02. Sepsis - Prof. Suharto [OBGYN]

8/20/2019 02. Sepsis - Prof. Suharto [OBGYN]

1/8

3/2/20L2

I

I

I

I

L-_

--1

SEPSIS

:

_*t

Suharto

Sepsis:

Defining a Disease

Continuum

'?';ix '

srRS

Sepsis Severe

Sepsis

I

s"pli"

"ith

"1

.is" .f

fi;i

I failure I

'

Cadlovscular0el@iory

I

-

hypdcnslC{l)

I Rcnal

\

'

fi:;:lil'"

t5hocl,li

i lcmatologtc

I

I

cils

i-. t*t"1"-:"lge'"

---

I

Emd

al. GhS 1992i101:1044ikwad

Beha.d,

NE@lJMd1W9,W:N

Relationship Of

lnfection,

SIRS, Sepsis

Severe

Sepsis

and

$eptic

$hock

Modality lncreases in

Septic

Shock

lnciGnce

Mortalitv

$epsis:

Defining a

Disease

Continuum

lnfectiorl

Trauma

SIRS

Sepsis Severe

$epsis

L

.

KsrpltrBns >rur-Tl:t

, i

glRS

=

Syslemia lnflemalqry

Respon$e Syhddhe

I

.

wBc @unt:1l0oo/frmr

ar

l

I

s4,M/ffir

o.

>tovo

l

i

irnsltur€

neutrcphilr

l

Adaprd

hm:

Bdne Rc.

st

al. cN

1992:101:164

Caar S, €t

31.

Cd CaE ffi mC€;28:sE1

Deficiencies of 1991

Consensus Conference

r

Limitations inherent in these definitions:

.

lncomplete agreement as to what defines

"Systemic

Response"

r

Inflammation only?

r

Organ/System failures

not

defined

r

Except

hypotension

(sBP

40

mml'lg decline from baseline; need for

vasopressor support)

"Dear

SIRS,

I

do not like

you"

Jean Louis Wncent


2/8

3/2/24L2

2001

Sepsis

Definitions

Conference

.

Current

definitions will remain unchanged

r

However,

will accept

the

uncertainty

of definitions

.

SIRS expanded to eiEns and

gymptoms

.

Chills

.

Alteratlon

in

temperatura

.

Tachypnea

'

change

in

m€ntal

st€tus

'

Tachycardia

.

Altered

WBC,

Bandemla

.

Thrombocytopenia

.

De€reased

perfusion;

mottling,

poor

cqpillary refill

.

lncreased blood sugar

.

Petichine/Purpura

tciin-toatpricccepl-iimifeisf oidmodyna;icsupptti-

j

ofpedlatrlc and neonatal

patlents

in

septic

shock*

i

i

Joseph A. Carcillo, MD; Alan L Fields, MD; Task

Force

I

i

Committee Membels.

{Crit

Care Med 2002; 30:f

365-

i

i-*-,

-

--

-

----:lt-2,8l

---J

r

Shock

pathophysiology

and

r€sponse

to

therapies

is age

sp&ific.

For

example, €rdiac

I I

failure

is

a

prodominant

cause of

death

in

I

neonats

and

childr€n,

but

wscular failure

is a

|

.

\

predominant

ca$€

of

d€ath

in

adulE.

l_

_

-

2'

lnoBopes,wsodilators{children),inhalednitric

.'

oxide

(neonats).

and

exfacorpor€l membEne

oxygenation

can

be more

impodant

contributoF

to

suruival

in

ths

pediakic

populalions,

whereas

r

vasoptossors

can be

more

important

contributoF to

adult

$urvival.

;;;hf..l

I

rlrlr$1rl

cohl:ilfqa

l

.;Lt1" I

lor-rarl.

l

1*jil

2.

necdmeMions

torstq$s.maEFmant

dbc@dFftip

rspd

tntem nMoms

#tig*ls

otnomd

Ftuion

ad

pffidon

presture

lnsn

ddalge$uE

edElve@s

resse)

and

Fedld3l

atu

pod{wtd

qy$n

sa@tlon

dtr€reffi ot

5%. P@ead to e*

dS lf sh6k

ped s.

2

2001

Sepsis Definitions Conference

FXRO staging system

proposed

'

Fredisposition: Genetics, Chronic

illness

.

fnsult:

Infection, Injury,

lschemia

.

Response:

Physiologic, Medrators, Markers

.

Organ Dysfunction: outcome, Organ dysfunction

To

be

pdi6hed

?00?

{vsd

ctrtucatid Mltchct

lry, sccM

?002)

pd,odto.ln

MEtuondwsWMEG.

m&oDhib.

Dlalel#

and endothelw

*aseswdos cyroknes lnd dhr

ftdato.E

tL€ [,a lL'10

9SF

Pded

Prdnftmd5ry

6trect

bdrop$ cturchdc ftdo.

Ms

Es

prun,

tudaie6

B and

T

ll4@yte

pDffie.ation,

iMbts

cytokn€

pdwliff.

id6$

immunos#€don

Ad€{ion

6nd

&gaouhfion

d

nedophb

Cyl& .. au@nb Eocurr

Fmeabifty

@dribde6

10

sto*

lNtud hbdlmsic ater.tons

olsqnc

€hock

Promde

sedqhil

and ftsodE$.

pW#

adMgon

ad che@ds

dBprciniammioy

ffied6

Enboe wc&r

Ffrls$Fty

and coddMec to

&ng

injq

hance

Mr4illaddhdia'

€n lilaadlm,

reg&te

Hksyle

doEtim

aod aft6€ioa. and

play

a

rc16

h

Fsogffijs

sf €psis

medtttrg

Litid

rudatoB

Pnorpirlipase A?

Ecdel6

kchidonic

aqld

mdabdlit6€

trds

m&cdes

Sl6din6

Ledocyte

idqdne

Flff6

l. Rocommddons

lor dwi$

f,a{6ll@ of hmodnmb

Wpd

h

itu6

affikn

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gd6

ot

nd

pl1&n.nd ptun

prrBs6

(ms

d6dal

pr.ss

csMd

v6muc

pr6ssuo

lffAp

Cyq].

Prcc.ed

to n6xr

rr.p

il

sho*

p6Ehs


3/8

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HTSTORY

I

Y

r---iNienve-runoNs

AND

--

-*l

i_

_enngrslqrgo1ygqEBEp

_-,]

o

Vasopressor therapy

as needed

(norepinephrine,

dopamine, vasopressin)

r.

lnotropic therapy (dobutamine or

a

combination

of

dobutamine and

a

vasopressor)as

indicated

s Steroids (hydrocortisone

with

or

without fludrocortisone,

dexamethasonel

s. Recombinant

nr*"n

activated

protein

C

(rhAPC)

ro.

Blood

produci

administration

{red

blood

eell

transfusion,

erfihropoietin,

fresh

fozen

plasma,

antithrombin*,

piatelets)

rr

Mechanical ventrlation

ofseDsis-induced acute luno

injury

(ALl)/adult

respiratory'

distress

svndrome

(A{DS

)

\

.6.4,:

s*rws/$s

r

,.,

S*,F*I#

{3$f :9J$r''l,,

i

tNfECtENfaoNs-AND-

---

l

l

L,_,_l8AqrpEg

qgugtp_E_REp,

__,

l

ra. Sedation,

analgesia,

and neuromuscuiar

blockade

rs.

Glucose control

r Renal replacement

{hemofiltration,

hemodialysis)

rs Bicarbonate thetapy*

ro

Deep vein thrombosis

(DW)

prophylaxis

(low-dose

unfractionated

heparin, low-molecular

weight heparin,

mechanical

prophylactic

devices)

rz.

Stress

ulcer

prophylaxis

{H2

receptor inhibitors)

re. Consideration for

limitation

of

support

rg

Pediatric

considerations

\.

-.:,.lrl-

#u.wv n*t

-"

SdpsJs

4i3or

r

4r

*

?grr

r

3

PATHOGENESIS

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TABLE

1,

lEFNF$re

Of

SEF3HANS IIELATEO CdUTNS

it8S2.1S?);

FROTOS€O PIRO

cussFEATEil

WffiE

FOft

aEp93

IAOArE

FRil

?0Q3 cOflSHSUs

pApEF

:-llti-"-.ji-ii..-..-,,--...,-,

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INTERVENTIONS AND

PRACTICES CONSIDERED

initial re$uscitation

Diagnostic studies,

as

indicated

l.lmaging studies, as indicated,

such as ultrasound

2" Blood cultures

and

culturee

from other sites, as

indicated, such

as urine, cerebrospinal fluid, wounds,

respiratory

secretions, or other body {luids

: Antibiotic therapy

r

Source

conkol

mea$ures

s Fluid therapy

1.

Natural or artificial colloids

or crystalloids

2.

Fluid

challenge in patients with suspected hypovolemia

\

"

ar,

"'

S {reiFrnSr

i

,r

sG/EsJs

Catt4t algt

t


4/8

312/2AL2

i--

Anti6ibtiEThe-rapv

-

"t

L----,.,---

"

lntravenous

antibiotic

therapy should be stiarted

within

the

first

hour

of

recognition of

severe sepsis,

after appropriate

cultures

have

b*n

obtained. {

E

}

"

lnltial empidcal anli-infective theapy should

include

one

or

more

drugs

that have activity against the

likely

pathogens

{bacteriai

or

fungali

and

tha

pen€tate

into

the

prasumsd

soure of spsis.

The

choice

of

drugs

should

be

guided

bythe

(

O)

"

The

antimicrobial regimgn should always

b6

reassessed

ater 48-72

hrs

on

th6

basis

of microbiological and clinical

dala

wiih the

aim

of

using a

narow-spectrum aniibiotic to

prevent

the

development of

resisiance,

to

reduce toxicity, and

to

roduce

msts. Once

a

Gusatlve

pathogen

is

idedmed, ther€

rs

no

€lidenc€

that

combinalicn

th€tapy

is more etfectiv€

than monotherapy.

The

duration {d

therapy

should

iypicafiy

b€

7-1 Q

days

and

guid€d

by

clinical

response-

(E)

1

"4'ilsrviyrrr€

1

S

6Jt-+iat

*eur1:r ei91

I

i__- _4ii lib

L{F,[F'?

p[__

_ _,r

,

Some

experts prefer combination therapy

for

patients

with

Pseudomorlas infections,

(

E

)

"

Most experts would use

combination therapy for

neutropenic

patients

with

severe sepsis or 5eptic

shock. For

neutropenic

patients,

broad-spectrum

therapy usually

must

be continued for

the

duration

of the neutropenia.

Grade of

R€commendationr

(

E

)

"

If

the

presenting

clinical syndrome

is

determined

to be

due

to a noninfectious

cause, antimicrobial therapy

should be

stopped

promptly

to minimize the development

of resistant

pathoEens

and superinfection

with other

paihogenlc

organisms.

(

E

)

'

:i

.r

s.5psj*

S+rr;r*u'yr

r

SEP5IS MANAGEMENT

."

M].t'M

fhe

ooal

6

to

F{orr

al

,ndhted

tasis

fffor€

to ac@mplish lhese

goal6

should

b$rn

100rh

ot

rhe

r4e

dhin ihe

i.sr

6

n

of FTedr#rt.

biltfhese

ftems may be

conpieted

identification of

severe

gepsj9.

wiihin

:it

h

oi

prsanbtbn

for

palients

wfth severe

sepsis

ot s6ptic

ahock

M6SUre

$rum lac€te

Obbin hlmd c ltures

befo.e

antibidic

admin&{sn

Admrnisier

b16d-spedrum

antibroth

y?fr

hh

3 h d ED edmission end

wfrin

t h

of

dGntifrcation of 6epsis

on

the

hospltal fler

ln the

Mnt

of hypotens'on and/or

a serum

lachb

'4

mmol/L

Deltuer an

inthi

minimum

ol

20

hllko

cryslilloid

or

equvalen'l

Apply

€gopressors

ior

hyFtenston

not

respoh0rngto

initral

fluo

Resuscitatr

lo

maintain

MAP

>65

mmhg

ln

the event

oi

pe sEtent

hypotenglon

desprF

Adoquate

fluld

resuscitation

{septlc

ahock)

And/or

lachte

>4

mmolll

AchieveaCVPSmmhg

Achieve

an scvot

70% oasvoi 6i%

funm

ster

ltu-oosage

steroids

{or

gepr,c

sn@k ln

eodane*t\

a

shndardired CU

Fhc .

J

mt

adrnrnse.eo

then aocumeni

wly

the

pat,ent

dd

ndquallfy

for

l@-dosage

steroids besed oa

the

standa.dized

protocol

Administsr

rhapc-xigns

in rccordance

with

r

stanoamized'CU

polrcV,

f not

adnrnJftred,

then

documentwhy the

patient

did notqualfyfor ftapc

lvain?ain a median

lFp

30

cmhp fol

mechanically

ventiiated

patients

r

.::;":,:;,s{rrvryrns

'l

-/

: erl*i$

f*:-.rFai:ilrr

S€PSIS MANAG€MEN1:,

R6uicihtirn .nd Inl€dion

Esuacibtlon

(fid

6h6)

Cherk

4rum lr.tab

to aid in rEsus.ilalion

qoals

.

&din resu*lbtidn

'nrmdiarelv

rn DG { tr

h-,yDotension or elevated lact;c:

ilo

not

d6lay

psndrns

ICU adm,s5ron

(1C)

. cesuscibbon

s€ls

(1C)

a) flP

8-12,

b)

MAP

i 65mmHo: c) urine olbut :

0.5m

/kq/,hr

,

teln

cuitures

before

aillibiahcs

{1C)

a)

So

or more

rcs;

b)

one

or morc

should b€

Frcutaneous;

c) one

8C kom

6ach vascular

a..ess

device io

Dl..e >

4Ahrc;

dl .ulture

orh€r

siFs

as

cInicarly

lmadind *udier D.omorlv b coilfirm and

simulew sirce cit iifxtion

,f

sare b

ntibiod.

Thenpy

Beqln

orodd

sgedrum

IV abx w/rhrn the

fiEt

hour

oi

recoqnhinq

severc sepsrs

(1D)

and seDtic shock

{1Cl

L-€i f G?e

Ed@qt

q'

m-, .:l

.

Sourc€ idahtilEatior rdd aonkol

r

Esteblish

anltomjc

siie of infuction

ilC)

.

Implement

sou€e

control measures

(1C)

. R€move

inlEvasc0iar

a.ae5s

davices iF

potentially

inf€cted

ilC)

heeodvnamJc

Suppct trd Adiundive

FluidThcrepy

.

Fluid

aerusciule rsinc

crys6ilo,d5

o.

colloros

(18)

.'larsercVPre(lC)

.

Grve flu,o

challenag o'1L

crysbllords o 300.

500m1

of

collords over l0

rirns

(l

D)

.

Majnbin

UAP

>

85mmHg

.

NoreDineDhnf,e Bnd

domnrne

are the

'nitlal

aioDrisrs

or chorce

{

1C)

Va$Drsrn

0.03 uf,lts/mrfi

ma

be

sutiseqiently

aod€d {ir

andiipat,o.

of

al

effecL equ,valent to noreprnephflne alone

(2C)

.

b

not use low-dose dopamrne

for

renai

.

In

D6

,€dunrno insd

arteral

caherei

(1Dl

.

Rsssess abr dail/

to opllm,?e

effrc.c ,

Drevedt

rerbirce, avod to1i.itv,

Bnd

m rimiz€

cos6

{lc}

.

Consder

ombinabon

dreraev in

tueudomr$ rnfebors

(2b)

r Gmbination

thEraDv

31"5

dAVs and d€

lnotropic

tfi+rrpy

.

U5e dobuhmrne in

pE

wth

mytradr3l

dysluncuon

in

pts

wiffi

low CO

{1C)

. Do not

in.rsse radlac

index to

4


5/8

Consroer

lv hydrocodsone

when

hvmbnsron

r€soonds Doorlv b flurd resuEcrtatlon and

vasopressbE

{lc)

,r

acTH stimulation

test

not

reommerded

(28)

hvorocodsone

D,eled€d b apxamethd50ne

128)

.

nrorocorlrr.ne do €

shodld

be

sl00

mq/day

{1a)

Rssmbinlrt

humin

6b Bd

p@ir

C

CoilsrderhAPc

In

pb

wldl

sFsr5-induced

oroan d/sfLncUon

*;Ur

cll&caJ

as*ssqenr

oflrdh isk

o

d€ad

f thera aru no

(ont;arndrcat,ons

(28,

2C

for

pstop€ralive

Ftiens

Oth6r SuFpoftka

TherrFy

glood

Produclg

.

6rve RBCa whe4 Ho < 7 ro

Hroet

Ho

ci

7 0-

I

0

{18).

A

hrqhelr Hr

may b€

req-uired in

5p*Ltsl.rrcumstincs

(€.9

myGadial

lschem)a,

*vere

tryFxefrra,

{cure

h€morhdg€,

q4nohc

head

disa*,

or

Lo noi

uF

e.ythropolebn

to

treat *psrs.

r€iaEd anemia, lt

mat

be u*d

for

dh€r

acc€pEd Easo4s

(16)

F

not

Jse

f+ b

corr€(t

laboratory

ilottug

ahn6rmalt,ec unlF

r2@;tr

t,.,

i.00i

/Lror*i :

riri

in'r.u,€ bNe

lrirft

C{eicrya

p,a(€ i

>

I

50:bove ihc,o,,iil

viile

PbrnF

r,o.iJrtroni.

>

2 SD

ibcve ftc roil.il litic

s'{ok ul*i

p,.${€

<

c0

n\.i H€o.

*in

1

rura

br@d

pr.n,'.e

tsi:.d

ve.orr

axtEan

3r.rEr6n

>

704

Cndri( iter

>

3.5 L,rnin H

1r

O4r,

dtsfunaz{ 4.dier

Ur&. qu

<

0.5

sL:kB' irrcr r

t

'nrol

HrFe.hdilqn,a

>

I mfto/L

ha

B

od

v,

am

Ic

cI

stqbe

@,

w8

alyslbrtlgh or t/66w

I

Ert6io, alromslltr*

Research article

serum

procalcitonin

elEvation in

critielly ill

Fati€nts

at the

onset

of

bacteromiacausd

by

elihrr

gram

negative or

gram

positive

bact€rla

Conclusion: In a critically ill

patient

with clinical

sepsis, GN bacteremia could be associated

with

higher

PCT

values

than those found

in

GP

bacteremia, regardless of the severity of

the

disease.

i

Sepsisi

t

.

Vasodilatation

.

Distributive

shock

ri

.,

1

N

Enql

Jil6d

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The localizing symptom$

referable to organ

systems may

provide

useful clues to the etiology of

sepsis and are as

follows:

'

Head

and neck infections

-

Ear*che,

sor€ throat, sinus

pain,

or swollen lymph

glands

.

Chest

and

pulmonary

infectlons

-

Cough

(especially

if

productive), pleurltlc

chest

pain,

and dyspnea

r Abdominal and cI infectlons

-

Abdominal

pain.

nausea,

vomiting, and

diarrh€a

. Pelvlc and oenitourinarv lnf€ctiong

-

Pelvic or flank Dain.

vaginal or

irethral

discharge, and urlnary frequency and

urgency

.

Bone

and soft tlssue lnfections

-

Localized

llmb

paln or

tenderness,

focal

erythema,

edema, and

swollenJoint

Empirical antimicrobial therapy

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8/8

3/U2AL2

I

lnie€lloft

lDocumer*ed

q

gu*peeied)

and Some o{ lhe

Follwlng

TABLE 1.

I

c*;rr"t

"*irfi;-

DTAGNOATIC CRITERIA

FOn SEPSTS

ACCORDING

10

THE

$EPSIS

D€FIHIlIONS

CONFgnErilcE

F*i.or

hyFthcmi.

:1.jw*9-

Ahred mnbl ftk

Uowl'ined

hypqrylycfrlr

Iilllfrmlsry

Y.drblsr

L.ukocyt6li

or

l,.ukop€ni.

IocE *d cRP

(>

2 5D

abovc

nomtl)

r1"r1 :;K .i+.ry1,.trryl

_ __-:

I

?irioe

parf .i6n

v.rfubld

lf'.:r r,ry{ t:ll.-g:nr-.

--

---

,--

i

Dlar€ra€d

6Fittary

rcfill o, rkiD mottling

I

oEah

dY6t{ndion

vorlabl€3

Unoxphin.d

hypdffilr

Ac&

ollgurla

Grglldtoo .bnomaliiis

Ileo,

Hyrrbilitobincmit

Silt*flr

EFKS

TABLE2.

THE PIRO

CONCEPT

I

Clinical

I

OtherTests

dtdi";o-fir)

'fis".atJor,orurrr"",

"t",ocoi-_-fffi*r"e";*it"*s

i:':::::::::"::::::1,

_

i:.:i*

iintectaon)

i Site-spsific

ie.g.,

pneumonia,

j

X-rays,

Ci

scan,

__ gll S Irs)

1cte o,oel

_ ,

R

rresoorse)

I

Malaise

temmmrure

heart

rale.

,

WBc cRP

pcl

modrfied

respimtoryrate

iAPTT

{oroan

dysfunction}

I

Artedal

pressur€,

urine output,

I

Paor/F,",

creatinine,

Giasgow coma score

]

Dilirubrn.

plaielets

8

Documents

02. Sepsis - Prof. Suharto [OBGYN]