Infection

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SEPSIS
 Infection
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Sepsis =
infection plus systemic inflammatory
response syndrome (SIRS)
 Infection
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PERJALANAN INFEKSI

KEMATIAN
 Infection
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ANGKA KEJADIAN DAN MORTALITAS AKIBAT SEPSIS

Incidence Mortality

Approximately total
Sepsis 200,000 death/year
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

 Infection
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FAKTOR RESIKO
 Infection
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SUMBER INFEKSI
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ORGANISME PENYEBAB
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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
 Infection
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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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TINGKATAN SEPSIS
T > 38o or < 36o Sepsis
PR > 90 bpm Sepsis +
RR > 20/min or +
PaCO2 < 32 Hypotension and
Invasion of Infection Organ hypoperfusion
L > 12,000/uL or despite adequate
microorganisms dysfunction,
< 4,000/Ul + volume
hypoperfusion or
Or > 10% immatur SIRS hypotension replacement
neutrofil
 Infection
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 Infection
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 Infection
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MATERNITY PATIENT
 Infection
Tatalaksana
MANAGEMENT sepsis
OF SEVERE
International
berat
SEPSIS

RESUSITASI AWAL DIAGNOSIS ANTIBIOTIK

KENDALI SUMBER
TERAPI CAIRAN Vasopressors
INFEKSI

Recombinant
Inotropic Therapy Corticosteroids Human Activated
Protein C (rhAPC)

TRANSFUSI
DARAH
 Infection Tatalaksana Sepsis (2013)
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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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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
Cannula Mask
4 transfusion Mechanical ventilation

Kristaloid / DO2= CO x Hb x SaO2 x 1.36 1

Koloid

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
 EARLY
Infection GOAL DIRECTED THERAPY
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 Infection
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Early Goal-Directed Therapy Results
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.
 Infection

Terapi antibiotik
International

• Berikan terapi antibiotik

sedini mungkin segera setelah
kondisi sepsis dicurigai
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PEMILIHAN ANTIBIOTIK PADA SEPSIS

• There is no, single, “best” regimen

• Consider the site of the infection
• Consider which organisms most often
cause infection at that site
• Choose antibiotic(s) with the appropriate
spectrum
• After obtaining cultures, give antibiotics
quickly and empirically at appropriate
dose
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Terapi antibiotik

Terapi 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

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TERAPI ANTIBIOTIK

• Dugaan infeksi aerob dan anaerob : kombinasi penisilin,

aminoglikosida, dan klindamisin/metronidazol
• Alternatif pada pasien tanpa netropeni: sefalosporin
generasi II/III
• Severe sepsis: kombinasi sefalosporin generasi III/IV
dengan aminoglikosida
• imunitas turun atau mudah infeksi jamur : Ampotericin
B atau Flukonazol
 Infection
E.Source Control Examples
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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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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
 Infection

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