepsis with organ hypoperfusion one
of the followings :
– SBP < 90 mmHg
– Acute mental status change
– PaO2 < 60 mmHg on RA (PaO2 /FiO2 < 250)
– Increased lactic acid/acidosis
– Oliguria
– DIC or Platelet < 80,000 /mm3
– Liver enzymes > 2 x normal

American College of Chest Physicians/Society of Critical Care Medicine Consensus

Conference Committee. Crit Care Med. 1992;20:864-874.
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MODS
(Multiple Organ Dysfunction Syndrome)
• Sepsis with multiorgan hypoperfusion
Two or more of the followings:
– SBP < 90 mmHg
– Acute mental status change
– PaO2 < 60 mmHg on RA (PaO2 /FiO2 < 250)
– Increased lactic acid/acidosis
– Oliguria
– DIC or Platelet < 80,000 /mm3
– Liver enzymes > 2 x normal

American College of Chest Physicians/Society of Critical Care Medicine Consensus

Conference Committee. Crit Care Med. 1992;20:864-874.
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Pathogenesis of Severe Sepsis

Infection

Microbial Products
(exotoxin/endotoxin)

Cellular Responses
Platelet Coagulation Kinins Cytokines
Activation Activation Oxidases Complement TNF, IL-1, IL-6

Coagulopathy/DIC
Vascular/Organ System Injury

Multi-Organ Failure

Death
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Angka kejadian dan mortalitas
akibat sepsisMortality
Incidence
Approximately total
200,000 death/year
Sepsis
400,000 7-17%

Economic burden Severe Sepsis 20-53%

~ $ 16.7 billion 300,000
nationally

Approximately 200,000 Septic

53-63%
patients including 70,000 Shock
Medicare patients have
septic shock annually

Balk, R.A. Crit Care Clin 2000;337:52

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BIOCHEMICAL MARKERS

Several biochemical markers present in blood:

• Serum procalcitonin (PCT) ,
• C-reactive protein (CRP)
• Triggering Receptor Expressed on Myeloid
cells (TREM) have been proposed to be useful
in this distinction.
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C-reactive protein levels correlate with

mortality and organ failure in critically ill
patients.
Chest 2003, 123:2043–2049.

Serum procalcitonin and interleukin- 6 levels

may help to differentiate systemic
inflammatory response of infectious and non-
infectious origin

Chin Med J (Engl) 2003, 116:538–542.

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PCT AS A TOOL TO
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GUIDE ANTIMICROBIAL THERAPY.

PCT Level
Less than .1ng/ml-absence of infection.
.1 to.25ng/ml-bacterial infection unlikelly and use of
antibiotic-discouraged.
.25 to.5ng/ml indicate possible bacterial infection, initiate
antimicrobial therapy.
More than .5ng/ml-suggestive of presence of bacterial infection
and antibiotic treatment is strongly recommended.

Muller B et al(2000).Calcitonin precursors are reliable markers of sepsis in a MICU

.Crit Care Med 28:977-983
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MANAGEMENT OF SEVERE SEPSIS
International Tatalaksana sepsis berat

RESUSITASI DIAGNOSIS ANTIBIOTIK

AWAL

KENDALI
SUMBER TERAPI CAIRAN Vasopressors
INFEKSI

Recombinant
Inotropic Therapy Corticosteroids Human Activated
Protein C (rhAPC)

TRANSFUSI
DARAH
 Infection
International Tatalaksana sepsis (2013)
A. Initial resuscitation
B. Screening for sepsis and performance improvement
C. Diagnosis
D. Antimicrobial therapy
E. Source control
F. Infection prevention
G. Fluid therapy for severe sepsis
H. Vasopressor
I. Inotropic therapy
J. Corticosteroids
K. Blood production administration
L. Immunoglobulin
M. Selenium
N. History of recommendations regarding use of recombinant activated protein C
O. Mechanical ventilation of sepsis induced Acute Respiratory Distress Syndrome
(ARDS)
P. Sedation, analgesia and neuromuscular blockade
Q. Glucose control
R. Renal replacement therapy
S. Bicarbonate therapy
T. Deep vein thrombosis prophylaxis
U. Stress ulcer prophylaxis
V. Nutrition
W. Setting goals of care
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SvO2, Mixed venous O2 saturation DO2, Oxygen delivery, VO2, O2 consumption

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Tujuan resusitasi
• CVP 8–12 mm Hg
• MAP ≥ 65 mm Hg
• Produksi urine ≥ 0.5 mL/kg/jam
• SvO2 ≥ 70%
 Optimalisasi
Infection pengiriman oksigen
International
Packed red cell

4 transfusion Cannula
Mask
Mechanical
ventilation

DO2= CO x Hb x SaO2 x 1.36

Kristaloid /
Koloid 1
Oxygenation/ mech.
ventilation vent.
HR x SV MAP < 65mmHg → Vasopressor
(norepinephrine) MAP > 90mmHg → Vasodilator
(NTG)
2 3
fluid Preload Afterload vasoactive

Contractility inotrope 5
Dobutamine
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Rivers, E. et al. N Engl J Med 2001;345:1368-1377

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Early Goal-Directed Therapy Results
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28-day Mortality
60
49.2%
50 P = 0.01*

40
33.3%
30

20

10

0
Standard Therapy EGDT
n =133 n=130
*Key difference was in sudden CV collapse, not MODS

Rivers E. N Engl J Med 2001;345:1368-77.

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Terapi antibiotik
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• Berikan terapi antibiotik

sedini mungkin segera setelah
kondisi sepsis dicurigai
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Terapi antibiotik

Terapi Empiris
Kombinasi antibiotik satu atau lebih yang dapat meng-
cover berbagai jenis bakteri dan/atau jamur yang
dicurigai, serta memiliki kemampuan penetrasi jaringan
yang baik

Antibiotika kombinasi diberikan maksimal 3-5 hari

Diubah menjadi terapi tunggal setelah jenis kuman

diketahui

Antibiotika diberikan paling tidak 7-10 hari

 Infection
E.Source Control Examples
International
Drainage • Intra-abdominal abscess
• Thoracic empyema
• Septic arthritis
Debridement • Pyelonephritis, cholangitis
• Infected pancreatic necrosis
• Intestinal infarction
• Mediastinitis
Device removal • Infected vascular catheter
• Urinary catheter
• Infected intrauterine contraceptive device
Definitive control • Sigmoid resection for diverticulitis
• Cholecystectomy for gangrenous cholecystitis
• Amputation for clostridial myonecrosis
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G. Terapi cairan

• Cairan kristaloid harus

digunakan sebagai terapi
cairan awal untuk kasus sepsis
berat dan syok sepsis
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K. Pemberian produk darah

• Transfusi PRC jika :

– Hb < 7.0 g/dl dengan target Hb 7.0–
9.0 g/dl pada orang dewasa.

• Transfusi TC jika :
3
– < 10,000/mm tanpa adanya
perdarahan
3
– < 20,000/mm with dengan risiko
kejadian perdarahan

• Target kadar trombosit ≥

3
50,000/mm jika akan dilakukan
tindakan bedah atau prosedur
invasif
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Q. Kendalikan kadar glukosa

International

• Gunakan insulin untuk mengatasi kondisi

hiperglikemia
• Pertahankan kadar glukosa darah < 180 mg/dl
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Summary
Resusitasi Terapi Kendali
Diagnosis
awal antibiotik sumber

Terapi pendukung
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TERIMA KASIH