1

Name : Lie Khie Chen

Birth : Jakarta

Graduates

MD : FKUI 1994

Internist : FKUI 2003

Consultant : FKUI 2006

Occupation

Internal Medicine Department

Tropical Medicine and Infectious Diseases Division

Interest

Sepsis

Antimicrobial Treatment

Antimicrobial Resistance

Fungal Infection

HIV and opportunistic infections

Curriculum Vitae

Diagnostic and Risk

Stratification in Severe Sepsis

Khie Chen

Tropical Medicine and Infectious Disease Division

Internal Medicine Department

Medical Faculty University of Indonesia

Sepsis

Clinical syndrome

Host response to infection

Systemic process

Multi organ system affected

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The Sepsis Cascade Bacterial Product

And Component

TNF –a

IL-1

IL-6

PAF

NO

etc

Activation of Coagulation

And Complement

System

Tissue Factor Release

Fibrinolytic acitvity

T cell Release

Of IL-2

IFN gamma

GM-CSF

Metabolism of

Arachidonic Acid

Release of

Tromboxane A2

PGS, LTS

Neutrophyl

Activation

Agregation

Degranulation

Release of O2

Radical and

Proteases

Platelet

Activation

Aggregation

Endothelial Damage

Tissue Injury

Organ Dysfunction

Macrophage

Source : Medscape.com

Hemodynamic disturbance in Sepsis

1. Hypovolemic

2. Peripheral vasodilatation

3. Myocardial dysfunction

4. Maldistribution of blood volume

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Systemic Inflammatory Response Syndrome (SIRS)

Host response to Inflammation include 2 of:

1. Temp >38oC or <36oC 2. Heart rate >90x/’ 3. Respiratory rate >20x/’ or PaCO2<32mmHg 4. White blood cells count >12.000/mm3, < 4.000 or bands >10%

Bone et al. Chest 1992;101:1644

SIRS and host response

Vincent JL. Sepsis : The magnitude of the problem. In : Vincent

JL, Carlet J, Opal S (eds). The sepsis text. Boston: Kluwer

Academic Publishers; 2002. p. 1-9.

Host Response in Sepsis

Compensated state :

Tachycardia

Tachypnea

Fever

Leucocytosis

Thrombocytosis,

Hyperglycemia

Increased acute phase

reactant

(CRP, procalcitonin,

LDH and albumin)

Decompensated state (Multiple organ dysfunction or failure) :

Decreased of consciousness, Hypothermia

Hypotension

Shock

Decreased PaO2

Increased serum creatinine, Oliguria

Anemia, leucopenia, thrombocytopenia and Coagulopathy.

Pohan HT, Med J Indones

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ACCP/SCCM Consensus Conference Definitions ofSepsis, Severe Sepsis and Septic Shock

• Systemic Inflammatory Response Syndrome (SIRS)• Sepsis

• Severe Sepsis• Septic Shock• Multiple Organ Dysfunction Syndrome (MODS)

Bone RC, et al : American College of Chest Physician/ Society of Critical Care MedicineConsensus Conference: Definitions for Sepsis. 1992

Definition of Severe Sepsis &

Septic Shock

SEVERE

SEPSIS

SEPSIS

SIGNS OF SEPSIS

RELATED ORGAN

DYSFUNCTION

SUCH AS :

• Altered lung function

(hypoxemia)

• Altered renal function (increased

creatinine conc.)

• Altered coagulation (low

platelets, DIC)

• Altered liver function

(hypoalbominemia)

• Altered mental status

• Altered hemodynamic status

SEPTIC SHOCK

Pyramid of Sepsis Demonstrating Increased

Mortality with Increasing Severity of Sepsis

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Definisi Sepsis

SCCM/ESICM/ACCP/ATS/SIS 2001

Infeksi : terdokumentasi atau suspek

Parameter umum: Suhu (temperatur rectal/core >38,3oC)

Hipotermia (temperatur rektal/core <36oC)

Frekuensi jantung >90x/menit atau

>2SD diatas nilai normal menurut umur

Takipnu >30x/menit

Perubahan status mental/kesadaran

Edema atau balan cairan positif (>20ml/kg/24jam)

Hiperglikemia (glukosa plasma>110 mg/dl) tanpa diabetes

Parameter inflamasi: Lekositosis (Lekosit>12.000/ul)

Lekopenia (Lekosit<4.000/ul)

Lekosit normal dengan lekosit imatur/batang>10%

Peningkatan CRP > 2SD nilai normal

Peningkatan PCT > 2SD nilai normal

Parameter hemodinamik: Hipotensi arterial

(tekanan sistolik <90 mmHg, MAP<70

atau tekanan sistolik turun >40mmHg pada dewasa)

Saturasi vena oksigen campuran (SmcvO2) >70%

Indeks kardiak >3.5 l/menit/m2

Levy MM, Fink MF, Marshall JC, et al. 2001

SCCM/ESICM/ACCP/ATS/SIS international sepsis definition confrences. Intensive Care Med 2003; 29: 530-8.

Parameter disfungsi organ: Hipoksemia arterial (PaO2/FiO2 <300)

Oliguria akut (produksi urin <0.5 ml/kg/jam)

Peningkatan kreatinin >0.5 mg/dl

Abnormalitas koagulasi (INR>0,5 atau APTT>60 detik)

Masa tromboplastin > 60 detik

Ileus

Trombositopenia (trombosit<100.000/ul)

Hiperbilirubin (bilirubin total>4 mg/dl)

Hiperlakatemia (>3mmol/L)

Penurunan pengisian kapiler

Levy MM, Fink MF, Marshall JC, et al. 2001

SCCM/ESICM/ACCP/ATS/SIS international sepsis definition confrences. Intensive Care Med 2003; 29: 530-8.

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Laboratory Diagnosis in sepsis

Endotoxin

Microbiological identification

Biomarkers

Immune monitoring

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PCT increase reflects the continuous development from healthy

condition to the most severe state of disease ( severe sepsis

and septic shock

Brahms.PCT literature.internal document.2005

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Sepsis Severity The Sequential Organ Failure (SOFA) Score

SOFA SCORE 0 1 2 3 4

R E S P I R A T I O N

PaO2/FiO2, mmHg >400 ≤400 ≤300 ≤200 ≤100

C O A G U L A T I O N

Platelets x 103/mm3 > 150 ≤ 150 ≤ 100 ≤ 50 ≤ 20

L I V E R

Bilirubin, mg/dL (μmol/L) < 1.2

(< 20)

1.2-1.9

(20-32)

2.0-5.9

(33-101)

6.0-11.9

(102-204)

> 12.0

(>204)

C A R D I O V A S C U L A R

Hypotension No

hypotension

MAP<70 Dopamine ≤ 5

or dobutamine

(any dose)*

Dopamine >5 or

epinephrine ≤0.1 or

norepinephrine ≤0.1*

Dopamine >15 or

epinephrine >0.1 or

norepinephrine >0.1*

C E N T R A L N E R V O U S S Y S T E M

Glasgow coma scale 15 13-14 10-12 6-9 <6

R E N A L

Creatinine, mg/dL

(μmol/L) or urine output

< 1.2

(<110)

1.2-1.9

(110-170)

2.0-3.4

(171-299)

3.5-4.9

(300-400) or < 500 mL/d

> 5.0

(>440) or < 200ml/d

------------- With respiratory support -------------

Importance of early detection sign of

sepsis progresion

Prevent progressing to severe condition

Optimizing antimicrobial and supprotive

treatment

Reduce morbidity and mortality

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SEPSIS

Mortality 20-30%

SEPSIS BERAT

Mortality 50-80%

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Kasus

Pasien 65 tahun datang ke IGD

dengan sesak nafas, Riwayat Ca

cervix post radioterapi. kompos

mentis. TD 100/70 N 120x/mt S

38,5oC Nafas 28x/menit; ronki

basah di kedua lapangan paru.

Thorak foto tampak infiltrat

Hb 10,8 L 27.000 Tr. 400.00

Ur 77 Cr 1.1 GDs 177

AGD :

7,48/32/137/21.6/98.8/-3.3

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Kasus

Masalah : Pneumonia (HCAP)dg

sepsis

Pasien mendapat terapi :

-Cefepime

-O2 4 L/menit

-IVFD RL/8jam

- Pada perawatan hari berikutnya : kesadaran apatis

Produksi urin 100 cc/6 jam

Laktat 5.6