CURRICULUM VITAE

Nama : dr. Anna Mira Lubis, SpPD-KHOM

Tempat Tanggal Lahir : Medan, 5 Juli 1978
Jenis Kelamin :Perempuan
Pekerjaan :Staf Divisi Hematologi Onkologi Medik,
Departemen Ilmu Penyakit Dalam, FKUI/RSCM
Status : menikah
Alamat : Puri Botanical Residence, Jl. Dillenia 5 Blok G6
no. 8, Mega Kebon Jeruk, Jakarta Barat
No. Telepon : 021-71062407 / 08129179515
Alamat email : mirafanani@yahoo.com
 PENDIDIKAN FORMAL

2011 – 2016 : Program Pendidikan Dokter Subspesialis

Kekhususan Hematologi-Onkologi Medik IPD FKUI-RSCM
2003-2008 : Program Pendidikan Kedokteran Spesialis,
Fakultas Kedokteran Universitas Indonesia
2000-2002 : Profesi Dokter, Fakultas Kedokteran Universitas
Indonesia
1996-2000 : Sarjana Kedokteran, Fakultas Kedokteran
Universitas Indonesia
1993-1996 : SMUN 1 Medan
1990-1993 : SMPN 1 Medan
1984-1990 : SD Kemala Bhayangkari 1 Medan
DR. ERNI JUWITA NELWAN, PH.D, SP.PD-KPTI
• Education
• GP, Universitas Indonesia 2001
• Internal Medicine, Universitas Indonesia 2006
• Infectious Disease and Tropical Medicine Consultant 2013
• Ph.D, Radboud University, Nijmegen 2017
• Position
• Staff of Infectious Disease and Tropical Medicine Division, Department of Internal Medicine,
Universitas Indonesia / Cipto Mangunkusumo Hospital
• Infectious Disease and Tropical Medicine Consultant in Cipto Mangunkusumo Hospital,
MMC Hospital, Abdi Waluyo Hospital
• Organization
• Member of IDI, PAPDI, PETRI
• Fellow of American College of Physician, Indonesian Society of Internal Medicine
 SKILL STATION 3

Sepsis, Infeksi, DIC, ARDS, KAD, Gangguan Ginjal Akut

Dr.Erni Juwita Nelwan ,SpPD,KPTI,PhD
dr.Anna Mira Lubis SpPD-KHOM
Pria, umur 51 tahun, BB 55 kg, TB 150 cm, masuk ke IGD dengan :
Keluhan Utama
kesadaran menurun 4 jam SMRS

Riwayat Penyakit Sekarang:

Dua minggu SMRS:
Nafsu makan menurun, lemah, demam (+), batuk (+).
Dua hari SMRS:
Sesak (+), dan kesadaran menurun
PEMERIKSAAN FISIK
KU : LEMAH, APATIS–SOMNOLEN
TV : TD 100/70 MMHG,
N 114/M
T 380C
FP 32/M DALAM
THORAX : JANTUNG TAKIKARDI,
PARU RONKHI BASAH KASAR NYARING
(+)
EXT : TURGOR , TANDA PERDARAHAN (-)
PRODUKSI URIN: 125CC/6 JAM
• Berdasarkan survey primer, masalah kegawatdaruratan apa yang anda tegakkan
pada pasien ini?
• Berapa skor WPS pasien ini?
• Jelaskan alasannya!
• Apa rencana dan saran diagnostik selanjutnya?
• Kesadaran menurun
• Hipotensi
• Sepsis
• Oliguria
WORTHING PHYSIOLOGICAL SCORING SYSTEM
( WPS )

Duckitt R. Br J Anaesth. 2007; 98: 769−74

 “URGENT CALLING SCORE”
• Skor ≥ 5, mortalitas meningkat 10,5%
• Skor = 6, mortalitas mencapai 20%.

• skor > 11, mortalitas mencapai 100%. (1)

• Duckitt :
• Skor = 2 , mortalitas 10 % (2 )
• Skor ≥ 5, = urgent calling

BACK

1. Fanny O. Tesis , 2013

2. Duckitt R. Br J Anaesth. 2007; 98: 769−74
LABORATORIUM
HB 15,5 G/DL
LEUKOSIT 22.700 /MM3 (SEGMEN 90 %)
TROMBOSIT 232.000 /MM3
GDS 458 MG/DL
ASETON DARAH (+)
UR/CR 103/3,25 MG/DL
ALBUMIN 3,0
AGD : PH 6,95 PCO 2 : 17,9 MMHG PO 2 : 57,0 MMHG
HCO3- : 4 O2 SAT. : 70% BE : -28,0.
URINE : GLUKOSA (+++)
FOTO THORAKS : INFILTRAT (+)/(+)
HEMOSTASE : PT/APTT NORMAL, FIBRINOGEN : 531,
D-DIMER : + 800
Apakah masalah dan
bagaimana kajian pada
pasien ini ?
MASALAH

1. Pneumonia sangat berat dengan gagal nafas tipe 1

2. Sepsis berat dengan DIC terkompensasi
3. Diabetikum ketoasidosis
4. Acute Kidney Injury stad. 2 (kriteria AKIN) atau Injury (kriteria RIFLE)
(dengan asidosis metabolik berat)
 CRB65 skor : 4 atau
Satu kriteria mayor :
* Memerlukan ventilator mekanik
PNEUMONIA * Syok SANGAT
septik BERAT
Dua kriteria minor :
* PO2 < 60 mmHg dan / atau PCO2 > 55 mmHg
(udara kamar)
* PaO2 / FiO2 < 300 (ALI / ARDS)
* Foto toraks : infiltrat luas / multilokulasi
* TD sistolik < 90 mmHg

BACK
Sepsis

Infection/
Trauma/shock SIRS Sepsis Severe Sepsis

A clinical response arising from SIRS plus/with a

a nonspecific insult, including  presumed or confirmed
2 of the following: infectious process
• Temperature 38oC or
36oC
• HR 90 beats/min
• Respirations 20/min
• WBC count 12,000/mm3 or
SIRS = Systemic Inflammatory
4,000/mm3 or >10% Response Syndrome
immature neutrophils
Adapted from: Bone RC, et al. Chest 1992;101:1644
Opal SM, et al. Crit Care Med 2000;28:S81
Severe Sepsis

Infection/
Trauma/shock SIRS Sepsis Severe Sepsis

Sepsis with 1 sign of organ failure

Cardiovascular (refractory hypotension)
Renal
Respiratory
Septic
Hepatic
Hematologic Shock
CNS
Metabolic acidosis

Bone et al. Chest 1992;101:1644; Wheeler and Bernard. N Engl J Med 1999;340:207
BACK
DIAGNOSIS KID

1. Konsensus Nasional 2001 :

• Adanya penyakit pencetus
• Manifestasi perdarahan dan, atau
thromboemboli
• Trombositopenia, Burr cell / D-Dimer (+)
 DIC SCORING SYSTEM
• 2001: International Society on Thrombosis &
Haemostasis reviewed a DIC scoring system (1),
subsequently validated in adults (2):
Does patient have underlying disorder associated with DIC?
0 1 2 3
Platelets (103/mm3) >100 <100 <50
FDP/D Dimer No Moderate Strong
Increase Increase Increase
< 500 500-1000 >1000
Prolonged PT < 3 sec 3-6 sec >6 sec
Fibrinogen (mg/dL) > 100 < 100
Scores ≥5 are compatible with DIC, Scores <5 suggest no DIC
1) Taylor FB, et al. Thromb Haemost 2001;86:1327-30
2) Bakhtiari K, et al. Crit Care Med 2004;32:2416-21
DIAGNOSIS KID : (LANJUTAN)
3. Kriteria Bicks (1998)
• Aktifasi koagulan.( PF1+2 , TAT, sFM, fibrinopeptida A
)
• Aktifasi fibrinolisis.( PAP, FDP, D-dimer )
• Konsumsi inhibitor. ( AT , protein C , protein S )
• Disfungsi organ. ( LDH, Ur/ Cr, AGD )

KID : 1 uji abnormal dari setiap kelompok + 2 uji

abnormal dari disfungsi organ.

BACK
Diagnostic criteria for DKA and HHS BACK

DKA (Blood glucoce serum >250 mg/dl ) HHS

Mild Moderate Severe Plasma glucose
>600 mg/dl
Arterial pH 7.25-7.30 7.00 to < 7.24 < 7.00 > 7.30

Serum bicarbonate ( mEq/l) 15-18 10 to < 15 < 10 > 18

Urine ketone* Positive Positive Positive Small

Serum ketone* Positive Positive Positive Small

Effective serum osmolality Variable Variable Variable > 320 mosm/kg

†
Anion gap+ > 10 > 12 > 12 Variable

Mental Status Alert Alert/drowsy Stupor/coma Stupor/coma

* Nitroprusside reaction method .†Effective serum osmolality: 2[measured Na * (mEq/l)] + glucose (mg/dl)/18. Anion gap : (Na† )
– [(CI- + HCO, - (mEq/I)] (Data adapted from ref 13. )
 KLASIFIKASI AKI
RIFLE Classification
Class Glomerular Filtration Rate Urine Output Criteria
Criteria
Risk Serum creatinine x 1,5 < 0,5 ml\kg\hour x 6 hours
Injury Serum creatinine x 2 < 0,5 ml\kg\hour x 12 hours
Failure Serum creatinine x 3, or serum < 0,3 ml\kg\hour x 24 hour, or
creatinine ≥ 4 mg/dL with an acute anuria x 12 hours
rise > 0,5 mg/dl
Loss Persistent acute renal failure ▪
complete loss of kidney function > 4
weeks
End-stage kidney End stage kidney disease > 3 months
disease

Hoste et all. Critical Care 2006.

Classification / staging system for acute kidney injurya
Stage Serum Creatinine Criteria Urine Output Criteria
1 Increase in serum creatinine of more than or equal Less than 0,5 ml\kg per
to 0,3 mg/dl (≥26,4 µmol/l) or increase to more hour for more than 6
than or equal to 150 % to 200% (1,5 to 2 fold) from hours
baseline
2b Increase in serum creatinine to more than 200% - Less than 0,5 ml\kg per
300% (> 2 to 3 fold) from baseline hour for more than
12hours
3c Increase in serum creatinine to more than 300% (> Less than 0,3 ml\kg per
3 fold) from baseline (or serum creatinine of more hour for 24hours or
than or equal to 4.0 mg/dl (≥ 354 µmol/l ) with an anuria for 12 hours
acute increase of at least 0,5 mg/dl (44µmol/l))

a Modified from RIFLE (Risk, Injury, Failure and End-stage kidney disease) criteria. The staging system proposed is a highly sensi tive intern staging system and is
based on recent data that a small change in serum creatinine influences outcome. Only one criteria (creatinine or urine outpu t) has to be fulfilled to qualify for
a stage. B200% to 300% increase ▪ 2 to 3 fold increase. cGiven wide variation in indication and timing of initiation of renal replacement therapy (RRT), individuals
who receive RRT are considered to have met the criteria for stage 3 irrespective of the stage they are in at the time of RRT.

Mehta et all. Critical Care 2007 11:R31. BACK

 TERAPI APA YANG ANDA
REKOMENDASIKAN PADA PASIEN INI
BERDASARKAN SKALA PRIORITASNYA
?
TERAPI YANG TELAH DIBERIKAN PADA
PASIEN INI:

1. Intubasi dan ventilasi mekanik

2. Infus NaCl 0,9 % : rehidrasi
3. Antibiotik : Cefoperazone 3 x 1 g (4hr) 
Meropenem 2 x 1 g
4. PPI : Omeprazole
5. Fluconazole (hari ke 6 perawatan) 1 x 400 mg IV 
200 mg
6. Terapi Insulin sesuai protokol
7. Imunoglobulin 400 mg/kgBB/hari (selama 5 hari)
APA KOMENTAR ANDA TENTANG TERAPI TERSEBUT ?
 VENTILATOR MEKANIK
Mode control (assist / control)
• Volume tidal : mulai 6 cc / kg BB, dititrasi antara 4 –
10 cc / kg BB berdasarkan hasil PCO2
• Peak Inspiratory Pressure (PIP) tak lebih dari 26
mmHg
• PEEP mulai dari 5 mmHg, dititrasi s/d 10 mmHg
berdasarkan PO2 yang dicapai
• FiO2 mulai 100 %, tapering down sebelum 24 jam,
berdasarkan PO2 yang dicapai

BACK
 REHIDRASI
• Inisial : menggunakan protokol ketoasidosis : kristaloid (misalnya NaCl 0,9%) :
500 cc / 15 menit pertama, 500 cc / 45 menit berikutnya, 500 cc / 1 jam
berikutnya.
• Pasang CVP selanjutnya rehidrasi dipandu CVP dengan target 8 – 12 mmHg (
10 – 14 cm H2O)

BACK
 PROFILAKSIS STRESS ULSER
• PPI lebih dipilih dari penyekat H2 karena terdapat AKI.
• Pemberian profilaksis stress ulser pada pasien kritis akut memiliki evidence base
class IIA
• Pemberian profilaksis stress ulser direkomendasikan segera dihentikan ketika
masa akut terlewati dan pasien telah bisa mendapat nutrisi enteral.

BACK
DKA – TREATMENT

Rehydration 1. Correct shock with bolus saline

2. Rehydration rate depends on clinical
status, age and kidney function
Normal saline (0.9%) for resuscitation
and rehydration initially
Glucose/saline solution when glucose
around 250 mg/dL
Rehydrate steadily over 48 hours
3. Consider NG tube

Potassium Essential after resuscitation and when

urine output confirmed
Kitabchi et al 1976
DKA – TREATMENT
Insulin Infusion: 0.1 units/kg/hour after
resuscitation, saline established and BG
falling
Rate should be increased by 10-20% if
glucose not fallen by 50-75 mg/dL over
first hour

Monitoring BG, BP, urine output and hourly

neurological status
Blood gases and electrolytes 2-hourly
initially
DKA- RESOLUTION
• Blood glucose < 200 mg/dl
• Bicarbonat > 15 mEq/l
• Anion gap ≤ 12 mEq/l
• Clinical finding

BACK
 TERAPI EMPIRIK
Hasil tes
Hasil Kultur Antibiotik
Resistensi
- - B-laktam ( cefotaxim / ceftriaxon / ampisilin-
sulbaktam ) kombinasi dengan azitromisin atau
fluorokuinolon paru-paru
Bila alergi pencilin : fluoroquinolon dan aztreonam
Pseudomonas -- B-lactam anti pseudomonas dan pneumokokus
( piperasilin-tazobaktam / cefepim / imipenem /
meropenem ) kombinasi dengan salah satu
- Siprofloksasin / levofloksasin (750 mg)
- Kombinasi antara azitromisin dan aminoglikosida
- Kombinasi antara fluoroquinolon antipneumokokus
dan aminoglikosida
Bila alergi pencilin B laktam dapat diganti dengan
aztreonam.
Methicillin- ditambahkan vankomisin atau linezolid
Resistant S.
aureus (MRSA),
 ANTIBIOTIK

• Deeskalasi :
Mulai dari meropenem, bukan dari cefoperazone baru naik meropenem

BACK
 BIKARBONAT
1. Bikarbonat dapat mengakibatkan detereorasi klinik bila
terdapat hipoksemia jaringan serta dapat menyebabkan
hiperkarbia, karena itu bikarbonat harus didahului dengan
ventilasi yang adekuat
2. Pada ketoasidosis diabetikum, bikarbonat diberikan bila
terdapat hiperkalemia atau asidosis metabolik berat/letal
(pH < 7,15)
3. Pada asidosis laktat pemberian bikarbonat mungkin
memperberat karena hilangnya inhibisi asidosis oleh
glikolisis (pada kasus ini laktat tidak diperiksa)
4. Bikarbonat mungkin akan lebih bermanfaat bila asidosis
adalah dengan anion gap normal atau hiperkloremik (pada
kasus ini data elektrolit tidak ada).
 Dellinger, et. al. Crit Care Med 2004, 32: 858-873.

Surviving Sepsis Campaign

Bicarbonate Therapy
Bicarbonate is not recommended for the purpose of
improving hemodynamics or reducing vasopressor
requirements for the treatment of hypoperfusion
induced lactic acidemia with pH  7.15 Grade C

 No difference revealed in vasopressor requirements or

hemodynamic variables between bicarbonate and
normal saline for treating hypoperfusion-induced
acidemia
 Effects of bicarbonate therapy at pH levels < 7.13 have
not been studied
Cooper DJ. Ann Intern Med 1990;112:492-498.
Mathieu D. Crit Care Med 1991;19:1352-1356.
 Dellinger, et. al. Crit Care Med 2004, 32: 858-873.

Steroid
Surviving Sepsis Campaign:
 Intravenous corticosteroids are recommended in patients with septic
shock who require vasopressor therapy to maintain blood pressure
 Administer intravenous hydrocortisone 200-300 mg/day
for 7 days in three or four divided doses or by continuous
infusion
Grade C
 Shown to reduce mortality rate in patients with relative
adrenal insufficiency

Annane, D. JAMA, 2002; 288 (7): 868

 Dellinger, et. al. Crit Care Med 2004, 32: 858-
873.

Surviving Sepsis Campaign:

Steroids
 May use 250 mcg ACTH stimulation test to identify
responders and discontinue therapy in these patients
 Responders can be defined as >9 mcg/dL increase in
cortisol 30-60 minutes post ACTH administration
 Clinicians should not wait for ACTH stimulation test
results to administer corticosteroids
 After the resolution of septic shock, may decrease
dosage of steroids
 Consider tapering the dose of corticosteroids at the
end of therapy
Grade E
 May add fludrocortisone to the hydrocortisone regimen
Annane, D. JAMA, 2002; 288 (7): 868
 Dellinger, et. al. Crit Care Med 2004, 32: 858-873.

Surviving Sepsis Campaign :

Steroids
 Doses of hydrocortisone >300 mg daily should NOT be used in
septic shock or severe sepsis for the purpose of treating shock

 In the absence of shock, corticosteroids should not be used for

treatment of sepsis
Grade A

Grade E
Bone RC. N Engl J Med 1987;653-658.
VA Systemic Sepsis Cooperative Study Group. N Engl J Med 1987;317:659-665.
Pada hari ke 1 jam ke-6 di IGD Pada hari ke 3
Hasil Lab darah: Hasil Lab darah:
→ 8,8 g/dL
• Hb 10,8 g/dL
→ 16.000 /mm3
• Leukosit 18.000 /mm3
→ 80.000 /mm3
• Trombosit 98.000 /mm3 → 23” (kontrol 12)
• PT 20” (kontrol 12) → 53” (kontrol 35)
• aPTT 48” (kontrol 35)
• Fibrinogen 165 (kontrol 250)
mg/dL
• D dimer 1000 ng/mL
• Bagaimana kajian Anda mengenai hasil lab tersebut?

• Apa usulan terapi Anda terkait hasil lab tersebut?

TERIMA KASIH