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TATALAKSANA SEPSIS
DAHULU
SEPSIS
EPIDEMIOLOGI
ETIOLOGI
DEFINISI
MANIFESTASI KLINIK
PATOGENESIS
DIAGNOSIS
PENATALAKSANAAN
EPIDEMIOLOGI
EPIDEMIOLOGI
Angus DC. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs
of care. Crit Care Med. 2001.
Munford RS. Severe sepsis and septic shock. Harrisons principal of internal medicine. Edisi ke-18. 2012.
SEPSIS
EPIDEMIOLOGI
ETIOLOGI
DEFINISI
MANIFESTASI KLINIK
PATOGENESIS
DIAGNOSIS
PENATALAKSANAAN
Mortality
Sepsis
400,000
7-17%
Severe Sepsis
300,000
Septic
Approximately 200,000
patients including 70,000 Shock
Medicare patients have
septic shock annually
Balk, R.A. Crit Care Clin 2000;337:52
20-53%
53-63%
SEVERE SEPSIS:
COMPARATIVE INCIDENCE AND MORTALITY
Mortality
Deaths/Year
Cases/100,000
Incidence
40%
With Co-morbidity
Overall
35%
Mortality
30%
25%
20%
15%
10%
5%
0%
0
10
15
20
25
30
35
40
45
50
55
60
Age
Angus DC, et al. Crit Care Med 2001.
65
70
75
80
85
EPIDEMIOLOGI
ETIOLOGI
DEFINISI
MANIFESTASI KLINIK
PATOGENESIS
DIAGNOSIS
PENATALAKSANAAN
PATHOGEN DISTRIBUTION
Fungi
Grampositives
Gramnegatives
Microbiology of Sepsis
EPIDEMIOLOGI
ETIOLOGI
DEFINISI
MANIFESTASI KLINIK
PATOGENESIS
DIAGNOSIS
PENATALAKSANAAN
Sepsis
Severe Sepsis
Septic shock
SIRS
DEFINITIONS
Sepsis
Systemic inflammatory response to known or suspected infection
Severe Sepsis
SIRS associated with organ dysfunction (failure), hypoperfusion, and perfusion abnormalities
DEFINISI (LANJUTAN)
Munford RS. Severe sepsis and septic shock. Harrisons principal of internal medicine. Edisi ke-18. 2012.
DEFINITIONS CONTINUED
Septic shock
A subset of severe sepsis, where patients experience combined
decreased systemic vascular resistance and the presence of
reduced myocardial performance
SIRS
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
Sepsis
Severe
Sepsis
Sepsis: Defining a
Disease Continuum
Infection/
Trauma
SIRS
Sepsis
Severe
Sepsis
Sepsis with 1 sign of organ
failure
Cardiovascular (refractory
hypotension)
Renal
Respiratory
Hepatic
Hematologic
CNS
Metabolic acidosis
Shock
PANCREATITIS
SEVERE
SEPSIS
INFECTION
SEPTIC
SHOCK
SIRS
BURNS
TRAUMA
OTHER
Bone et al. Chest 1992;101:1644
EPIDEMIOLOGI
ETIOLOGI
DEFINISI
MANIFESTASI KLINIK
PATOGENESIS
DIAGNOSIS
PENATALAKSANAAN
Pulmonary: 50%
Abdomen/Pelvis: ~25%
Urosepsis: 10%
Skin: 5%
Vascular: 5%
Other: ~15%
MANIFESTASI KLINIK
Vital Sign
Fever, Chills/Rigors, Hypotermia
Tachycardia
Tachypnea
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
MANIFESTASI KLINIK
Gejala klinik non spesifik demam, menggigil.1
Gejala konstitutif lelah, malaise, gelisah,
kebingungan.1
Gejala-gejala sepsis lebih berat penderita usia lanjut,
diabetes, kanker, gagal organ utama, dan pasien
dengan granulositopenia.1
1.
Hermawan AG. Sepsis. Buku ajar ilmu penyakit dalam. Jilid III. Edisi ke-5.2009.
1.
2.
Munford RS. Severe sepsis and septic shock. Harrisons principal of internal medicine. Edisi ke-18. 2012.
Pohan HT. Diagnosis dan penatalaksanaan sepsis. Bunga rampai penyakit infeksi .2004.
1.
Munford RS. Severe sepsis and septic shock. Harrisons principal of internal medicine. Edisi ke-18. 2012.
1.
Hermawan AG. Sepsis. Buku ajar ilmu penyakit dalam. Jilid III. Edisi ke-5.2009.
KOMPLIKASI
Sepsis berat dan renjatan sepsis gangguan atau
komplikasi pada berbagai sistem organ.
, compliance paru
1.
2.
KOMPLIKASI (LANJUTAN)
EPIDEMIOLOGI
ETIOLOGI
DEFINISI
MANIFESTASI KLINIK
PATOGENESIS
DIAGNOSIS
PENATALAKSANAAN
Coagulation
Activation
Oxidases
Kinins
Complement
Cytokines
TNF, IL-1, IL-6
Coagulopathy/DIC
Vascular/Organ System Injury
mage
a
d
l
a
i
l
e
h
Endot
Endothelial d
amage
Multi-Organ Failure
Death
Fever
Hypotension
BIOLOGIC
EFFECTS OF PROINFLAMMATORY
Acute phase protein response
CYTOKINES
SUCH AS TNF AND IL-1
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
PENATALAKSANAAN
DIAGNOSIS
SEVERE SEPSIS:
INITIAL RESUSCITATION (1ST 6 HOURS)
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%
HATUR NUHUN