Kuliah Sepsis 2016

8/17/2019 Kuliah Sepsis 2016

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RISNA HALIM MUBINBAG. ILMU PENYAKIT DALAM

FAK. KEDOKTERAN

SEPSIS


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SEPSIS

Affects ± 700,000 e!"e #$% #cc!&$ts f!' ± ()0,000%e#t*s #$$""+ -$ US

I$c-%e$ce '#te -s '-s-$/ ± ).1 2 31 e' +e#' → s&'4-4#"

'#te -s !$"+ 1251 → %es-te tec*$-c#" %e4e"!6e$ts-$ IU 8 #%4#$ce% s&!'t-4e t'e#t6e$t

Bef!'e )937 t*e 'e%!6-$#$t #t*!/e$s: gram- negativebacteria, #fte' )937: gram positive (1, -$ t*e ((2+e#'

e'-!% t*e '#te !f fungal infections ↑ (071


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http://content.nejm.org/content/vol347/issue13/images/large/02f1.jpeg


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O$e !f t*e 6!st c!66!$ c#&ses !f %e#t* -$ IUs

O4e' #st ( %ec#%es, ↑ #%4#$ces -$ &$%e'st#$%-$/ !f pathophysiology of (severe) sepsis & septic shock, and

numerous new approaches to treatment → t!t#" $&6;e'!f %e#t*s c!$t-$&e% t! ↑

P!ss-;"e 'e#s!$s f!' t*e ↑ -$ -$c-%e$ce !f ses-s:-$c'e#se% &se !f invasive procedures,immunosuppressants, chemotherapy, transplantation,HIV infection, #$% microbial resistance

SEPSIS


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CLINICAL DEFINITION (SCCM-ACCP 1992)

SIRS: ≥ ( !f t*-s c!$%-t-!$s: te6e'#t&'e =( 66H/, @B 90 66H/ !' ↓ !f


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EXTENDED CRITERIA FOR THE

DIAGNOSIS OF SEPSIS

(SCCM/ESICM/ACCP/ATS/SIS 2001)

). Ge$e'#" 4#'-#;"es

(. I$f"#66#t!'+ 4#'-#;"es

=. He6!%+$#6-c 4#'-#;"es

. O'/#$ %+sf&$ct-!$

. T-ss&e e'f&s-!$


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Ge$e'#"4#'-#;"es

Fe4e' !' *+!t*e'6-# te6e'#t&'e < =3.=° !' > =5°He#'t '#te < 90 ;6 !' < ( SD #;!4e t*e $!'6#" 4#"&e f!' #/eT#c*+$e#, #"te'e% 6e$t#" st#teS-/$-f-c#$ce e%e6# !' !s-t-4e f"&-% ;#"#$ce < (0 6"?/ !4e' ( *H+e'/"+ce6-# PG < )(0 6/?%" !' < 7.7 66!"?" C*-"e %-#;etes #;se$ts

I$f"#66#t!'+4#'-#;"es

Le&!c+t!s-s < )(000?66= !' "e&!e$-# >000?66=N!'6#" @B c!&$t C-t* < )01 -66#t&'e f!'6sP"#s6# 2'e#ct-4e '!te-$ "e4e" < ( SD #;!4e t*e $!'6#" 4#"&eP"#s6# '!c#"c-t!$-$ "e4e" < ( SD #;!4e t*e $!'6#" 4#"&e

He6!%+$#6-c

4#'-#;"es

A'te'-#" *+!te$s-!$ SBP > 90 66H/, MAP > 70 66H/, !' SBP

%ec'e#se < 0 66H/ -$ #%&"ts !' > ( SD ;e"!C $!'6#" f!' #/eS4O( < 701#'%-#c -$%e < =. "?6-$ M2(

O'/#$%+sf&$ct-!$

A'te'-#" *+!e6-# P#O(?F-O( > =00 Ac&te !"-/&'-# &'-$e !&t&t > 0. 6"?/?* !' 66!"?" f!' #t "e#st ( *'e#t-$-$e -$c'e#se < 0. 6/?%"

!#/&"#t-!$ #;$!'6#"-t-es INR < ). !' #PTT < 50 sI"e&s #;se$t ;!Ce" s!&$%sT*'!6;!c+t!e$-# "#te"et c!&$t > )00000?66=H+e';-"-'&;-$e6-# t!t#" ;-"-'&;-$ < 6/?%" !' < 70 66!"?"

T-ss&ee'f&s-!$

H+e'"#ct#te6-# < ( 66!"?"Dec'e#se% c#-""#'+ 'ef-""


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Sepsis: Defining a Disease ContinuumSepsis: Defining a Disease Continuum

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

SepsisSepsisSIRSSIRSInsultInsult Severe SepsisSevere Sepsis

Ses-s C-t* ≥) s-/$ !f !'/#$f#-"&'e#'%-!4#sc&"#' 'ef'#ct!'+

*+!te$s-!$

Re$#"

Res-'#t!'+He#t-c

He6#t!"!/-c

NS

Met#;!"-c #c-%!s-s

Shock Shock

Infection

Bacterial,

viral,

trauma,

heat, etc


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PATHOPHYSIOLOGY

Ses-s -s # c!6"e -$te'#ct-!$ ;etCee$ 6-c'!!'/#$-s6s,t!-$s,#$% t*e -66&$e s+ste6, C*-c* 'es&"ts -$ #ct-4#t-!$!f t*e SIRS, c*#'#cte'-e% ;+ cytokine production(inflammatory mediators) #$% activation of the coagulation

cascade

T*e 'es&"t#$t effects t! t*e *!st #'e generalied

endothelial in!ury, increased capillary permeability,distributive hemodynamic compromise, coagulopathy,tissue ano"ia, #$% ischemia, #"" !f C*-c* c#$ "e#% t! t*e%e4e"!6e$t !f 6&"t-!'/#$ s+ste6 f#-"&'e


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PATHOPHYSIOLOGY


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M!"ec&"es '!-$f"#66#t-!$ 8 #$t--$f"#66#t-!$

P'!-$f"#66#t-!$ A$t--$f"#66#t-!$

TNF-α

IL-1β , IL-1α

IL-2

IL-6

IL-8

IL-15

IFN-γ

Neutropil

el!st!seProtein "in!se

#$P-1 % 2

Leu"e&i!

ini'itor( )!*tor

Tro&'o+!ne

Pl!telet !*tiv!tin,

)!*tor

Solu'le !esion&ole*ules

.!so!*tive

neuropepties

Pospolip!se A2

T(rosin "in!se

PAI-1

/ree r!i*!l ,ener!tion

Neopterin

$0 1

Prost!*(*lin

Prost!,l!nin

IL-1 r!

IL- IL-6

IL-10 IL-11

IL-13 T(pe II IL-1 re*eptor

TG/-βEpineprine

Solu'le TN/-α re*eptors

Leu"otriene β-re*4!nt!,onis&

Solu'le re*o&'in!nt $0

1

LPS binding protein

(LBP)


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Hoth!"ss et al N Engl J Med 2003;34#:2


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Endothelium

Neutrophil

Monocyte

IL-6IL-1TNF-

IL-6

Inflammatory Responseto Infection

Thrombotic Responseto Infection

Fibrinolytic Responseto Infection

TAFI

AI-1

!uppressedfibrinolysis

Factor "IIIa Tissue Factor

COAGULATION

CASCADE

Factor "a

T#R$M%IN

Fibrin

Fibrin clotTissue Factor

P#t*!*+s-!"!/+ !f Se4e'e Ses-sP#t*!*+s-!"!/+ !f Se4e'e Ses-s

Organisms


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MANAGEMENT

M#$#/e6e$t !f Ses-s

Diagnosis

L#; '!&t-$e

&"t&'e

R#%-!"!/-c e#6

B-!c*e6-c#"

6#'e's: LBP, PT,RP, IL

Therapy

Supportive"$-t-#" 'es&sc-t#t-!$

F"&-% t*e'#+

Ste'!-%s

V#s!'ess!'s?-$!t'!-c

Mec*#$-c#" 4e$t-"#t-!$

B"!!% t'#$f&s-!$

D-#"+s-s, /"&c!se

c!$t'!", RRT

Specific

A$t-6-c'!;-#"s

AP

S!&'ce c!$t'!"

M!%-f-c#t-!$ !f

-$f"#66#t-!$


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I%e$t-f-c#t-!$ !f H-/*2R-s Se4e'e Ses-sI%e$t-f-c#t-!$ !f H-/*2R-s Se4e'e Ses-s

GRAPH: $nsert ont"n%%&' (. 4' el)" #291' see attahed.

SPECIFIC

THE!P"


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S&!'t-4e t*e'#+

♣ -$-t-#" 'es&sc-t#t-!$, f"&-% #%6-$-st'#t-!$, 4#s!'ess!'s #$%

-$!t'!-c #/e$ts, ste'!-%s, ;"!!% t'#$sf&s-!$, 6ec*#$-c#"4e$t-"#t-!$, /"&c!se c!$t'!", %-#"+s-s, 'e4e$t-!$ !f DVT #$%

st'ess &"ce', ;-c#';!$#te, #$% 'e$#" 'e"#ce6e$t

Sec-f-c t*e'#+

♣ #$t-6-c'!;-#" #/e$ts, #ct-4#te% '!te-$ , s!&'ce c!$t'!", #$%

6!%-f-c#t-!$ !f -$f"#66#t!'+ 'es!$se

MANAGEMENTBase# on Surviving Sepsis Campaign guidelines for

management of severe sepsis and septic shock 2003


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Initi!l Resus*it!tion (early goal directed

therapy)

M#$-&"#te !f c#'%-#c 'e"!#%, #fte'"!#%, 8 c!$t'#ct-"-t+ t!#c*-e4e # ;#"#$ce ;etCee$ !+/e$ %e"-4e'+ 8 %e6#$%

A%6-$-st'#t-!$ !f c!""!-%?c'+st#""!-% f"&-%, 4#s!#ct-4e, #$%

t'#$sf&s-!$ !f PR

T*e f-'st 52*!&'s e$%!-$ts:

♣VP: 3 2 )( 66H/

♣MAP ≥ 5 #$% ≤ 90 66H/♣U'-$e !&t&t ≥ 0. 6"?/?*♣S4O( ce$t'#"?6-e% O( s#t&'#t-!$ ≥ 701


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Vasopressors and Inorop!c A"ens

St#'te% C*e$ #'!'-#te f"&-% c*#""e$/e f#-"s t! 'est!'e#%ete BP 8 !'/#$ e'f&s-!$

#orepinephrine or dopamine -s t*e f-'st c*!-ce t! c!''ect

*+!te$s-!$ -$ s*!c

I$ "!C O %es-te #%ete f"&-% #%6-$-st'#t-!$, &sedobutamine, -f "!C BP, c!6;-$e C-t* vasopressors

I$c'e#s-$/ c#'%-#c -$%e t! s&'#$!'6#" "e4e"s $!t'ec!66e$%e% → /!#" !f 'es&sc-t#t-!$ -s t! #c*-e4eade$uate levels of %2 delivery or avoid flow-dependent

tissue hypo"ia


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V#s!'ess!' #$% -$!t'!-c #/e$ts

Drug Pharmacologic ole Clinical Effect $sual Doseange

Epinephrine α2 8 β2#%'e$e'/-c#/!$-st

c*'!$!t'!-s6,-$!t'!-s6,4#s!c!$st'-ct-!$

2(0 µ/?6-$

%orepinphrine α 8 β #%'e$e'/-c #/!$-stα2 -s /'e#te' t*#$ β2

c*'!$!t'!-s6,-$!t'!-s6,4#s!c!$st'-ct-!$

2(0 µ/?6-$

Dopamine D!#6-$e 8 β2#%'e$e'/-c #/!$-st,'!/'ess-4e α2 effect

C-t* -$c'e#se% %!se

c*'!$!t'!-s6,-$!t'!-s6,4#s!c!$st'-ct-!$

(2(0 µ/?/ !fB@?6-$

Do&utamine β2#%'e$e'/-c #/!$-st c*'!$!t'!-s6,-$!t'!-s6, 4#s!%-"#t-!$

2) µ/?/?6-$

Phenylephrine α2#%'e$e'/-c #/!$-st 4#s!c!$st'-ct-!$ (2(0 µ/?6-$


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Sterois

I$ #t-e$t C-t* set-c s*!c 'e&-'e 4#s!'ess!'s, %es-te#%ete f"&-% t*e'#+, c#$ ;e /-4e$ -.4 *+%'!c!'t-s!$e (002=00 6/?%#+ f!' 7 %#+s

D!ses !f < =00 6/?%#+ *+%'!c!'t-s!$e s*!&"% $!t ;e &se%f!' t'e#t-$/ set-c s*!c

I$ t*e #;se$ce !f s*!c → $! 'ec!66e$%e%

N! c!$t'#-$%-c#t-!$ t! c!$t-$&-$/ 6#-$te$#$ce ste'!-%t*e'#+ !' &s-$/ st'ess %!se, -f $ee%e% f!' #t-e$t C-t*'-!' *-st!'+ !f ste'!-% t*e'#+ !' #%'e$#" %+sf&$ct-!$


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loo prou*t !&inistr!tion

O$ce t-ss&e *+!e'f&s-!$ *#s 'es!"4e%, $! AD, $! #c&te*e6!''*#/e, $! "#ct-c #c-%!s-s → ' transfusion !$"+C*e$ H; >7 /?%" t! t#'/et 729 /?%"

EPO -s $!t 'ec!66e$%e% f!' #$e6-# #ss!c-#te% C-t*se4e'e ses-s

R!&t-$e &se !f FFP -$ t*e #;se$ce !f ;"ee%-$/ !' -$4#s-4e'!ce%&'es -s $!t 'ec!66e$%e%

A$t-t*'!6;-$ #%6-$-st'#t-!$ -s $!t 'ec!66e$%e%

A%6-$-ste' platelets C*e$ c!&$ts >000?66=, c!$s-%e'C*e$ c!&$ts 0002=0000?66= #$% *-/* '-s !f ;"ee%-$/


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Intensive Insulin Therapy in the Critically ill

H+e'/"+ce6-# #$% -$s&"-$ 'es-st#$ce #'e c!66!$

4#$ %e$ Be'/*e et #" c!$%&cte% # RT !f )3 #t-e$ts t! e4#"te'!"e !f -$te$s-4e BG 302))0 4s c!$4e$t-!$#" BG )302(00 /"+ce6-c c!$t'!" -$ c'-t-c#""+ -"" -$c". se4e'e ses-s?s*!c

I$te$s-4e -$s&"-$ 'es&"te% -$

=1 %ec'e#se -$2*!s-t#" 6!'t#"-t+

51 'e%&ct-!$ -$ ;"!!%st'e#6 -$fect-!$

)1 'e%&ct-!$ -$ 'e$#" f#-"&'e 'e&-'-$/ RRT

01 %ec'e#se -$ 6e%-#$ RB t'#$sf&s-!$s

Van den erghe et al #*+ ../0 1234 /135-67


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A$t-6-c'!;-#" #/e$ts

I$t'#4e$!&s #$t-;-!t-c s*!&"% ;e st#'te% C-t*-$ t*e )st *!&' !fse4e'e ses-s, #fte' #'!'-#te c&"t&'es ;e !;t#-$e%

I$-t-#" e6-'-c#" #$t-2-$fect-4e #/e$ts s*!&"% -$c"&%e ) %'&/

#/#-$st t*e "-e"+ #t*!/e$s. T*e c*!-ce !f %'&/s -s /&-%e%;+ s&scet-;-"-t+ #tte'$s -$ t*e c!66&$-t+ 8 *!s-t#"

Assess6e$t s*!&"% ;e %!$e #fte' 327( *'s ;#se% !$6-c'!;-!"!/-c#" 8 c"-$-c#" %#t#. If c#&s#t-4e #t*!/e$ -s

-%e$t-f-e% ⇒ $! 'e#s!$ f!' c!6;-$#t-!$ t*e'#+

If t*e 'ese$t-$/ c"-$-c#" s+$%'!6e -s $!t %&e t! -$fect-!&sc#&se ⇒ st! #$t-6-c'!;-#" t*e'#+


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Act-4#te% P'!te-$

Act-4#te% P'!te-$ #$ e$%!/e$!&s #$t-c!#/&"#$t*#s anti-thrombotic, anti-inflammatory #$% pro-fibrinolytic properties

Eff-c#c+ 'ece$t"+ st&%-e% -$ t*e PRO@ESS st&%+(00) ⇒ -6'!4e% s&'4-4#" -$ #t-e$ts C-t* ses-s -$%&ce%!'/#$ %+sf&$ct-!$

D'!t'ec!/-$ #"f# 'ec!6;-$#$t *&6#$ AP, c!$t-$&!&s-$f&s-!$ #%6-$-st'#t-!$ !4e' 95 * ⇒ #'!4e% ;+ FDA


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Endothelium

Neutrophil

Monocyte

IL-6IL-1TNF-

IL-6

Acti&ated rotein '

Inacti&ation

Inacti&ation

Inacti&ation

r e & e n t i o n

o f a c

t i & a t i o n

Acti&ated rotein '

Inflammatory Responseto Infection

Thrombotic Responseto Infection

Fibrinolytic Responseto Infection

TAFI

AI-1

!uppressedfibrinolysisActi&ated

rotein '

R e d u c t i o n

o f R o l l i n (

I n h i b i t i o n

I n h i b i t i o n

Acti&ated rotein '

Factor "IIIa Tissue Factor

COAGULATIONCASCADE

Factor "a

T#R$M%IN

Fibrin

Fibrin clotTissue Factor

The Role of Acti&ated rotein ' In !e&ere !epsisThe Role of Acti&ated rotein ' In !e&ere !epsis

Organisms


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Short'term (ortality in )verall PopulationShort'term (ortality in )verall Population

0

5

10

15

20

25

30

35

Placebo

Drotrecogin Alfa (Activated)

In-Hosital2!-Da"

# 0$005 # 0$023

P e r c e n t % o r t a l i t " 24.7%

30.8% 29.4%

34.6%

'%8*99, ../


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Source Control

E4#"t-!$ f!' # f!c&s !$ -$fect-!$ -$c"&%e: %'#-$#/e !f#;scess !' f!c&s -$fect-!$, %e;'-%e6e$t, 'e6!4#" !f!te$t-#""+ -$fecte% %e4-ce

Se"ect-!$ !f 6et*!%s 6&st Ce-/* ;e$ef-ts 8 '-ss !f t*e

sec-f-c -$te'4e$t-!$: ;"ee%-$/, f-st&"#s, !'/#$ -$&'+

@*e$ # f!c&s !f -$fect-!$ *#s ;ee$ -%e$t-f-e% #s t*e c#&se!f se4e'e ses-s?s*!c, s!&'ce c!$t'!" 6e#s&'es #s s!!$#s !ss-;"e #fte' -$-t-#" 'es&sc-t#t-!$

If -.4 %e4-ces #'e !te$t-#""+ #s s!&'ce ⇒ '!6t"+ 'e6!4e%#fte' est#;"-s*-$/ !t*e' -.4 #ccess


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S##ARY

9epsis remains a serious cause of morbidity andmortality, while the pathophysiology of the disease isunclear:

;he syndrome of sepsis is a comple" interaction betweenmicroorganisms, to"ins, and the immune system, whichresults in 9I'9 activation characteried by cytokines

production, activation of prostaglandin, and coagulationcascade:


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;he resultant effects to the host are generalied endothelialin!ury, increased capillary permeability, distributivehemodynamic compromise, coagulopathy, tissue hypo"ia,and ischemia, all of which can lead to the development of

multiorgan system dysfunction or failure:

;he definition of clinical manifestations of sepsis and the

searching efforts for effective therapeutic interventions areever evolving:

S##ARY


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T!n" You


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Levinson 2773


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EN)$T$*IN'N!

'omplement

Nitric

o+ide

IL-1TNF-

Macropha(e

L!-bindin(

protein

Factors *II

',a MN

acti&ationTissuefactor

)I'%radiinin

'ycloo+y(enase

.prostanoids/AFLypo+y(enase

.leuotriens/

!tress

hormones

'RF

Endorphinhospholipase A0

Mandell G, 2002; Essential Atlasof Infectious Diseases

SEPSIS !%D B!CTEE(I!

4ram


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*PS'&in#ing

protein +*BP

Nu*le!rtr!nslo*!tion

*PS-*BPComple.

CD/0

T%F I*'/ I*'1 I*'2 I*'3 P!F IF%

*PS-BPIComple.

*PS#egra#ation

Increase# transcription

in!se !*tiv!tion

N/ "

*ipopolysacchari#e+*PS

negative&acteria

B!CTEICID!*Permea&ility'increasing

protein +BPI

P(%

4protein

(acrophage

*iver


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LPS &

&

CD#$

Macropha"e

TNF % IL% IL&'% IL&(%p)ee)e&ac!*a!n" +acor

Ac!*a!on o+coa",)a!on

cascade

Prosa")and!n

)e,kor!ens

Ac!*a!ono+

co-p)e-encascade

ARDS

DIC

Endohe)!a)da-a"e

MOF

.acer!a))/s!s LPS

0!nd!n"proe!n

LPS 0!nd!n"

pro!n co-p)e1


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!ite of infection pulmonary infection2 intra abdominal infections2intra&ascular infections2 (enitourinary infections2 3ound and sin-related

infections

Antimicrobial dosin(

'ombination antibiotic treatment

Mechanisms of antibiotic resistance

)iscontinue antibiotics at the point 3hen the infection has cleared

ANTI%I$TI'-IN)4'E EN)$T$*IN RELEA!E

!%TIBI)TIC SE*ECTI)% B!SE )%


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E#'"+ ;-!c*e6-c#" e4e$ts -$ ses-s

S S S S S C S S


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SEPSIS% SIRS% CARS% MARS (Bone,

1997)

%ld paradigm for sepsis0

infection

⇓

en#oto.in 5 other micro&ial to.ins

⇓

proinflammatory state 6ith cyto7ine release an# otherproinflammatory me#iators

⇓

sepsis - SIS

⇓

shoc7 5 ()DS 5 possi&le #eath


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SEPSIS% SIRS% CARS% MARS (Bone, 1997)

I$-t-#" -$s&"t ;#cte'-#", 4-'#",

t'#&6#t-c, t*e'6#"

L!c#"

#$t--$f"#66#t!'+

'es!$se

L!c#"'!-$f"#66#t!'+

'es!$se

S+ste6-c s-""!4e' !f'!2-$f"#66#t!'+

6e%-#t!'s

S+ste6-c s-""!4e' !f#$t-2-$f"#66#t!'+

6e%-#t!'s

Systemic reaction

SIRS?'!2-$f"

ARS?#$t-2-$f"

MARS?6-e%

!!t!s-s

De#t* C-t*

6-$-6#"

-$f"#66#t-!$

H!6e!st#s-s

ARS 2 SIRS

;#"#$ce

C#'%-!4#sc&"#'

c!6'!6-se

s*!c

SIRS

'e%!6-$#te

)'/#$

%+sf&$ct-!$

SIRS

'e%!6-$#tes

S&'ess-!$

!f -66&$e

s+ste6

ARS


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9tages of the development of 9epsis-%


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%ot &eneficial

A$t- TNF %!se %ee$%e$t -$c'e#se -$ (3 %#+ 6!'t#"-t+

A$t- E$%!t!-$ #$t-;!%-es

A$t- IL2) 'ecet!' #$t#/!$-st

⇒ G'e#test ;e$ef-t -$ #t-e$ts C-t* *-/*e' 6!'t#"-t+

⇒ M!st #$-6#" st&%-es &se 'e2t'e#t6e$t '!t!c!"s


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%orepinephrine

P!te$t α2#%'e$e'/-c #ct-4-t+

Less ;&t s-/$-f-c#$t β2) #ct-4-t+

L-tt"e !' $! c*'!$!t'!-c effect %&e t! effect !f-$c'e#se% 4e$!&s c##c-t#$ce !$ ;#'!'ecet!'s -$'-/*t s-%e !f *e#'t

N! "#'/e c"-$-c#" t'-#"s c!6#'-$/ !&tc!6es C-t*%-ffe'e$t 'ess!'s

P'efe''e% #/e$t f!' ses-s


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Dopamine

V#'-#;"e *+s-!"!/-c effects %ee$%-$/ !$ %!se

>(6c/?/?6-$ st-6&"#tes %!#6-$e 'ecet!'s 'es&"t-$/-$ 4#s!%-"#t-!$

2)0 6c/?/?6-$ st-6&"#tes β) 'ecet!'s, -$c'e#s-$/c#'%-#c !&t&t


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Dopamine

D!se 'es!$se 4#'-#;"e -$ set-c #t-e$ts

M#+ %ec'e#se PO( ;+ -$c'e#s-$/ I #$% e'f&s-!$t! !!'"+ 4e$t-"#te% "&$/ &$-ts

!$t-$&!&s "!C %!se %!#6-$e t! #t '-s #t-e$ts$! effect !$ %ec'e#s-$/ 'e$#" f#-"&'e

ellomo et al =ancet ...41360/15-21


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Phenylephrine

Se"ect-4e α) #/!$-st

I$ t*e!'+ $! effect !$ *e#'t '#te !' I ;&t O c#$%ec'e#se


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8asopressin

Act-$/ 4-# V) 'ecet!'s -t #cts #s !te$t4#s!c!$st'-ct!' -$ 4-t'!, "ess !te$t -$ 4-4!

Se'&6 c!$ce$t'#t-!$s '-se -$ c#'%-!/e$-c #$%

*+!4!"e6-c s*!c #$% #'e -$#'!'-#te"+ "!C -$set-c s*!c

@*-"e s+ste6-c ;"!!% 'ess&'e 6#+ '-se 6#+ /et #s-/$-f-c#$t f#"" -$ s"#$c*$-c ;"!!% f"!C


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8asopressin

D!&;"e ;"-$% "#ce;! c!$t'!""e% st&%+ !f )0 #t-e$ts

P'-6#'+ e$%!-$t C#s *e6!%+$#6-c 'es!$se

V#s!'ess-$ -$f&s-!$ #t 0.0U?6-$

S-/$-f-c#$t -$c'e#se -$ MAP 55 t! 303, >0.0

SVR -$c'e#se% f'!6 373()3 t! ))90()=, >0.0

M#"#+ et #" J T'#&6# )9997:599


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T'-#" %es-/$ -$te$s-4e -$s&"-$ t*e'#+

P#t-e$ts #%6-tte% t! s&'/-c#" IU, 6ec*#$-c#""+ 4e$t-"#te%

A"" #t-e$ts 'ece-4e% (002=00 / /"&c!se?%#+ !$ #%6-ss-!$

TPN !' #'e$te'#" f"&-% C-t*-$ ( *!&'s !f #%6-ss-!$ C-t*

502301 /"&c!se c#"!'-es

!$4e$t-!$#": t-t'#te /"&c!se t! )302(00 6/?%L

I$te$s-4e: t-t'#te /"&c!se t! 302))0 6/?%L



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R!"e !f I$te$s-4e I$s&"-$

I$te$s-4e -$s&"-$ 'es&"te% -$

=1 %ec'e#se -$2*!s-t#" 6!'t#"-t+

51 'e%&ct-!$ -$ ;"!!%st'e#6 -$fect-!$

)1 'e%&ct-!$ -$ 'e$#" f#-"&'e 'e&-'-$/ RRT

01 %ec'e#se -$ 6e%-#$ RB t'#$sf&s-!$s



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R!"e !f I$te$s-4e I$s&"-$

Conventional Intensive

Insulin(median units/day)

== 7)L

Duration of Insulinuse ( IC! days)

57 )00L

"# glucose(all patients)

)= )0=L

"# glucose(Insulin patients)

)7= )0=L

Van den Berghe et al NEJ 200!: 34"# !3"9$67 P&0.00!


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Kuliah Sepsis 2016

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