Sepsis Berat & Syok Sepsis2015

8/9/2019 Sepsis Berat & Syok Sepsis2015

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Sepsis Berat &

Syok Sepsis


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Defnisi

SIRS ( Systemic Inammatory reponse syndrome ) :1. Demam > 38 o ! "ypotermia # 3$ o

%. ac'ypnea > %)!m

3. ac'ycardia > *+)!m

. ,e-kocytosis > 1%.+++!-, ,e-kopenia # +++!-,

Sepsis : SIRS yan/ did-/a ata- s-da' ter0-kti dikarenakan karena ineksi

Sepsis Berat : 2eadaan Sepsis dimana s-da' terdapat sat- ata- e0dis-n/si or/an

Syok Sepsis : S-da' ter4adinya "ipotensi ( #*+mm"/ sistoik yan/dikoreksi den/an pem0erian cairan sek-ran/5k-ran/nya seama 1 4


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6tioo/i & 6pidemioo/i

Mikroorganisme BloodsteamInfection%

Non BloodstreamInfection % Total E

Bakteri 7rame/ati a

39

Bakteri 7ram ositib

+ %

;-n/i < 9oymicro0a 11 %1

assic pat'o/ens c #9 #9. 6ntero0acteriaceae se-domonas "aemop'i-s spp Bakter /ram ne/ati ainnya. Stapyococc-s a-re-s Streptococc-s pne-monia 6nterococci Bakteri /ram ositi. eisseria menin/itides "aemop'i-s In-en=a dan Streptococc-s pyo/enes


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• Setiap ta'-nnya Sepsis 0erat men/aki0atkan > %++.+++ menin//amerika

• Saat ini setidaknya ada >


5/25

atofsioo/i


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7/25

?ekanisme 2ontro ,oca contromekanisme

Intracellular factors (e./. s-ppressor ocytokine si/nain/ 3

and I,51 receptorassociated kinase 3)

diminis' t'eprod-ction o

proinammatorymediators

0y ne-trop'is andmacrop'a/es

?oec-es deri@edrom essentia

polyunsaturatedfatty acids (ipoins

reso@ins andprotectins)

promote tiss-erestoration

6n=ymatic inacti@ationo micro0ia si/na

moec-es (e./. ,S)

restore 'omeostasisA

e-kocyte

acyoyacy

pre@e

in0y ina


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9/25

7e4aa 2inis


10/25

,a0oratori-m

• LEUKO!TO"I" Fit' aet s'it

• T#rombocytopenia

• $yperbilirubinemia

• roteinuria

• Neutrop#ils


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•6ary sepsis: 'yper@entiation

respiratory alkalosis•Respiratory m-sce ati/-e & acc-m. o actate metabolic acidoincreased anion /ap )

•&rterial Blood 'as: #ypo(emia

•E': sin-s tac'ycardia & nonspecifc S5 Fa@e a0normaities

•)iabetic patients:G de@eops 'yper/ycemiaG Se@ere inection dia0etic ketoacidosis (may eacer0ate 'ypotension)


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Hr/an Dis-n/sion

ardiop-monary

-mona

2etidak seim0an/an@entiasi & per-si

rteria H% 4at-'

?enin/katnyaker-sakan ep'ite

a@eoar &permea0iitas

kapier

?en/aki0atkanmenin/katnyacairan di daam

par-5par-

?en/an//-pert-karan Hksi/en

& ?en/-ran/i2iner4a par- par-

DiC-se inftratepar- & "ypoksemia

arteriaH%!;IH% #

3++

c-te ,-n/ In4-ry

RDS

aH%!;IH% #%++

2eeti'an Htoternaasan

"ipoksemia "ipercapnia

H% daam dara'tin//i

ardio@asc-ar

2e0ocoran 2apier(cairan intra@asc-ar

)

7an//-an distri0-siairan pem0--'dara' Jo-me

dara' dan"ypo@oemia

"ipotensi

ardiac o-tp-tmenin/kat!norma &

Sistemik @asc-arresisten yan/

0erk-ran/

Depersi ;-n/si?yocardia

drena Ins-Kciency

2er-sakan str-ct-rapada keen4ar

drena

0norma reseptor/-cocorticoid !menin/katnya

kon@ersi cortiso5cortisone

IR

"ipotensi

Rena

"ypotensi !ker-sakan kapier

Rena ;ai-re

Hi/-ria =otemiarotein-ria non

specifc -rinary cast

2ompikasi

ritica iness5reated corticosteroid ins-Kciencyyan/ inadeE-ate pada pasien yan/ menderita penRDS ( c-te Respiratory Distress )


13/25

Imm-nos-ppresion asien den/an Sepsis Berat san/at serin/ ditem-kan den/an keadimmon-s-ppresionG 2e/a/aan daam contro ineksi primer

G ?enin/katkan resiko ineksi sek-nder ( Stenotrop'omonas matop'iiacineto0acter cacoacetic-s50a-manni dan andida a0ican )

G 1 dari 3 pasien ( "erpes Simpe Jaricea5=oster cytome/ao@ir-s )


14/25

Dia/nosis

NO specifc dia/nostic testDia/nosticay sensiti@e

fndin/s: ;e@er or 'ypot'ermia ac'ypnea ac'ycardia ,e-kocytosis or

e-kopenia

c-tey ateredmenta stat-s

'rom0ocytopena

6e@ated 0oodactate e@e

'ypotension


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)e*niti+e etiologic diagnosisreE-ires isoation o t'e microor/anism rom 0ood or a site o inection

ulture, &t least - blood samples

os'o-d 0e o0tained (rom diCerent @enip-nct-re sites)

oin a patient Fit' an indFein/ cat'eter one sampe s'o-d 0e coeac' -men o t'e cat'eter and anot'er @ia @enip-nct-re


16/25

ataaksana ntimicro0a ( IJ )

G "ar-s diak-kan secepatnya

G Intra@ena

G ertim0an/kan 4enis 0akteri yan/ serin/ men/aki0atkan ter4adinya inekter4adi daam kom-nitas pasien r-ma' sakit dan pada pasien sendiri

G nti4am-r 0isa dipertim0an/kan 4ika pasien s-da' mendapatkan nti0io0roadspectr-m

Gem0erian antimicro0a se0aiknya di e@a-asi setiap 'arinyaG ain/ sedikit di0erikan seama 1 min//-

Initia ntimicro0ia 'erapy or Se@ere Sepsis Fit'


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Clinical Condition Antimicrobial Regimens (Intravenous Therapy)

Immunocompetent adult The many acceptable regimens include (1) ceftr iaxone (2 g q24h) or ticarcillin-c(!"1 g q4#$h) or piperacillin-ta%obactam (!"!&' g q4#$h) (2) imipenem-cilastator meropenem (1 g q*h) or cefepime (2 g q12h)" +entamicin or tobramycin ('#q24h) may be added to either regimen" If the patient is allergic to -lactam agent

ciprofloxacin (4 mg q12h)or

leofloxacin ('#&' mg q12h) plus

clindamycq*h)" If the institution or the community has a high prealence of /0 isolatesancomycin (1' mg,g q12h) to each of the aboe regimens"

3eutropeniaa (' neutrophils,5)

0egimens include (1) imipenem-cilastatin ("' g q$h) or meropenem (1 g q*h) og q*h) (2) ticarcillin-claulanate (!"1 g q4h) or piperacillin-ta%obactam (!"!&' g plus tobramycin ('#& mg,g q24h)" 6ancomycin (1' mg,g q12h) should be addpatient has an infected ascular catheter. if staphylococci are suspected. if the receied quinolone prophylaxis. if the patient has receied intensie chemotheraproduces mucosal damage. if the institution has a high incidence of /0 infecthere is a high prealence of /0 isolates in the community"

plenectomy 7efotaxime (2 g q$#*h) or ceftriaxone (2 g q12h) should be used" If the local prcephalosporin-resistant pneumococci is high. add ancomycin" If the patient is -lactam drugs. ancomycin (1' mg,g q12h) plus ciprofloxacin (4 mg q12h) o(&' mg q12h) or a%treonam (2 g q*h) should be used"

I6 drug user 3afcillin or oxacillin (2 g q*h) plus gentamicin ('#& mg,g q24h)" If the local pre/0 is high or if the patient is allergic to -lactam drugs. ancomycin (1' mg,ggentamicin should be used"

I9 7efepime (2 g q*h). ticarcillin-claulanate (!"1 g q4h). or piperacillin-ta%obactamq4h) plus tobramycin ('#& mg,g q24h) should be used" If the patient is allergic

drugs. ciprofloxacin (4 mg q12h) or leofloxacin (&' mg q12h) plus ancommg,g q12h) plus tobramycin should be used"

Initia ntimicro0ia 'erapy or Se@ere Sepsis Fit'o H0@io-s So-rce in d-ts Fit' orma Rena

;-nction


18/25

"emodynamic Respiratory & ?eta0oic s -4-an Ltama : ?en/em0aikan transer oksi/en dan s-0strate yan/ adek-at ke 4arin/a

m-n/kin.1. airan IJ ( orma Saine 15% , ( 15% 4am )

G Lnt-k mence/a' 6dema ar- :

G ekanan @ena sentra ( 851% cm"%H )

G en/e-aran Lrine > +9 m,!k/ per 4am ( Di-retik seperti ;-rosemid 0isa di/-nakan 4ika diper-kan )

'a ini diak-kan -nt-k memperta'ankan mean arteria 0ood preass-re > $9 mm"7 Systoi*+mm"/)

%. Mika tidak 0er'asi maka diper-kan terapi @asopressor ( nonepinep'rine ! dopamine )

3. Dis-n/si ?yocardia > penin/katan pen/isian 4ant-n/ & 0erk-ran/nya cardiac o-p-t mado0-tamine

. IRI > "ydrocortisone (9+m/ IJ setiap $ 4am )

9. Jentiator > "ypoemia "ypercapnia ( $ m,!k/ 0erat 0adan idea )

$. rans-si Dara' diper-kan 4ika "0 N < /!d ( ar/et "0 O * /!d )

7a/a /in4a ! "ypercata0oic


19/25

7enera S-pport•ada asien den/an Sepsis 0erat > %!3 'ari S-pemen n-trisi danmen/-ran/i eek dari 'ypercata0oisme protein.

•"eparin -nt-k mence/a' t'rom0osis pada @ena ( ada pasien yan/ditem-kan pendara'an akti ! coa/-opat'y )

•2ontro /-a dara' san/at diper-kan dan ins-in 'anya akan di/-nsan/at diper-kan ( 2ontro /-a dara' # 19+ m/!d, ) >> asien yamendapatkan Ins-in intra@ena 7DS 'ar-s di monitor setiap 15% 4a


20/25

?en/'ian/kan S-m0er Inek• IJ at'eter ! arteria at'eter se0aiknya dica0-t dan di/-nakan dapemeriksaan k-t-r dara'

•en/antian men//-nakan at'eter yan/ 0ar- setea' terapi anti0idiak-kan dan dimas-kkan mea-i tempat yan/ 0er0eda oey dacat'eter 4-/a di/anti

• aranasa sin-sitis > 4ika pasien men//-nakan int-0asi nasa


21/25

• 6ndotoin5ne-trai=in/ proteins

• in'i0itors o HP or nitric oide synt'ase

• anticoa/-ants

• poycona imm-no/o0-ins

• /-cocorticoids and

• anta/onists to ;5 I,51 ; and

• 0radykinin.

Ot#er Measures


22/25

.ecombinant acti+ated protein /a0• reatment o patients Fit' se@ere sepsis or septic s'ock

• frst dr-/ to 0e appro@ed 0y t'e L.S. ;ood and Dr-/ dministrationtreatment o patients Fit' se@ere sepsis or septic s'ock

• s-r@i@a rate Fas si/nifcanty 'i/'er amon/ a recipients F'o Fesick ("6 II score O%9)

• increased risk o se@ere 0eedin/


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24/25

ro/nosis• pproimatey %+Q39 o patients Fit' se@ere sepsis and +Q$+

patients Fit' septic s'ock die Fit'in 3+ days.

• ,ate deat's oten res-t rom poory controed inectionimm-nos-ppression compications o intensi@e care ai-re o m-or/ans or t'e patients -nderyin/ disease


25/25

re@enti In de@eoped co-ntries most episodes o se@ere sepsis and septic

compications o nosocomia inections

Red-cin/ t'e n-m0er o in@asi@e proced-res -ndertaken 0y imitin(and d-ration o -se) o indFein/ @asc-ar and 0adder cat'eters

Indiscriminate -se o antimicro0ia a/ents and /-cocorticoids s'o-a@oided

Documents

Sepsis Berat & Syok Sepsis2015