Nama : M. Vitanata Arfijanto,dr.

,SpPD, K-PTI,
FINASIM
Tempat, Tanggal Lahir : Surabaya, 15
September 1971
Jenis Kelamin : Laki-Laki
Agama : Islam
Alamat Asal : Ketintang Wiyata I / 32,
Surabaya
Alamat Email : drvitanata@yahoo.co.id
No Tlp Kantor : 031 5035975
No Tlp Pribadi : 081230299371
SMF/Departemen/Instalasi

SMF/Departemen/instalasi : Depart-SMF Ilmu Penyakit

Dalam Divisi : Divisi Penyakit Tropik Infeksi
Sub Keahlian : Spesialis Penyakit Dalam
Jabatan : Staf Divisi Penyakit Tropik
Infeksi; Depart-SMF Ilmu
Penyakit Dalam
Sertifikat GCP (Tahun) : 2017
Riwayat Pendidikan Formal
1 Dokter umum 1996
2 Dokter Spesialis Penyakit Dalam 2006
3 Dokter Spesialis Konsultan 2010
Pelatihan dan Seminar
1 Workshop Pendidikan Pembicara 29 Mei 2015
Kedokteran Berkelanjutan XXX
Ilmu Penyakit Dalam
2 Dutch Foundation For Post Peserta 29-31 Oktober
Graduate Medical Courses in 2015
Indonesia Course on Allergy
and Immunology
3 Ministry of Heath Scientific Pembicara 14-15 November
Workshop & Joint Simposium 2015
Regenerative Medicine and
Sitokine-8
4 Pengetahuan-Ketrampilan Peserta 17 April 2017
bidang International Patient
Safety Goals (IPSG)
5 Pelatihan Basic Life Support (BLS) Peserta 18 April 2017

6 Pelatihan Kesehatan dan Peserta 19 April 2017

Keselamatan Kerja Rumah Sakit
RSUD dr. Soetomo

7 Pelatihan Pencegahan dan Peserta 20 April 2017

Pengendalian Infeksi RSUD dr.
Soetomo

8 Pengetahuan Standar-standar Peserta 22 April 2017

dalam akreditasi Joint Commision
International (JCI)
Peserta
 Sepsis dan SIRS
evaluation&management
BUMI HYATT 2017
Infection, SiRS, Sepsis

Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., Schein, R., et al. (1992). Definitions for sepsis and organ failure and guidelines for the
use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of
Critical Care Medicine. Chest, 101(6), 16441655.
 Diagnostic criteria for sepsis

Sepsis Severe Sepsis Septic Shock

SIRS
Sepsis plus Sepsis-induced
Infectious & SIRS plus
Sepsis-induced hypo-perfusion or
non infectious Presumed hypotension
causes or organ
dysfunction or persisting despite
Clinical confirmed 30 mls/kg fluid
response arising infection tissue
hypoperfusion rescusitation
from a non
specific insult
 SIRS Criteria
T > 38.3, < 36
HR > 90
RR > 20
WCC > 12, < 4
BSL > 7.7 mmol/l in non-diabetic
Altered mental status
 2016
Sepsis-3
JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288

Suggested Clinical Criteria for Sepsis

(if in ICU?)

Infection + 2 or more SOFA points

(above baseline)

Consider Sepsis outside ICU if

Infection + 2 or more qSOFA points

 THE SEQUENTIAL ORGAN FAILURE ASSESMENT ( SOFA )

0
0 1
1 2
2 3
3 4
4
Respiratory
Respiratory >400
>400 <400
<400 <300
<300 <200
<200 <100
<100
PaO2
PaO2 // Fi
Fi O2
O2
Creatinin
Creatinin <1,2
<1,2 1,2-1,9
1,2-1,9 2,0-3,4
2,0-3,4 3,5-4,9
3,5-4,9 >5
>5
(mg/dl) urin<500ml/day urin
(mg/dl) urin<500ml/day urin ml/day
ml/day

Bilirubin
Bilirubin 1,2
1,2 1,2-1,9
1,2-1,9 2,0-5,9
2,0-5,9 6,0-11,9
6,0-11,9 >12
>12
mg/dl
mg/dl
cardiovascu
cardiovascu No
No HT
HT MAP<70
MAP<70 Dopa<5
Dopa<5 or
or Dopa
Dopa >5,
>5, Dopa
Dopa >15
>15
lar
lar dobu
dobu Epi<0,1
Epi<0,1 or
or or
or NE
NE >0,1
>0,1
NE<0,1
NE<0,1 or
or Epi>0,1
Epi>0,1

Platelet
Platelet >150
>150 <150
<150 <100
<100 <50
<50 <20
<20
(103 3
(103/mm
/mm3))
GCS
GCS 15
15 13-14
13-14 10-12
10-12 6-9
6-9 <6
<6
 Common mistake - 1
Other inflammatory parameters
o CRP, PCT
Organ dysfunction parameters
o Hypoxia, Oliguria, Creatinine, Coag, Platelet,
Bilirubin, Ileus
Tissue perfusion parameters
o Mottling, capillary refill, lactate
Haemodynamic variables
o BP <90, MAP < 70, SBP > 40mmHg from baseline
 IL-6
sepsis
Result
PCT
sepsis

Maximum values
CRP IL-6 on day 0
sepsis PCT and CRP on day 1
LBP on day 2
IL-6 with sepsis decline
CRP rapidly after day 1.
SIRS
The difference in PCT
levels between sepsis
and SIRS patients is
PCT
SIRS
maintained at least until
day 3 or 4.

Critical Care Research and Practive Vol.2011, article ID 594645, 6 pages

 Procalcitonin

Normal serum level: <0.5 ng/ml

Half time: 24-36 hrs
PCT is a precursor of the hormone calcitonin and is
synthesized physiologically by thyroid C cells.
In bacterial infection PCT is synthesized in various
extrathyroidal neuroendocrine tissues.
Two main ways:
direct way: toxins or lipopolysaccharides
Indirect way: induced by cytokines such as IL-1b, IL-6, TNF-
Low or negligible rises in localized, viral and intracellular
bacterial (ex: Mycoplaxma pneumoniae) infections.
Antimicrob Chemother 2011; 66 Suppl 2: ii33ii40 doi:10.1093/jac/dkq523
 Procalcitonin
Elevation at the status
Infection
Major trauma, surgical trauma, burns
The first 2 days of a neonates life
Medullary C-cell carcinoma
Small cell lung carcinoma, bronchial carcinoid
Treatment with OKT3 antibodies, interleukins,
TNF-
Prolonged or severe cardiogenic shock
Child-Pugh Class C liver cirrhosis, peritoneal
dialysis treatment
The Scientific World JOURNAL (2010) 10,1941-1946
 So What is Sepsis Then?
Sepsis now defined as life-threatening organ dysfunction caused by a
dysregulated host response to infection. This is a clinical diagnosis. Note
that Severe sepsis (previously used for sepsis with organ dysfunction) is no
longer recognized since it would be redundant.

Septic Shock a subset of Sepsis with circulatory and cellular/metabolic

dysfunction associated with a higher risk of mortality. This is a clinical
diagnosis.

Sepsis and Septic Shock are medical emergencies and it is recommended

that treatment and resuscitation begin immediately (Best Practice
Statement).
Give 3 Take 3
1.OXYGEN: Titrate O2 to saturations 1. CULTURES: Take blood cultures
of 94 -98% or 88-92% in chronic lung before giving antimicrobials (if no
disease. significant delay i.e. >45 minutes)
and consider source control.

2. FLUIDS: Start IV fluid 2.BLOODS: Check point of care

resuscitation if evidence of lactate & full blood count. Other
hypovolaemia. 500ml bolus of tests and investigations as per
isotonic crystalloid over 15mins & history and examination.
give up to 30ml/kg, reassessing for
signs of hypovolaemia, euvolaemia,
or fluid overload.

3. ANTIMICROBIALS: Give IV 3. URINE OUTPUT: Assess urine

antimicrobials according to local output and consider urinary
antimicrobial guidelines. catheterisation for accurate
measurement in patients with severe
sepsis/septic shock.
 Antibiotic therapy
1. We recommend that intravenous
antimicrobial therapy be started as early as
possible and within the first hour of
recognition of septic shock (1B) and severe
sepsis without septic shock (grade1C).
 Fluid therapy
4. We recommend that initial fluid challenge in
patients with sepsis-induced tissue
hypoperfusion with suspicion of hypovolemnic
be started with 1000 mL of crystalloids (to
achieve a minimum of 30ml/kg of crystalloids
in the first 4 to 6 hours).
(Grade 1B).
Fluid resuscitation and Mortality

Figure 3. Mean hospital mortality among patients with decreased lactate within 8 hours of index test, stratified by total fluid received in increments of
7.5 ml/kg based on medication administration record.

Annals ATS, 2013

http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201304-099OC
 Early antibiotics are good
Author N Setting Median Odds ratio
time (mins) for death
Gaieski 261 ED, USA 119 0.30
CCM 2010; 38;1045- (shock) (1st hour vs all
53 times)

Daniels 567 Whole hospital, 121 0.62

Emerg Med J 2010; UK (1st hour vs all
doi:10.1136 times)

Kumar 2154 ED, Canada 360 0.59

CCM 2006; 34(6): (shock) (1st 3 hours vs
1589-1596 delayed)

Appelboam 375 Whole hospital, 240 0.74

CCM 2010; UK (1st 3 hours vs
14(Suppl 1):50 delayed)

Levy 15022 Multi-centre 0.86

CCM 2010; 38(2): 1- (1st 3 hours vs
8 delayed)
 Sources of sepsis
Respiratory 38%
Urinary tract 21%
Intra-abdominal 16.5%
CRBSI 2.3%
Device 1.3%
CNS 0.8%
Others 11.3%
 Microbiology of Sepsis
The International Cohort Study

Severe Septic
Sepsis Shock
Gram-positive 44 40

Gram-negative 47 47

Fungal 9 13

Polymicrobial - -
Goals in resuscitation

Early, quantitative resuscitation

goals vs. standard care have
resulted in improved mortality

The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis *.
Jones, Alan E. MD; Brown, Michael D. MD, MSc; Trzeciak, Stephen MD, MPH; Shapiro, Nathan I. MD, MPH; Garrett, John S. MD; Heffner, Alan C.
MD; Kline, Jeffrey A. MD; on behalf of the Emergency Medicine Shock Research Network investigators
Critical Care Medicine. 36(10):2734-2739, October 2008.
Goals in resuscitation

Initial fluid resuscitation:

CVP 8-12, MAP > 65, UOP 0.5 mL/kg/hr, ScVO2
70% and Lactate Clearance.

Give enough volume to maximize stroke volume.

Start with 20cc/kg in most patients. Goal?
Give vasopressors to raise the MAP enough to
maintain adequate end-organ perfusion.
Assessment of Cardiac Function
UOP and Lactate Clearance are nice global
indicators of success.
 Evidence Based Sepsis Treatment
to Meet the CMS Sepsis Core Measure
Patients > 18 Years of Age: Meeting the Measure is ALL OR NONE
At UNC Hospitals target *FLAB in the first hour

S e p s i s a n d Tr e a t m e n t
Suspected/documented infection and Life Threatening Organ Dysfunction
(Creatinine >2, Lactate > 2, oliguria, new oxygen demand - respiratory distress/failure, AMS, SBP<90, RR>20)
list is not all inclusive
In first 3 hours: Lactate, Blood Cultures, broad spectrum Antibiotics
In first 6 hours: repeat Lactate if initial > 2

S e p t i c S h o c k a n d Tr e a t m e n t
(Sepsis + SBP <90 not responsive to 30mL/kg IV fluid given + requires vasopressors for SBP <90 or MAP <65 + lactate >2)
In first 3 hours: Lactate, Blood Cultures, broad spectrum Antibiotics, and Fluid
resuscitation with 30 mL/kg crystalloid fluids
In first 6 hours: repeat Lactate, complete .SEPSISEXAM, and start Norepinephrine if
hypotension persists after 30 mL/kg Fluid resuscitation

Renal Failure, Heart Failure, Liver Failure & Surgical patients are NOT exempt from this measure
*FLAB in the first hour Give Fluids, Result Initial Lactate, Give Antibiotics after Drawing Blood Cultures
 6 Hour Resuscitation Bundle

Early Identification
Early Antibiotics and Cultures
Early Goal Directed Therapy
 6 - hour Severe Sepsis/
Septic Shock Bundle
Early Detection:
Obtain serum lactate level.
Early Blood Cx/Antibiotics:
within 3 hours of
presentation.
Early EGDT:
Hypotension (SBP < 90, MAP
< 65) or lactate > 4 mmol/L:
initial fluid bolus 20-40 ml of
crystalloid (or colloid equivalent)
per kg of body weight.
Vasopressors:
Hypotension not
responding to fluid
Titrate to MAP > 65
mmHg.
Septic shock or lactate > 4
mmol/L:
CVP and ScvO2 measured.
CVP maintained >8 mmHg.
MAP maintain > 65 mmHg.
ScvO2<70%with CVP > 8
mmHg, MAP > 65 mmHg:
PRBCs if hematocrit < 30%.
Inotropes.
 Rhode Island Hospital EGDT Data

Time from Entering ED Time from Entering ED

to Receiving Antibiotics to Catheter Insertion Time from Entering ED
to Transfer to MICU
Reduced by 42% Reduced by 60%
Reduced by 51%
200 350
185 500

180
450
300
160
148 400

140 250
350

120 11 300
106 200

100 95
90 250

150
80 200

60 150
100

100
40
50
50
20
 24 - hour Severe Sepsis
and Septic Shock Bundle

Glucose control:
maintained on average <150 mg/dL (8.3 mmol/L)
Drotrecogin alfa (activated):
administered in accordance with hospital guidelines
Steroids:
for septic shock requiring continued use of vasopressors
for equal to or greater than 6 hours.
Lung protective strategy:
Maintain plateau pressures < 30 cm H2O for
mechanically ventilated patients