2 Simpo Amnion Sepsis Purpuralis Fix1

8/13/2019 2 Simpo Amnion Sepsis Purpuralis Fix1

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Sepsis Puerpuralis

A.Guntur H.

Subbagian Alergi-Imunologi Tropik Infeksi Bagian Ilmu Penyakit Dalam

Fak. Kedokteran UNS. / RSUD.Dr. Moewardi Surakarta


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Introduction

Generally, a measure used to assess the merits of the state

of obstetric care (maternity care) within a country or

region is maternal death (maternal mortality).

According to the WHO definition of "maternal mortality

is the death of a woman during pregnancy or within 42

days after the end of pregnancy in any way, regardless of

the parents of pregnancy and the actions taken to

terminate the pregnancy".


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High mortality rates are generally half a century ago has three

main reasons:

(1) is still a lack of knowledge about the causes and prevention of

important complications in pregnancy, childbirth, and childbirth;

(2) lack of understanding and knowledge about reproductive

health, and

(3) less prevalence of good obstetric care for all pregnant. One of

which belongs to the important causes of maternal mortality is

puerperal sepsis


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Although Semmelweiss in 1874 already showed that

puerperal sepsis caused by infection and that doctors

and midwives are often the carriers of the infection in

women who are birthing, but still a long way in the 20th

century this has not been generally accepted among

doctors.


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Only after the advancement of microbiological sciences

demonstrated that the main cause of the disease are

different types of bacteria (streptococcus), that the germs

are carried by a doctor, midwife, or other personnel whoattended the delivery

However, the occurrence of sepsis reduction is achieved

with the discovery of new drugs that have antibiotic

functions "Narrow Spectrum" and "Broad Spectrum."


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Definition

Puerperium is the period that begins after the placenta

was born after 6 weeks (42 days) to return to normal

reproductive or pre-pregnancy state.


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(Patholgic change in the uterine cavity)

The uterine cavity is normally free of bacteria

during pregnancy.

Approximately 48 hours postpartum, progressive

necrosis of the endometrial and placental remnants

produces a favorable intrauterine environment for

the multiplication of aerobic and anaerobic bacteria.


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Pathologic change in the uterine cavityEndomyoparametritis

Endomyoparametritis is a potentially life-threatening condition.

It commonly begins with:

Retention of secundines (placental and amniochorionic

membrane fragments) that block the normal lochial flow,

Allowing accumulation of intrauterine lochia,

Which in turn changes the local BH.

And acts as a culture medium for bacterial growth.


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The body's normal defense mechanisms that

can prevent the occurrence of a progressive

infection, but decreased defense mechanisms

(imunocompromise) enables microorganisms

(bacteria) to invasion into endometrium ormyometrium.

A rise of temperature of 100.4 F (38 C)

or higher that lasts longer than 2 consecutivedays (not including the first day postpartum)

during the first 10 days postpartum.


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further invasion into the lymphatics of the parametrium

can cause: lymphangitis, pelvic cellulitis.

Infection during childbirth have clinical manifestationsincreased body temperature (fever), and increased pain

around the uterus and lower abdomen.


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When developing these infections erratic bodytemperature, increased with fluctuations, it is a sign

of Systemic Inflammatory Response Syndrome

occurs (SIRS) onset of sepsis.

Puerperal sepsis at the time was still significantly

contribute to postpartum maternal morbidity andmortality.


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Sepsis

Clinical syndrome that occurs by excessive body

response due to stimuli Microorganisms products.

SIRS + Infection.


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SIRS/SEPSIS : CLINICAL SYNDROM

Hyperthermi / Hypothermi

(> 38,3 0C / < 35,6 0C )

Tachypneu ( resp > 20 / mnt )

Tachycardi ( pulse > 100 / mnt ) Leukocytosis > 12000 / mm

Leukopenia < 4000 / mm

10% > cell immature

Suspected infection Blood Glucose > 120 mg/dL (without diabetes)

Mental status disorders

Biomarker dini Pct dan Crp (ccm 2003)


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Grade of Sepsis

1. SIRS, caracterized with two or more following symptom :

a. Hyperthermia/ Hypothermia (> 38,3 0C / < 35,6 0C )

b. Tachypnoe ( resp > 20 / mnt )

c. Tachycardia ( pulse > 100 / mnt )

d. Leucocytosis >12000/mm atau Leucopenia < 4000/mm

e. 10% > immature cell

2. SEPSIS

SIRS that has a proven or suspected infection

3. SEVERE SEPSIS

Sepsis with one or more sign of Multi Organ Disfunction syndrome (MODS)/ Multi organFailure (MOF), Hypotension, oligouria or anuria.

4. SEPSIS with Hypotension

Sepsis with hypotension ( systolic blood Pressure (SBP) < 90 mmHg or reduced SBP > 40mmHg).

5. SEPTIC SHOCK

septic shock as subset of severe sepsis difined as sepsis-induced hypotension persistently

despite adequate fluid resuscitation along with the presence of tissue hypoperfusion.


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Diagnosis

Good ananemsa to eliminate other causes of fever are caused by the

purpurium.

Physical examination.

Laboratory investigations:

Aerobic and anaerobic cultures should be obtained from the blood,

endocervix, and uterine cavity,

Urine specimens for culture

Complete blood

CTS or abdominal pelvic ultrasound scan.


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Management Sepsis

di HCU (High Care Unit) Penyakit Dalam RSUD

Dr.Moewardi Surakarta

A. NONMEDIKAMENTOSA

B. MEDIKAMENTOSA


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NONMEDIKAMENTOSA

Total bed rest, the position depending on the condition

of the patient's illness

Oxygenation 3-4 lt

DC Plug

If the patient is unconscious or inadequate intake and

gastro intestinal massive bleeding, plug NGT for bleeding

and evacuation sonde diet.


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MEDIKAMENTOSA

I. Fluid resuscitation Changes in sepsis hemodynamic

capillary permeability Liquid come outinterstitial space

Reduced intravascular fluid

Dilation of blood vesselsresistance

decreased blood pressureshock

Restoration of intravascular volume

Colloid + crystalloid


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Goal of fluid resuscitation:

- Improvement of blood volume

- Optimizing Cardiac Output

- Reduce the risk of pulmonary edema

- Correction of acidosis


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Emperik

- Cephalosphorin

- Cephalosphorin + Lactam inhibit- Sesuai pola kuman dirumah sakit

setempat

Gram (+) Gram (-)

72 jam

72 jam

CephalosphorinC. Lactam inhibit

Aminoglycosida

- Vancomycin

- Teicoplanim

METRONIDAZOL

Sensitivitas

Test

Carbapenim

Imepenim

Fungus : Fluconazol

Parasite

VirusGuntur, 2002

Antibiotik


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ANTIBIOTIC

Culture Not AvailableCulture Available

Empirical Treatment

broad spectrum antibiotics

Combination

Deescalation

Definite / Rational

Therapy

Blood culture obtained prior to antibiotic administration

From the time of presentation, broad spectrum antibiotics administeredwithin 3 hours for ED admissions and 1 hours for non-ED ICU

admissions.Intensive Care Med (2010) 36:222231

DOI 10.1007/s00134-009-1738-3


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III. Nutrisi EnteralIMUNONUTRISI

Imunonutrisi - omega 3

- L. arginin

- Nukleutida

respons imun

perfusi splanikus

Folat

B12

Vit E

MALT

GALT


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INSTALASI GIZI RSUD Dr. MOEWARDI SURAKARTA

Tabel ZONDE LENGKAP

Items analyzed :

150 gram wortel

150 gram tempe kedelai murni40 gram hati sapi

40 gram tepung beras

90 gram tepung susu skim

120 gram gula pasir75 gram telur ayam

20 gram margarine

Code

298

111139

49

365

393147

369

Guntur, 2001


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Weight : 685 Gram (24.2 oz)

Calories 1515

Protein 81.7 G

Carbohydrates 228 G

Dietary Fiber G

Fat-Total 343 G

Fat-Saturated G

Fat-Mono G

Fat-Poly GCholesterol Mg

Vit A-Carotene RE

Vit A-Preformed RE

Vit A-Total 36710 RE

Thiamin-B1 887 Mg

Ribloflavin-B2 Mg

Niacin-B3 Mg

Water weight : 329 G

Vitamin B6 Mg

Vitamin B12 Mcg

Folacin Mcg

Pantothenic Mg

Vitamin C 27.7 Mg

Vitamin E Mg

Calcium 1477 Mg

Copper MgIron 21.8 Mg

Magnesium Mg

Phosphorus 1552 Mg

Potassium Mg

Selenium Mcg

Sodium Mg

Zine Mg

Calories from protein : 21% Poly/Sat

= 0.0 : 1Calories from carbohydrates : 59% Sod/Pot

Guntur, 2001


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IV. SUPLEMENTATIF THERAPY

- Strategy and Anti Exotoxin endotoxin

- Monoclonal antibody

- Corticosteroids

- Strategy Anti Mediator

- Neutralization of NO

- CVVH

- Herbal Treatment

- Intra Venus Immuno Globulin (IVIG)


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LPS bp

CD 14

IL 6

TNF -

IL -1

IL 8

APC

CD 4+ TCR

IFN -

SUPER ANTIGEN

IL - 10

IL - 4IL - 5

IL - 6

Ig

NO ICAM -1

a

g TH - 2TH - 1B cell

CD 8+

LPSIMUNOCOM

SEPSIS

MOD

SHOCK

SEPTIC

IL-2

CSF

Compl.

N

NK

(Guntur, 2006)

C3a, C5a

PGE2

TLR 4

TLR2

C7a MHC II

PAI-1

Imunopatogenesis

Kortikosteroid


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UnderlyingDiseases + Sepsis

Better (+)

Worst (-)

Underlying Treatment

MODS-MOFSeptic-Shock

Resuscitation

AB + Underlying Diseases

Immunonutrition

Suplementatif

Management Sepsis

72% - 80% die > 72 hr

30% - 80% ARDSGuntur, 2000


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Conclusions

At purpuralis, frequent infections causing sepsis.

Need to be careful, because it has a high mortality rate.

Precision / accuracy for detecting "purpuralis infection"

to sepsis.

Immediately take action in accordance with a protocol

that has been done as these above.


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2 Simpo Amnion Sepsis Purpuralis Fix1