Sepsis Fk Uki

SEPSIS

dr. Donnie Lumban Gaol, SpPD

DAHULU

“Sepsis” the Greek word for putrificationDenoted tissue breakdown that resulted in illness

SEPSIS

EPIDEMIOLOGI MORTALITAS DAN MORBIDITAS ETIOLOGI DEFINISI MANIFESTASI KLINIK PATOGENESIS DIAGNOSIS PENATALAKSANAAN

EPIDEMIOLOGI

1995: 6 million records analyzed from 7 states

750,000 cases of severe sepsis occur annually

( 3/ 1000) Mortality 28.6% or 250,000 deaths Projected increase by 1.5% per year

Angus et al , CCM 2001, 29: 1303-1310

SEPSIS


MORTALITAS DAN MORBIDITAS

Angka mortalitas secara keseluruhan sekitar 28.6%, setara dengan 215.000 kematian tiap tahun di Amerika Serikat.

Faktor-faktor yang mempengaruhi pada awal kematian adalah jumlah sistem organ yang terlibat, rendahnya pH darah arteri, dan skor SAPS, MEDS24 atau APACHE yang tidak baik

Angus DC, et al. Crit Care Med 2001

Mortality

Septic Shock

53-63%

20-53%Severe Sepsis300,000

7-17%Sepsis

400,000

Incidence

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

Mortalitas Meningkat Pada Pasien Syok Septik

Approximately 200,000 patients including 70,000 Medicare patients have septic shock annually

Severe Sepsis: Comparative Incidence and Mortality

Angus DC, et al. Crit Care Med 2001; American Cancer Society

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Mortality of Severe Sepsis by Age in the United States

Angus DC, et al. Crit Care Med 2001.

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• 0 • 1 • 5 • 10 • 15 • 20 • 25 • 30 • 35 • 40 • 45 • 50 • 55 • 60 • 65 • 70 • 75 • 80 • 85

Age

Mo

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• Without Co-morbidity

• With Co-morbidity

• Overall


60-70% penyebab sepsis adalah gram negatif

Infeksi gram negatif merupakan hal yang predominan pada sekitar tahun 1960an dan 1970an,

akan tetapi infeksi gram positif telah meningkat dalam 2 dekade terakhir dan sekarang penyebab pada sebagian kasus sepsis berat

Pathogen distribution

Gram-positives

Gram-negatives

Fungi

NNIS. Crit Care Med 1999;27:887–892

Microbiology of Sepsis

Martin GS, et al. NEJM 2003;348:1546

http://content.nejm.org/content/vol348/issue16/images/large/06f3.jpeg


ACCP/ SCCM Consensus Conference 1992

Systemic Inflammatory Response Syndrome

( SIRS) Sepsis Severe Sepsis Septic shock

Bone RC, CHEST 1992: 101(6):1644-55

SIRS

Temperature >38 C or < 36 C HR> 90/ min RR> 20/ min or PaCO2< 32mmHg WBC> 12,000 or < 4,000, or > 10%

immature (bands) forms

Bone RC, CHEST 1992: 101(6):1644-55

Definitions

Sepsis Systemic inflammatory response to known or suspected infection

Severe Sepsis SIRS associated with organ dysfunction (failure), hypoperfusion, and perfusion abnormalities

Bone, R et al. Chest 1992;101:1644

Definitions Continued

Septic shock A subset of severe sepsis, where patients experience combined decreased systemic vascular resistance and the presence of reduced myocardial performance

Bone, et al. CHEST , 1992;101:1644

Sepsis: Defining a Disease Continuum

A clinical response arising from a nonspecific insult, including 2 of the following:

• Temperature 38oC or 36oC

• HR 90 beats/min• Respirations 20/min• WBC count

12,000/mm3 or 4,000/mm3 or >10% immature neutrophils

SIRS = Systemic Inflammatory Response Syndrome

SIRS with a presumed or confirmed infectious process

SepsisSIRSInfection/Trauma Severe Sepsis

Bone RC, et al. Chest 1992;101:1644Opal SM, et al. Crit Care Med 2000;28:S81

Sepsis: Defining a Disease Continuum

Bone et al. Chest 1992;101:1644;

Wheeler and Bernard. N Engl J Med 1999;340:207

SepsisSIRSInfection/Trauma Severe Sepsis

Sepsis with 1 sign of organ failure

Cardiovascular (refractory hypotension)

RenalRespiratoryHepaticHematologicCNSMetabolic acidosis

Shock

Bone et al. Chest 1992;101:1644

Relationship Of Infection, SIRS, Sepsis Severe Sepsis and Septic

Shock

SIRSINFECTION

PANCREATITIS

BURNS

TRAUMA

OTHER

SEPSIS

SEVERESEPSIS

SEPTICSHOCK


Severe Sepsis: Primary Source

Pulmonary: 50% Abdomen/Pelvis: ~25% Primary bacteremia: ~15% Urosepsis: 10% Skin: 5% Vascular: 5% Other: ~15%

Martin GS, et al. NEJM 2003;348:1546

Manifestasi Klinik

Vital Sign Fever, Chills/Rigors, Hypotermia Tachycardia Tachypnea

Central Nervous System Encephalopathy

Cardiopulmonary Increased Cardiac output Decreased systemic vascular resistance Hypotension Metabolic asidosis hyperlactatemia Acute Lung injury, Hypoxemia

Vincent LJ.et.al. The Sepsis Text. Kluwer Academic Publisher 2002

Manifestasi Klinik Renal

Decreased urinary output Elevated BUN and creatinine

Gastrointestinal Ileus Elevated Bilirubin, predominantly direct

fraction Dermatology

Ecthyma gangrenosum Rash-maculopapular, vesicular, Bullous Toxic erythema

Metabolic Hyperglicemia, hypoglicemia

Hematologic Leukocytosis, leukopenia,

thrombocytopenia, DIC

Vincent LJ.et.al. The Sepsis Text. Kluwer Academic Publisher 2002


Bone, RC, Crit Care Med 1996; 24:1125.

Sepsis Battlefield: Cells and Mediators

Hotchkiss RS, Karl IE, NEJM 2003;348:138

Inflammatory Responses to Sepsis

Russel JA. Management of Sepsis. N Eng J Med 2006;355:1699-713

Pathogenesis of Severe Sepsis

Infection

Microbial Products(exotoxin/endotoxin)

Cellular Responses

OxidasesPlatelet

ActivationKinins

Complement

Coagulopathy/DICVascular/Organ System Injury

Multi-Organ Failure

Death

Endothelial damage Endothelial damage

CoagulationActivation

CytokinesTNF, IL-1, IL-6

Biologic effects of proinflammatory cytokines such as TNF and IL-1

Fever Hypotension Acute phase protein response Induction of IL-6 and IL-8 Coagulation activation Fibrinolytic activation Leukocytosis Neutrophil degranulation and augmented antigen expression

(TNF) Increased endothelial permeability (TNF) Stress hormone response Enhanced gluconeogenesis (TNF) Enhanced lipolysis (TNF)

Uptodate 2008


Severe Sepsis:Initial Resuscitation (1st 6

hours) Should begin as soon as the

syndrome is recognized and should not be delayed pending ICU admission.

Elevated serum lactate concentration identifies tissue hypoperfusion in patients at risk who are not hypotensive.

Resuscitation Goals

Goals in the first 6 hours: CVP: 8-12 mm Hg MAP > 65 mm Hg Urine output > 0.5 ml/kg/hr Central venous (SVC) or mixed

venous oxygen (SvO2) saturation > 70%

6 Hour Resuscitation Bundle

Early Identification Early Antibiotics

and Cultures Early Goal

Directed Therapy

6 - hour Severe Sepsis/Septic Shock Bundle

Early Detection: Obtain serum lactate

level.

Early Blood Cx/Antibiotics: within 3 hours of

presentation.

Early EGDT: Hypotension (SBP <

90, MAP < 65) or lactate > 4 mmol/L: initial fluid bolus 20-40 ml

of crystalloid (or colloid equivalent) per kg of body weight.

• Vasopressors:– Hypotension not responding

to fluid– Titrate to MAP > 65 mmHg.

• Septic shock or lactate > 4 mmol/L:– CVP and ScvO2

measured.– CVP maintained >8

mmHg.– MAP maintain > 65

mmHg.

• ScvO2<70%with CVP > 8 mmHg, MAP > 65 mmHg:– PRBCs if hematocrit <

30%. – Inotropes.

Early Goal Directed Therapy

EGDT in Severe Sepsis and Septic Shock

Rivers et al, NEJM 2001;345:1368

Terima Kasih

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Sepsis Fk Uki