Early Detection Pada Pasien
SEPSIS
Philip Purworahyono, [Link]
Incidence- 10th Leading Cause of Death
ADULTS
571,000/year in the US
Mortality
Severe Sepsis: 15-30%
Septic Shock: 20-60%
PEDIATRICS
40,000/year in the US
Mortality
Severe Sepsis: 4-7%
Septic Shock: 13-34%
Wang et. Al 2007, Critical Care Medicine, Noah, 2014 Clinical Pediatric
Emergency Medicine
Rp. 325 Jt Rp. 550 jt
PETER JD: NEMJ,343,2000
ARTHUR PW; NEMJ, 340, 1999
SEPSIS 3
Sepsis: Defining a Disease Continuum
Infection/
Trauma SIRS Sepsis Severe Sepsis
A clinical response arising SIRS with a
from a nonspecific insult, including presumed or
2 of the following:
confirmed
Temperature 38oC or 36oC
infectious process
HR 90 beats/min
Respirations 20/min 1992
WBC count 12,000/mm3 or
4,000/mm3 or >10% immature
SIRS = systemic inflammatory response syndrome.
neutrophils
Bone et al. Chest. 1992;101:1644.
Sepsis: Defining a Disease Continuum
Infection/
Trauma SIRS Sepsis Severe Sepsis
Sepsis with 1 sign of organ
failure
Cardiovascular (refractory
hypotension)
Renal
Shock Respiratory
Hepatic
1992 Hematologic
CNS
Unexplained metabolic
acidosis
Bone et al. Chest. 1992;101:1644; Wheeler and Bernard. N Engl J Med. 1999;340:207.
1992
Parasite
Virus
Severe
Infection Sepsis SIRS
Sepsis
Fungus
shock Severe
SIRS Trauma
Bacteria
BSI
Burns
Adapted from SCCM ACCP Consensus Guidelines
Diagnostic criteria for sepsis
General variables
Fever (> 38.3C) Organ dysfunction variables
Hypothermia (core temperature < 36C) Arterial hypoxaemia (PaO2/FiO2 < 300)
Heart rate > 90/min1 or more than two SD above the normal Acute oliguria (urine output < 0.5 mL/kg/hr for at least
value for age
2 hrs despite adequate fluid resuscitation)
Tachypnoea
Altered mental status Creatinine increase > 0.5mg/dL or 44.2 mol/L
Significant oedema or positive fluid balance (> 20 mL/kg over Coagulation abnormalities (INR > 1.5 or aPTT > 60s)
24 hr)
Hyperglycemia (plasma glucose > 7.7 mmol/L) in the absence Ileus (absent bowel sounds)
of diabetes
Thrombocytopenia (platelet count < 100,000 L1)
Inflammatory variables Hyperbilirubinaemia (plasma total bilirubin > 4mg/dL or
70 mol/L)
Leucocytosis (WBC count > 12,000 L1)
Leucopenia (WBC count < 4000 L1)
Normal WBC count with greater than 10% immature forms Tissue perfusion variables
Plasma C-reactive protein more than two SD above the normal
value Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Haemodynamic variables
Arterial hypotension (SBP < 90mm Hg, MAP < 70 mmHg, or an WCC
SBP decrease > 40 mmHg in adults or less than two SD below
normal for age)
Surviving Sepsis Campaign - International Guidelines for Management of Severe Sepsis and Septic Shock. Crit Care Med 2013; 41(2):
21
580-637.
Septic shock
Septic shock is defined as sepsis-induced tissue hypoperfusion
persisting after resuscitation with 30mls/kg intravenous isotonic
crystalloid fluid as evidenced by:
Systolic blood pressure < 90 mmHg or MAP < 65 mmHg
Decrease in systolic blood pressure by 40mmHg from baseline
and/or
Lactate > 4 mmol/l.
Surviving Sepsis Campaign - International Guidelines for Management of Severe Sepsis and Septic Shock. Crit Care Med 2013; 41(2):
22
580-637.
2016
THE DEFINITION OF SEPSIS
Life Threatening ORGAN DYSFUNCTION
caused by a DYSREGULATED HOST
RESPONSE to infection
Life Threatening ORGAN DYSFUNCTION
caused by a DYSREGULATED HOST
RESPONSE to infection
SOFA score :
Sequential
Organ
atau
Failure
Assesmen
Digunakan untuk pasien Non ICU
INFEKSI ( Suspect ) + 2 atau lebih dari kriteria mengalami organ dysfunction dan
diduga SEPSIS ------- Harus ditranfer ke ruang intensif
Tidak diperlukan pemeriksaan laboratorium
JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
European Society of Intensive Care Medicine Annual Congress in September 2014.
Sepsis Management National Clinical Guideline No. 6, 2014
Copyright 2016 American Medical
Date of download: 5/9/2016
Association. All rights reserved.
SOFA Score
Direkomendasikan untuk pasien yang dirawat di
ICU
Peningkatan SCORE 2 (dua) atau lebih ..
Diindikasikan adanya kecurigaan infeksi dan
gagal organ
SEPTIC SHOCK
Septic shock is a severe type of sepsis wherein
circulatory and cellular metabolism abnormalities are
extreme and substantially increase the risk of death
In-hospital mortality is >40%.
SEPTIC SHOCK
MAP <65 dengan
SEPSIS penggunaan Vasopressor
Lactat serum > 2mmol/L
Tidak ada tanda
HIPOVOLEMI
Monitor kondisi klinis
Pasien SEPSIS masih reevaluasi untuk
diduga No No
dinilai ulang bila ada
INFEKSI qSOFA 2 diduga
indikasi
Yes
Yes
Assesment
adanya kejadian
disfungsi ORGAN
qSOFA :
Pernafasan >22 x/menit
Yes Kesadaran Menurun
Tekanan Darah Sistolik < 100
mmHg
Monitor kondisi klinis
SOFA 2 No reevaluasi untuk
dinilai ulang bila ada
indikasi
Yes
SEPSIS
MAP < 65 dengan penggunaan
Vasopresor SOFA Variable :
PaO2/FiO2 Ratio
Level serum Lactat > 2 mmol/L GCS
MAP
( Tidak ada hipovolemia) Penggunaan
vasopresor (jenis dan
Yes dosisnya)
Serum creatinin dan
urine output
Billirubin
SEPTIC SHOCK Trombosit
SUMMARY
SIRS Masih digunakan untuk GIUDE klinisi dalam
mendeteksi adanya infeksi. Tapi severe sepsis
tidak digunakan dalam klasifikasi baru (SEPSIS 3)
qSOFA direkomendasikan untuk mendeteksi
secara dini adanya Sepsis
Hipotensi dan level LACTAT menjadi poin penting
dalam kriteria Shock Septic yang baru
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