Dr.dr.Dadik W.

Wijaya
SpAn.KAO

KSM Anestesiologi & Terapi Intensif

FK-UNPRI/RSU Royal Prima Medan
 1992; 1st
Definition of
Definisi Sepsis
published in
CHEST

Sepsis adalah kumpulan gejala akibat respons sistemik

terhadap inflamasi (Sistemic Inflammatory Respons
Syndrome = SIRS) akibat infeksi.

Dikatakan sepsis bila terdapat 2 dari 4 gejala yaitu :

1. Suhu tubuh > 38 atau < 36 C
2. Denyut jantung > 90 x/m
3. Pernafasan > 20 x/m atau PaCO2 < 32 mmHg
4. Lekosit > 12.000 atau < 4000 /mm3 atau
sel muda >10%
ADA BUKTI INFEKSI
atau SUSPEK INFEKSI
Hubungan antara Sepsis dan SIRS

BACTEREMIA TRAUMA

INFECTION SEPSIS
SEPSIS SIRS BURNS

PANCREATITIS
Urutan Paling Sering :

• Aerob Gram Negatif

• Aerob Gram Positif
• Jamu
• Parasit
• Virus
 The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock

Systemic Inflammatory Responds Syndrome

SIRS criteria
- Temp >96.8o or >100.4oF
- HR > 90
- RR >20 or PCO2 <32mmHg
- WBC <4 or >12 or bands > 10%

Bone et al. Chest 1992;101:1644

 The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock

Systemic Inflammatory Responds to Infection

- Suspected or confirmed infection
- 2 or more SIRS criteria

Bone et al. Chest 1992;101:1644

 The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock

Sepsis plus organ dysfunction

Bone et al. Chest 1992;101:1644

 The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock

Severe sepsis and hypotension

 Hypotension that does NOT
respond to fluid (30ml/kg bolus))

Bone et al. Chest 1992;101:1644

 Fisiologi Awal Sepsis

Transisi dari SIRS ke Syok sepsis ditandai dengan

perkembangan hipoksia jaringan secara
menyeluruh
– O2 delivery turun mengikuti pengurangan volume
intravaskular dan depresi miokard
– O2 demand meningkat karena metabolisme meningkat
Patofisiologi
The Sepsis Cascade

12
 Pathophysiology of Sepsis-Induced
Ischemic Organ Injury
Infection

Inflammatory Endothelial
Vasodilation
Mediators Dysfunction

Hypotension Microvascular Plugging Vasoconstriction Edema

Maldistribution of Microvascular Blood Flow

Ischemia

Cell Death

Organ Dysfunction
BIOMOLEKULER ASPEK
 Sepsis Berat
Salah satu penyebab kecacatan dan kematian
yang cukup tinggi di dunia.
Penyebab kematian dengan angka kejadian
tertinggi pada ICU (noncoronary)
Penyebab kematian pada urutan ke-11 secara
umum
Lebih dari 750.000 kasus sepsis berat terjadi di
USA setiap tahun
Di Amerika terjadi 500 kematian karena sepsis
setiap harinya
HATI
Hiperbilirubinemia
Peningkatan transaminase
Sintesa faktor pembekuan menurun  Koagulopati

GINJAL
Oliguria - anuria  Overload volume
Imbalans Elektrolit

JANTUNG
Sitokin menekan fungsi miosit  Gagal Jantung
Kerusakan sel  troponin meningkat
Paru:
acute lung injury (ALI) (PaO2/FiO2 < 300)
acute respiratory distress syndrome(ARDS)
(PaO2/FiO2 < 200)

Otak
Encefalopati, agitasi, konfusi, koma
PRINSIP PENATALAKSANAAN

1. Bunuh kuman dengan Antimikrobial

2. Hilangkan sumber infeksi dengan Drainase
3. Memperbaiki Hemodinamik dan Respiratorik
4. Penatalaksanaan disfungsi Organ
ANTIMIKROBA
Antimikroba empiris harus diberi sesegera
mungkin setelah sampel darah dan bagian lain
yang relevan sudah dikultur.
Keterlambatan 1 jam akan meningkatkan
kematian 7%

Jika hasil kultur sudah ada, regimen yang

diberikan adalah antimikrobial tunggal sesuai
hasil kultur
Menghilangkan / mendrainase sumber
infeksi
Drainase sumber kuman
Contoh : Abses, Cairan Peritoneum, Pleura, dll
Ganti Infus set  Kultur Kanula
Ganti Kateter Urin
Ganti NGT
Perhatikan apakah ada sinusitis bila ada intubasi
Cegah / rawat dekubitus
Memperbaiki Hemodinamik dan Respiratorik
Pemberian cairan IV untuk mencegah udem paru 
Tek.vena sentral dipertahankan 8-12 cmH2O.

Urine output harus dijaga > 0,5cc/kgBB per jam

dengan terus memberi cairan

Pertahankan MAP > 65mmHg , tek.sistolik > 90mmHg

dan Cardiac Index ≥ 4L/min per m2.
Penatalaksanaan disfungsi Organ

Gagal Ginjal  Hemodialisa

Gagal Nafas  Ventilasi Mekanis

History ofof
History Se psis De finitio n
Definition

2001
Expanded List Criteria
Diagnostic
Limitations
se p sis d e finitio n
in 1991 Did Not offer
alternatives because
lack of evidence

Le vy e t a l. Inte nsive C a re Me d . 2003;29(4):530-538

25
DIAGNOSIS/SCREENING
SEPSIS IS IMPORTANT

26
Sepsis: What Happened in 2016?
Sepsis-3
• Organ Dysfunction: Rise in SOFA of ≥ 2 points
 SOFA Scoring

The Sepsis-3 definitions recommend

using a change in the total SOFA
score of two or more points from the
baseline score to represent organ
dysfunction

Singer et al. JAMA (2016); adapted from Vincent et al

 Sepsis: What Happened in 2016?
Sepsis-3
• Severe Sepsis: No longer used
• Sepsis:
– Suspected or documented infection and
– Acute increase of ≥2 SOFA points (a proxy for organ)
dysfunction)
• Septic Shock:
– Sepsis and
– Vasopressor therapy needed to elevate MAP ≥65
mm Hg and
– Lactate >2 mmol/L (18 mg/dL) despite adequate
fluid resuscitation
 Sepsis: What Happened in 2016 ?
Sepsis-3
• qSOFA Score: A means of rapidly
identifying ED and hospital ward (non-
ICU) patients with suspected infection at
increased risk
• At least 2 of 3 criteria :
– RR ≥ 22/min
– Altered mentation
– SBP ≤ 100 mmHg
DIAGNOSIS/SCREENING
SEPSIS IS MORE SIMPLE
2016

31
 Identifikasi Pasien Sepsis dan Syok
Sepsis dengan kriteria Klinis qSOFA

32
HAT “Magic HAT predicts
 Limitations of SOFA + qSOFA

• SOFA and qSOFA scores were designed as research tools at a

population level to predict which patients with sepsis were likely to
die…they do not define sepsis

• Clinical deterioration in patients with a positive qSOFA score may be

due to causes other than sepsis

• New organ dysfunction should prompt you to consider occult infection

• *** The addition of serum lactate to qSOFA did not significantly change
the ability of qSOFA to predict mortality.

Singer et al. JAMA (2016)

 “Sepsis-4”: What does the future hold?

1992; 1st Definition 2001: International 2016: International

of Sepsis Sepsis Consensus Sepsis Consensus
Published in Conference; Conference; The Future: ???
CHEST "Sepsis-2" "Sepsis-3"

Sepsis is life-threatening organ dysfunction caused by a dysregulated

host response to infection

Septic Shock: Subset of sepsis with circulatory and cellular/metabolic

dysfunction associated with higher risk of mortality

Levy et al. Crit Care Med (2018)

2018 Sepsis Treatment Guidelines
 Surviving Sepsis Campaign 2018

Initially Proposed:
“The most important change in the revision of the SSC
bundles is that the 3-h and 6-h bundles have been
combined into a single “1-hour bundle” with the
explicit intention of beginning resuscitation and
management immediately.”

Levy et al. Crit Care Med (2018)

 Surviving Sepsis 2018 : 1-hr Bundle

The Society of Critical Care Medicine (SCCM) and the American College of
Emergency Physicians (ACEP) acknowledge concerns expressed about the
recently released Surviving Sepsis Campaign (SSC) Hour-1 bundle.

SCCM and ACEP along with other involved international experts are organizing
a meeting ASAP to carefully review the recommendations, and provide
guidance on bundle implementation and care of potentially septic patients who
present to emergency departments in the United States.

We recommend that hospitals not implement the Hour-1 bundle in its present
form in the United States at this time.

Levy et al. Crit Care Med (2018)

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