SEPSIS

Kelompok PGD/ERIA
21-25 Maret 2016

KASUS
Anak perempuan berumur 8 bulan, dirujuk dari RS IBNU SINA dengan
ensefalopati dengue + status epileptikus. Keluhan utama penurunan
kesadaran diperhatikan sejak 5 jam setelah anak kejang. Tidak
kejang, ada riwayat kejang, frek 4x, bersifat umum, durasi 20 menit.
Setelah kejang anak tdak sadar. Ada demam dialami sejak 4 hari
sebelum masuk RS. Terus-menerus, tidak batuk, ada sesak. Tidak
muntah, ada riwayat muntah 1x di rumah, tidak menyemprot isi sisa
susu dan lendir, ada residu NGT warna coklat kehijauan 10 cc.
BAB : belum
BAK : lancar, kuning
Riwayat penderita DBD di sekitar rumah ada
Riwayat perdarahan di mata, hidung, telinga, dan gusi tidak ada
Riwayat BAB kehitaman ada.
LAB: WBC = 27000
Neu = 79,2
monosit = 11,9

ASSESMENT
SEPSIS
ACUTE RESPIRATORY SYNDROME
HIPOALBUMINEMIA
PERDARAHAN SAL. CERNA

TATALAKSANA
JAMIN OKSIGENASI ventilator mekanik FiO2 = 100% ;
Pinps = 22 cmH2O; Pesp = 7 cmH2O; RR = 50x/menit
fentanyl 2mcg/kgBB/jam
midazolam 2mcg/kgBB/menit
JAMIN HIDRASI infus ASERING / Destrose 50% 20
ml/jam
ATASI DEMAM Paracetamol 90 mg/8 jam/inhalasi
ATASI INFEKSI Flukonazole 110 mg/12 jam/ I.V
Cefotaxime 450 mg/12 jam/ I.V
Cefoperazone sulbactam 450 mg/12 jam / I.V
ATASI PERDARAHAN Ranitidine 9 mg/ 12 jam/ I.V
ATASI HIPOALBUMINEMIA Hip Albumin 1 caps/12
jam/ogt
CEGAH SYOK BERULANG Dobutamin 5 mg/kgBB/menit

Definisi

Sepsis adalah respon sistemik terhadap

infeksi atau disebut sindrom respon radang
sistemik (Systemic Inflammatory Response
Syndrome/SIRS).

Diagnosis
Minimal 2 dari 4 kriteria, dimana salah
satunya harus kriteria suhu yang abnormal
atau jumlah leukosit.
1.
2.
3.
4.

Suhu yang abnormal (>38Catau <36C)

Takikardi
Takipneu
Leukositosis/leukopeni

Etiologi
1. Bakteri gram negatif
Staphylococcus, Pneumococus,
Streptococcus
2. Bakteri gram positif
3. Virus
virus dengue, virus herpes
4. Jamur
5. Protozoa
Falciparum malariae

PATOGENESIS SEPSIS

Sepsis Berat
Merupakan sepsis yang disertai disfungsi
organ kardiovaskular atau sindrom distres
pernapasan akut atau 2 disfungsi organ.

Syok Sepsis

Syok pada bayi dan anak dapat menyebabkan

syok sepsis melalui pelepasan endoktoksin
yang dapat memicu aktivitas cascade
pelepasan za-zat mediator lainnya dengan
efek terganggunya sistem hemodinamik

Kriteria Syok Sepsis:

Kesadaran menurun
Hipotensi, sistolik <70 mmHg pada infant,
<70 + 2 x umur pada anak usia diatas 1
tahun.
Hipoperfusi (akral dingin, CRT >3 detik,
pulsasi lemah pada dorsal pedis)
Low urine output

1. Stadium hiperdinamik (warm shock)

2. Stadium hipodinamik/dekompensasi (cold
shock)

Tata
laks
ana
Sep
sis

Tata
laks
ana
Sep
sis

TERIMA KASIH

Tatalaksana Sepsis
1. Assess ABCs (0-5 min)
Provide 100% oxygen at high flow rate (15L)
Early intubation may be necessary in
neonates and infants
Breathing assistance as necessary,
including mechanical ventilation

2.Establish IV access and place on monitor

(0-5min)
2 large-bore peripheral IVs (PIVs) preferred: if
difficult IV, place IO access per PALS
guidelines; 1 PIV may be sufficient unless
vasoactive drugs needed (see Step No. 6,
below)
Consider labs on IV placement: blood gas,
lactate, glucose, ionized calcium, CBC,
cultures (glucose check through finger stick
preferred for rapid result)

3.Fluid and electrolyte resuscitation (5-15min)

Fluids:
Push 20 mL/kg fluid (isotonic crystalloid) IV/IO over
5-20min or faster if needed (reassess for signs of
shock; see Step No. 11, below)
Repeat 20 mL/kg bolus push of fluid (up to 60
mL/kg) until clinical symptoms improve or patient
develops respiratory distress/rales/ hepatomegaly
May continue to require additional fluid above 60
mL/kg (fluid refractory) (see Step No. 6, below)
Fluid needs may approach 200 mL/kg in warm
septic shock (warm extremities, flash capillary refill)

Correct hypoglycemia:
Glucose levels in hypoglycemia: Neonates < 45
mg/dL; infants/children < 60 mg/dL
Glucose dosage: 0.5-1 g/kg IV/IO (max that can be
administered through a peripheral vein is 25%
dextrose in water) (see alternative treatments
immediately below)
Treatment options to provide 0.5-1 g/kg glucose:
For infant/child: dextrose 25% in water: 2-4 mL/kg
IV/IO; dextrose 10% in water: 5-10 mL/kg IV/IO; for
neonate: dextrose 10% in water: 2-4 mL IV/IO;
consider maintenance fluid containing dextrose

Correct hypocalcemia for low ionized calcium:

Calcium gluconate 100 mg/kg IV/IO (max
2g) PRN
Calcium chloride 20 mg/kg IV/IO PRN ( Note:
central line administration preferred over
60min in nonarrest situation)

4.Infection control (5-60min)

Immediate considerations:
Administer antibiotics immediately after cultures
obtained (blood, urine, +/- CSF/ sputum)
Do not delay antibiotics because of delay in obtaining
cultures; initial antibiotics should be given within 1h
General treatment recommendations:
Empiric therapy should be used for unknown etiology of
sepsis;
Tailoring of therapy to address suspected pathogens or
to achieve adequate drug penetration may be necessary;
Broader initial coverage may be needed for initial
stabilization
Dosing varies by age and weight (see specific
recommendations and dosages immediately below)

5.Fluid-refractory shock (persisting after 60 mL/kg fluid) (1560 min)

Continue fluid resuscitation and initiate vasopressor therapy titrated
to correct hypotension/poor perfusion
Central line placement and arterial monitoring if not already
established; vasopressors should not be delayed for line placements
Normotensive shock (impaired perfusion but normal blood
pressure): Dopamine 2-20 mcg/kg/min IV/IO, titrate to desired
effect; if continued poor perfusion, consider dobutamine infusion 220 mcg/kg/min IV/IO, titrate to desired effect (may cause
hypotension, tachycardia)
Warm shock (warm extremities, flash capillary refill): Norepinephrine
0.1-2 mcg/kg/min IV/IO infusion, titrate to desired effect
Cold shock (cool extremities, delayed capillary refill): Epinephrine
0.1-1 mcg/kg/min IV/IO infusion, titrate to desired effect

6. Shock persists following vasopressor initiation (60 min)

Continued fluid replacement; obtain CVP measurement to guide
SvO2 < 70% (cold shock): Transfuse Hgb >10 g/dL; optimize
arterial saturation through oxygen therapy, ventilation;
epinephrine 0.1-1 mcg/kg/min IV/IO infusion, titrate to desired
effect
SvO2 < 70% (normal BP but impaired perfusion): Transfuse Hgb
>10 g/dL; optimize arterial saturation through oxygen therapy,
ventilation; consider addition of milrinone 0.25-0.75 mcg/kg/min
IV/IO (titrate to desired effect) or nitroprusside 0.3-5
mcg/kg/min IV/IO (titrate to desired effect)
SvO2 >70% (warm shock): Norepinephrine 0.1-2 mcg/kg/min
IV/IO infusion, titrate to desired effect; consider vasopressin 0.22 mU/kg/min infusion, titrate to desired effect

7.Fluid refractory and vasopressordependent shock) (60 min)

Consider adrenal insufficiency
Hydrocortisone 2 mg/kg (max 100mg) IV/IO
bolus; obtain baseline cortisol level; if
unsure, consider ACTH stimulation test;
duration depends on response, laboratory
evaluation

8. Continued shock
Consider cardiac output measurement to
direct further therapy
Consider extracorporeal membrane
oxygenation (ECMO)

9. Supplemental therapies
Blood transfusion considered for Hgb < 10
g/dL (ideal threshold for transfusion
unknown)
Sedation/analgesia while ventilated
Optimize oxygenation through ventilation
IV immunoglobulin can be considered
(unknown benefit; see Step No. 6 Infection
Control for dosing information)

10. Therapeutic endpoints

Clinical
Heart Rate normalized for age
Capillary refill < 2sec
Normal pulse quality
No difference in central and peripheral pulses
Warm extremities
Blood pressure normal for age
Urine output >1 mL/kg/h
Normal mental status
CVP >8 mmHg
Laboratory
Decreasing lactate
SvO2 >70%