Syok Sepsis

Muhammad Fauzan Hasby

20164011200 - Interna
Pembimbing:
Dr. Chusni Mubarakh, M.Sc, Sp.PD
Identitas Pasien
 Nama: Ny. BR
 Usia: 29th
 Alamat: Sidorejo, 02/03, Purworejo
 Pekerjaan: IRT
 Status: Menikah
 No. RM: 00457025
Anamnesis
 Keluhan Utama: Lemah
 RPS: Pasien rujukan RS Panti Waluyo dengan
P1A0 Post VE IUFD, Post Manual Plasenta 3
jam SMRS. Kondisi lemah, menggigil, pucat,
kesadaran somnolen.
Anamnesis
 RPD: tidak ditemukan adanya riw HT, DM,
peny. Jantung sebelumnya
 RPK: tidak ditemukan adanya riw HT, DM,
peny. Jantung di keluarga
 RPSos: pasien tidak mengkonsumsi obat
obatan rutin saat kehamilan
Pemeriksaan Fisik
 Keadaan Umum: Lemah
 Kesadaran: Somnolen, GCS 12 E3V4M5
 Tanda Vital
 TD: 107/70 mmHg
 N: 156x/m
 R: 24x/m
 t: 36.7oC
 Pemeriksaan Fisik
 Kepala: CA (+/+) SI (-/-) Wajah tampak Anemis
 Leher: Perbesaran lnn (-/-) Glandula Thyroid tidak teraba
 Thorax : retraksi (-); VF kanan = kiri (+/+); perkusi sonor (+/+);
Auskultasi Vesikuler (+/+), wheezing (-/-), RBB (-/-)
 Jantung S1-S2 reguler meningkat, BJ (-)
 Abdomen : distended (-), bising usus (+) dbn, timpani (+),
hepatosplenomegali (-), TFU setinggi pusar, Nyeri Tekan (+)
 Ekstremitas : akral dingin, CRT >2dtk, Pulsasi lemah, edema (-/-)
Pemeriksaan Penunjang
 Lab DRO, GDS, Urine Lengkap, Ureum-
Kreatinin, SGOT-SGPT, Elektrolit
 EKG
 USG Abdomen-Obstetrik&Ginekologi
Pemeriksaan Penunjang
 DRO:  Diff Count:
 Hb: 5.9 (↓)  Neutrofil: 82.40 (↑)
 AL: 19.300 (↑)  Limfosit: 6.40 (↓)
 Hmt: 18 (↓)
 Monosit: 11.00 (↑)
 AE: 2.6 (↓)
 AT: 147.000 (↓)  Eusinofil: 0.10 (↓)
 MCV: 68 (↓)  Basofil: 0.10
 MCH: 23 (↓)
Pemeriksaan Penunjang
 Urine Lengkap:  Kimia Darah:
 Leukosit (++)  GDS: 95
 Darah (+++)  Ureum: 183.0 (↑↑)
 Protein (+)  Kreatinin: 5.44 (↑)
 Elektrolit:  SGOT: 37 (↑)
 Kalium: 4.70 (n)  SGPT: 20
 Natrium: 130.7 (↓)
Pemeriksaan Penunjang
 Hematologi:
 Fibrinogen: 580 (↑)
 Control Fibrinogen: 333 (↑)
 D-Dimer: 0.1 (normal)
Pemeriksaan Penunjang
 EKG : Sinus Takikardia HR 148x/m
Diagnosis
 Syok Sepsis
 Multiple Organ Dysfunction Syndrome
 DIC
 Penatalaksanaan
 O2 10 lpm NRM
 IVFD RL 25 tpm makro
 Drip Norepinephrine 5 mcg s/d MAP >65 mmHg
 Transfusi PRC 4 kolf/12 jam
 Inf. Metronidazol 3x500mg
 Inj. Ceftriaxone 2x1gr
 Pantau TTV/jam
 Pantau Urine output 0.5-1.0cc/kgBB/jam
 Sepsis-3 Definitions
 Sepsis: Disfungsi organ yang mengancam jiwa akibat
disregulasi respons tubuh terhadap infeksi.
 Septic Shock: bagian dari sepsis dimana terjadi
abnormalitas sirkulasi dan metabolisme seluler yang dapat
meningkatkan mortalitas.
 Sepsis dan syok septik adalah keadaan yang masih menjadi masalah
di dunia, di mana satu dari empat orang yang dalam keadaan sepsis
akan meninggal. Identifkasi keadaan sepsis dini dan penatalaksanaan
yang cepat dapat memperbaiki prognosis pasien.
JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
SSC Guidelines and Sepsis-3
Definitions
 “Sepsis” menggantikan istilah “Severe Sepsis”
 Kriteria
klinis di Sepsis-3 (i.e. qSOFA) tidak digunakan
dalam penelitian ini, yang menginformasikan terkait
rekomendasi pada revisi berikut ini.
 Could not comment on use of Sepsis-3 clinical criteria

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

 SSC Guidelines
 Adapun kriteria klinis pasien sepsis dapat diketahui
dengan menggunakan skor Sequential (Sepsis-
Related) Organ Failure Assessment (SOFA). Skor
SOFA dirasa lebih mudah untuk dimengerti dan
sederhana. Apabila pasien yang mengalami infeksi
didapatkan Skor SOFA ≥2 maka sudah tegak
diagnosis sepsis.
 SSC Guidelines
 Ketika mendapatkan pasien infeksi perlu dilakukan skrining
kemungkinan terjadinya sepsis. Skrining ini bisa dilakukan
dimana saja dan kapan saja. Metodenya dengan quick SOFA
(qSOFA). Skoring ini dirasa kuat dan lebih sederhana serta tidak
memerlukan pemeriksaan laboratorium.
Algoritme Skrining
pada Sepsis dan
Syok Sepsis
 Early insertion of
ScvO2 catheter
Rivers Protocol

Therapy
titrated to
CVP, MAP
and ScvO2

Potential for RBC and

Inotropes
 Kontrol Sumber Infeksi
 Rekomendasi untuk mencari dan mengetahui
penyebab dari sepsis dan syok sepsis dengan
melacak kemungkinan sumber dari infeksi
berdasarkan hasil anamnesis-pemeriksaan fisik-
pemeriksaan penunjang
(Best Practice Statement).
 Antibiotik
 Rekomendasi administrasi antibiotik Intravena
secepatnya dalam 1 jam setelah terdiagnosis sepsis
dan syok sepsis
(strong recommendation, moderate quality of evidence).
 Rekomendasi penggunaan antibiotik spektrum luas
untuk mengeliminasi kemungkinan seluruh
patogen
(strong recommendation, moderate quality of evidence).
 Resusitasi Awal
 Rekomendasi resusitasi untuk keadaan sepsis
akibat hipoperfusi sedikitnya 30ml/kgBB cairan
kristaloid intravena diberikan dalam 3 jam
pertama.
(Strong recommendation; low quality of evidence)
 Rekomendasi untuk mengawasi status
hemodinamik pasien selama proses resusitasi awal
berlangsung.
(Best Practice Statement)
 Terapi Cairan
 Rekomendasi penggunaan cairan kristaloid
sebagai cairan resusitasi awal untuk sepsis and
septic shock
(Strong recommendation, moderate quality of
evidence).

 Rekomendasi penggunaan albumin di samping

penggunaan kristaloid sebagai cairan resusitasi
(weak recommendation, low quality of evidence).
 Agen Vasoaktif
 Rekomendasi penggunaan norepinefrin sebagai
lini pertama vasopressor
(strong recommendation, moderate quality of evidence).

 Saran untuk penggunaan vasopressin lain sebagai

tambahan (sampai 0.03 U/min) atau epinefrin
menjadi norepinefrin untuk meningkatkan MAP
hingga mencapai target.
(weak recommendation, low quality of evidence)
Norepinefrin direkomendasi sebagai vasopresor lini pertama.
Penambahan vasopressin (sampai 0,03 U/menit) atau epinefrin untuk
mencapai target MAP (MAP ≥65 mmHg) dapat dilakukan.
Penambahan vasopressin lebih dini dapat dipertimbangkan untuk
mengurangi dosis norepinefrin.
(Strong recommendation; moderate quality of evidence)
If shock is not resolving quickly…..
 We recommend further hemodynamic assessment
(such as assessing cardiac function) to determine
the type of shock if the clinical examination does
not lead to a clear diagnosis.
(Best Practice Statement)
 We suggest that dynamic over static variables be
used to predict fluid responsiveness, where
available.
(Weak recommendation; low quality of evidence)
Lactate can help guide resuscitation
• We suggest guiding resuscitation to
normalize lactate in patients with elevated
lactate levels as a marker of tissue
hypoperfusion.
(Weak recommendation; low quality of evidence)
 Summary
 Start resuscitation early with source control,
intravenous fluids and antibiotics.
 Frequent assessment of the patients’ volume status
is crucial throughout the resuscitation period.
 We suggest guiding resuscitation to normalize
lactate in patients with elevated lactate levels as a
marker of tissue hypoperfusion.
SCREENING FOR SEPSIS AND
PERFORMANCE IMPROVEMENT
1. We recommend that hospitals and
hospital systems have a performance
improvement program for sepsis
including sepsis screening for acutely ill,
high-risk patients. (BPS)
Sepsis Performance
Improvement
 Performance improvement efforts for sepsis are
associated with improved patient outcomes
 A recent meta-analysis of 50 observational
studies:
 Performance improvement programs associated with a
significant increase in compliance with the SSC bundles
and a reduction in mortality (OR 0.66; 95% CI 0.61-
0.72).
 Mandated public reporting:
 NYS, CMS, UK
 Diagnosis
 1. We recommend that appropriate routine
microbiologic cultures (including blood) be
obtained before starting antimicrobial therapy in
patients with suspected sepsis and septic shock if
doing so results in no substantial delay in the
start of antimicrobials. (BPS)
 Remarks: Appropriate routine microbiologic
cultures always include at least two sets of blood
cultures (aerobic and anaerobic).
 Antibiotics
 We suggest empiric combination therapy (using
at least two antibiotics of different antimicrobial
classes) aimed at the most likely bacterial
pathogen(s) for the initial management of septic
shock.
 (Weak recommendation; low quality of evidence)
 Antibiotics
 We suggest that combination therapy not be routinely
used for on-going treatment of most other serious
infections, including bacteremia and sepsis without
shock.
 (Weak recommendation; low quality of evidence).

 We recommend against combination therapy for the

routine treatment of neutropenic sepsis/bacteremia.
 (Strong recommendation; moderate quality of evidence).
 Antimicrobial Therapy
Antibiotic Stewardship
 We recommend that empiric antimicrobial therapy be narrowed once
pathogen identification and sensitivities are established and/or
adequate clinical improvement is noted.
 (BPS)
 We suggest that an antimicrobial treatment duration of 7-10 days is
adequate for most serious infections associated with sepsis and septic
shock.
 (Weak recommendation; low quality of evidence)
 We recommend daily assessment for de-escalation of antimicrobial
therapy in patients with sepsis and septic shock.
 (BPS)
 We suggest that measurement of procalcitonin levels can be used to
support shortening the duration of antimicrobial therapy in sepsis
patients.
 (Weak recommendation; low quality of evidence)
CORTICOSTEROIDS
1. We suggest against using intravenous
hydrocortisone to treat septic shock patients if
adequate fluid resuscitation and vasopressor
therapy are able to restore hemodynamic
stability. If this is not achievable, we suggest
intravenous hydrocortisone at a dose of 200 mg
per day.
(Weak recommendation; low quality of evidence)
 Mechanical Ventilation
 We suggest using higher PEEP over lower PEEP in
adult patients with sepsis-induced moderate to
severe ARDS.
 Weak recommendation; moderate quality of
evidence
 We recommend using prone over supine position
in adult patients with sepsis-induced ARDS and a
PaO2/FIO2 ratio <150.
 (Strong recommendation; moderate quality of
evidence)
 Mechanical Ventilation
 We recommend against the use of HFOV in adult
patients with sepsis-induced ARDS.
 (Strong recommendation; moderate quality of
evidence)
 Werecommend against the use of beta-2
agonists for the treatment of patients with sepsis-
induced ARDS without bronchospasm.
 (Strong recommendation; moderate quality of
evidence)
 GLUCOSE CONTROL
1. We recommend a protocolized approach to blood glucose
management in ICU patients with sepsis, commencing insulin
dosing when 2 consecutive blood glucose levels are >180
mg/dL. This approach should target an upper blood glucose
level ≤180 mg/dL rather than an upper target blood glucose
≤110 mg/dL. (Strong recommendation; high quality of evidence)
2. We recommend that blood glucose values be monitored
every 1 to 2 hrs until glucose values and insulin infusion
rates are stable, then every 4 hrs thereafter in patients
receiving insulin infusions. (BPS)
 GLUCOSE CONTROL
3. We recommend that glucose levels obtained with
point-of-care testing of capillary blood be interpreted
with caution, as such measurements may not accurately
estimate arterial blood or plasma glucose values. (BPS)

4. We suggest the use of arterial blood rather than

capillary blood for point of care testing using glucose
meters if patients have arterial catheters.
(Weak recommendation; low quality of evidence)
 Nutrisi
 Pasien syok (hipotensi [MAP<60 mmHg], peningkatan kadar
laktat, hiperglikemia) hipoksia, hiperkapnea, dan asidosis
yang akut merupakan kontraindikasi untuk pemberian
nutrisi melalui enteral atau parenteral. Jika syok sudah
terkontrol (dosis vasopressor yang stabil, kadar laktat yang
cenderung turun, perbaikan asidosis metabolik) setelah
resusitasi cairan dan vasopressor yang adekuat, baru nutrisi
enteral dapat dimulai.
 Nutrisi
 Metode objektif dengan perhitungan shock index ≤1 (shock
index = nadi : tekanan darah sistolik) dapat digunakan
sebagai salah satu acuan untuk insiasi nutrisi enteral.
 Nutrisi
 Prokinetik diberikan pada intoleransi nutrisi enteral,
dengan metoclopramide, domperidone, erythromycin
(1-3mg/kgBB). Pada beberapa studi pada pasien kritis
didapatkan, penggunaan prokinetik menurunkan angka
intoleransi nutrisi enteral hingga 17%.
 Pemberian prokinetik dievaluasi setiap hari dan
dihentikan bila tidak ada indikasi klinis.