Manajemen Gangguan

Hemodinamik pada Pasien

dengan Syok Sepsis
Pembimbing : dr.Eka Purwanto,Sp.An

Disusun oleh : Elfira Sutanto (31.191.021)

 Pendahuluan
● Syok sepsis  Kondisi gawat darurat
● Angka mortalitas sepsis cukup tinggi
● Gangguan hemodinamik
● Kerusakan sel Disfungsi organ

● Tujuan:
○ Memahami tinjauan pustaka mengenai sepsis dan syok sepsis
○ Mendiagnosis syok sepsis secara cepat dan tepat
○ Memahami tatalaksana yang tepat untuk pasien dengan syok sepsis
 Definisi Sepsis dan Syok Sepsis
● Sepsis :
○ Kondisi terjadinya disregulasi inflamasi dan respon imun secara
sistemik sebagai adanya respon terhadap infeksi
○ Kriteria :
■ Adanya fokus infeksi
■ Leukositosis atau leukopenia (>12,000/ul atau <4,000/ul)
■ Suhu : >38oC atau <36oC
■ RR > 20x/min
■ HR > 90x/min
■ Gangguan fungsi organ
● Syok Sepsis
○ Gangguan hemodinamik akibat sepsis

Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published 2016 Jun 30. doi:10.1038/nrdp.2016.45
 Epidemiologi
● Jumlah kasus:
○ Terdapat 31,5 juta kasus diseluruh dunia
○ 19,4 juta kasus diantaranya merupakan sepsis berat
○ 5,3 juta kasus sepsis berujung dengan kematian setiap tahunnya.
● Sejak tahun 1999 angka mortalitas yang disebabkan oleh sepsis dan syok
sepsis cenderung menurun.

Fleischmann, C. et al. Assessment of global incidence and mortality of hospital‐treated sepsis — current estimates and limitations. Am. J. Respir. Crit. Care Med. 193, 259–272 (2016).
This population-level epidemiological data from 15 international databases over the past 36 years demonstrate a high level of sepsis incidence in developed countries. By contrast, the study
emphasizes the paucity of sepsis data from the developing world.
 Etiologi Sepsis

01 02 03
Levy MM, Artigas A, Phillips GS, Rhodes A, Beale R, Osborn T, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort
study. Lancet Infect Dis. 2012 Dec. 12(12):919-24.
 Faktor Predisposisi

● Diabetes Mellitus
● HIV
● Usia tua
● Anak-anak
● Trauma dan luka bakar
● Penggunaan antibiotik yang tidak terkontrol

Levy MM, Artigas A, Phillips GS, Rhodes A, Beale R, Osborn T, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort
study. Lancet Infect Dis. 2012 Dec. 12(12):919-24.
 Patofisiologi

Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published 2016 Jun 30. doi:10.1038/nrdp.2016.45
 Manifestasi Klinis

01 02 03
Demam Gangguan
Mual, Muntah
Kesadaran

04 05 06
Fatigue Gangguan Disfungsi Organ
ventilasi
Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published 2016 Jun 30. doi:10.1038/nrdp.2016.45
 Gambaran Syok Sepsis

WARM COLD
SHOCK SHOCK

Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published 2016 Jun 30. doi:10.1038/nrdp.2016.45
Diagnosis
 Kriteria Diagnosis

Shock:
+ Gangguan hemodinamik dan
perfusi

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
Crit Care Med. 2013 Feb. 41(2):580-637.
 Pemeriksaan Fisik
● Keadaan Umum
○ Kesan sakit: sakit berat ● Status Generalis:
○ Kesadaran: delirium; GCS ○ Mencari fokus infeksi:
■ CNS : meningeal sign
score
● Tanda vital: ■ Thoraks : Suara nafas
○ HR >90x/min tambahan, pericardium
○ RR > 20x/min friction rub
○ Suhu : >38oC atau <36oC ■ Kulit: ulserasi, abses
○ Tekanan darah : MAP<65
mmHg
○ Gangguan perfusi (cold
shock)
Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published 2016 Jun 30. doi:10.1038/nrdp.2016.45
 Pemeriksaan Penunjang
● Laboratorium darah: ● Radiologi
■ Leukosit : >12,000 / <4,000 ○ Foto thoraks
■ Hitung jenis
■ Platelet : Thrombositopenia
■ PT/aPTT
○ Kimia darah:
■ Serum laktat: >2,5 mmol
■ Fungsi ginjal : Creatinine
dan ureum serum
■ Fungsi hati: AST, ALT,
Albumin,Bilirubin
■ Analisa gas darah

Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published 2016 Jun 30.
doi:10.1038/nrdp.2016.45
 Pemeriksaan Penunjang
● Kultur

Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published 2016 Jun 30. doi:10.1038/nrdp.2016.45
Penilaian Derajat Keparahan
Tatalaksana
 Evaluasi ABC
● Airway
○ Patenkan jalan nafas
● Breathing
○ RR > 20x/min
○ Oksigenasi
● Circulation
○ Menilai pulsasi arteri
■ Denyut lemah
■ Cepat : HR> 90x/min
○ Memperbaiki hemodinamik
 Terapi Cairan

● Cairan kristaloid:
○ RL: 30 mL/kgBB dalam 30 menit
● Koloid :
○ Albumin 5%
● Target capaian terapi cairan :
○ MAP mencapai 65 mmHg

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
Crit Care Med. 2013 Feb. 41(2):580-637.
 Terapi Vasopressor

Norepinephrine Dopamine
Dosis : 0,1 mcg/kgBB/min Dosis : 5mcg/kgBB/min

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
Crit Care Med. 2013 Feb. 41(2):580-637.
 Cara Pemberian Vasopressor

● Norepinephrine : (BB : 50kg)

○ Kebutuhan dosis : 0,1 mcg x 50 = 5 mcg/ min
○ Sediaan : 4mg/4ml
○ Diluted in Dextrose 5%
■ 4 mg Norepinephrine → 500 ml Dextrose
■ Dextrose + 4 mg Norepinephrine = 8 mcg /cc norepinephrine
■ Jumlah drip/min = 5/8 x 20 tetes = 12 tetes/min
 Cara Pemberian Vasopressor
● Dopamine : (BB : 50kg)
○ Kebutuhan dosis : 5 mcg x 50 = 250 mcg/ min
○ Sediaan: 200mg/5ml
○ Diluted in Dextrose 5%
■ 200 mg Dopamine→ 500 ml Dextrose
■ Dextrose + 200 mg Dopamine= 400 mcg/cc Dopamine
■ Jumlah drip/min = 250/400 x 20 tetes = 12 tetes/min
 Evaluasi Terapi Cairan dan Vasopressor
● Menilai tanda vital :
○ HR
○ RR
○ Suhu
○ MAP mencapai 65mmHg - dicapai dalam 6 jam
● Urine output ;
○ 0,5-1cc/kgBB
● Serum laktat < 2mmol/L

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
Crit Care Med. 2013 Feb. 41(2):580-637.
 Terapi DIC

● Indikasi transfusi platelet

○ Bleeding
○ Resiko bleeding:
■ Platelet : <50.000 ul
● Antifibrinolitik:
○ Asam traneksamat

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
Crit Care Med. 2013 Feb. 41(2):580-637.
 Terapi Empiris Infeksi
● Pemberian antibiotik spektrum luas 1 jam setelah diagnosis
○ Cefotaxime
○ Levofloxacin
○ Ceftriaxone
○ Meropenem
● Antibiotik yang digunakan lebih dari 1 jenis
● Pemberian AB 7-10 hari

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
Crit Care Med. 2013 Feb. 41(2):580-637.
 Komplikasi

01 02 03
ARDS AKI DIC

04
Disfungsi Organ

Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS
Data Brief. 2011 Jun. 1-8
 Prognosis
● Biasanya buruk
● Disfungsi organ
● Penilaian prognosis : SOFA score
 Daftar Pustaka
1. Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. Published
2016 Jun 30. doi:10.1038/nrdp.2016.45
2. Singer, M. et al. The third international consensus conference on sepsis and septic shock (Sepsis ‐3). JAMA 315, 801–810 (2016).
The third consensus update of the definitions
and clinical criteria for sepsis and septic shock. Although there has been an important effort to improve the understanding of sepsis, controversy
remains as to whether these new criteria will be useful or practical as early warning signs, especially in low-income and middle-income countries
where it is often difficult to obtain the required measures of organ injury.
3. Majno, G. The ancient riddle of σηψιζ (sepsis). J. Infect. Dis. 163, 937–945 (1991).
4. Matzinger, P. Tolerance, danger, and the extended family. Annu. Rev. Immunol. 12, 991–1045 (1994).
5. Deutschman, C. S. & Tracey, K. J. Sepsis: current dogma and new perspectives. Immunity 40, 463–475 (2014).
6. Kaukonen, K. M., Bailey, M., Suzuki, S., Pilcher, D.& Bellomo, R. Mortality related to severe sepsis and septic shock among critically ill patients in
Australia and New Zealand, 2000-2012. JAMA 311, 1308-1316 (2014). This is a retrospective analysis of an administrative database from >100,000
patients with recorded sepsis or septic shock. Mortality significantly improved in patients with both severe sepsis and septic shock, but did so at rates
that were comparable to other diagnoses.  
7. Gordon, M. A. et al. Bacteraemia and mortality among adult medical admissions in Malawi predominance of non ‐typhi salmonellae and
Streptococcus pneumoniae. J. Infect. 42, 44–49 (2001).
8. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301
acute and chronic diseases and injuries in 188 countries, 1990– 2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386,
743–800 (2015).
9. van den Boogaard, W., Manzi, M., Harries, A. D. & Reid, A. J. Causes of pediatric mortality and case ‐fatality rates in eight Medecins San Frontieres ‐
supported hospitals in Africa. Public Health Action 2, 117–121 (2012).
10. Martin, G. S., Mannino, D. M., Eaton, S. & Moss, M. The epidemiology of sepsis in the United States from 1979 through 2000. N. Engl. J. Med. 348,
1546–1554 (2003)
11. Gaieski, D. F., Edwards, J. M., Kallan, M. J.
& Carr, B. G. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit. Care Med. 41, 1167–1174
(2013). The incidence and outcome of sepsis were estimated using four different published methods; depending on the methods of
data abstraction, the incidence of sepsis in the United States could vary as much as 3.5-fold.
12. Levy MM, Artigas A, Phillips GS, Rhodes A, Beale R, Osborn T, et al. Outcomes of the Surviving Sepsis Campaign in intensive
care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis. 2012 Dec. 12(12):919-24.
13. Kotb M, Norrby-Teglund A, McGeer A, El-Sherbini H, Dorak MT, Khurshid A, et al. An immunogenetic and molecular basis for
differences in outcomes of invasive group A streptococcal infections. Nat Med. 2002 Dec. 8(12):1398-404.
14. Nooh MM, Nookala S, Kansal R, Kotb M. Individual genetic variations directly effect polarization of cytokine responses to
superantigens associated with streptococcal sepsis: implications for customized patient care. J Immunol. 2011 Mar 1. 186(5):3156-
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Terima Kasih