8/20/2019 02. Sepsis - Prof. Suharto [OBGYN]
1/8
3/2/20L2
I
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--1
SEPSIS
:
_*t
Suharto
Sepsis:
Defining a Disease
Continuum
'?';ix '
srRS
Sepsis Severe
Sepsis
I
s"pli"
"ith
"1
.is" .f
fi;i
I failure I
'
Cadlovscular0el@iory
I
-
hypdcnslC{l)
I Rcnal
\
'
fi:;:lil'"
t5hocl,li
i lcmatologtc
I
I
cils
i-. t*t"1"-:"lge'"
---
I
Emd
al. GhS 1992i101:1044ikwad
Beha.d,
NE@lJMd1W9,W:N
Relationship Of
lnfection,
SIRS, Sepsis
Severe
Sepsis
and
$eptic
$hock
Modality lncreases in
Septic
Shock
lnciGnce
Mortalitv
$epsis:
Defining a
Disease
Continuum
lnfectiorl
Trauma
SIRS
Sepsis Severe
$epsis
L
.
KsrpltrBns >rur-Tl:t
, i
glRS
=
Syslemia lnflemalqry
Respon$e Syhddhe
I
.
wBc @unt:1l0oo/frmr
ar
l
I
s4,M/ffir
o.
>tovo
l
i
irnsltur€
neutrcphilr
l
Adaprd
hm:
Bdne Rc.
st
al. cN
1992:101:164
Caar S, €t
31.
Cd CaE ffi mC€;28:sE1
Deficiencies of 1991
Consensus Conference
r
Limitations inherent in these definitions:
.
lncomplete agreement as to what defines
"Systemic
Response"
r
Inflammation only?
r
Organ/System failures
not
defined
r
Except
hypotension
(sBP
40
mml'lg decline from baseline; need for
vasopressor support)
"Dear
SIRS,
I
do not like
you"
Jean Louis Wncent
8/20/2019 02. Sepsis - Prof. Suharto [OBGYN]
2/8
3/2/24L2
2001
Sepsis
Definitions
Conference
.
Current
definitions will remain unchanged
r
However,
will accept
the
uncertainty
of definitions
.
SIRS expanded to eiEns and
gymptoms
.
Chills
.
Alteratlon
in
temperatura
.
Tachypnea
'
change
in
m€ntal
st€tus
'
Tachycardia
.
Altered
WBC,
Bandemla
.
Thrombocytopenia
.
De€reased
perfusion;
mottling,
poor
cqpillary refill
.
lncreased blood sugar
.
Petichine/Purpura
tciin-toatpricccepl-iimifeisf oidmodyna;icsupptti-
j
ofpedlatrlc and neonatal
patlents
in
septic
shock*
i
i
Joseph A. Carcillo, MD; Alan L Fields, MD; Task
Force
I
i
Committee Membels.
{Crit
Care Med 2002; 30:f
365-
i
i-*-,
-
--
-
----:lt-2,8l
---J
r
Shock
pathophysiology
and
r€sponse
to
therapies
is age
sp&ific.
For
example, €rdiac
I I
failure
is
a
prodominant
cause of
death
in
I
neonats
and
childr€n,
but
wscular failure
is a
|
.
\
predominant
ca$€
of
d€ath
in
adulE.
l_
_
-
2'
lnoBopes,wsodilators{children),inhalednitric
.'
oxide
(neonats).
and
exfacorpor€l membEne
oxygenation
can
be more
impodant
contributoF
to
suruival
in
ths
pediakic
populalions,
whereas
r
vasoptossors
can be
more
important
contributoF to
adult
$urvival.
;;;hf..l
I
rlrlr$1rl
cohl:ilfqa
l
.;Lt1" I
lor-rarl.
l
1*jil
2.
necdmeMions
torstq$s.maEFmant
dbc@dFftip
rspd
tntem nMoms
#tig*ls
otnomd
Ftuion
ad
pffidon
presture
lnsn
ddalge$uE
edElve@s
resse)
and
Fedld3l
atu
pod{wtd
qy$n
sa@tlon
dtr€reffi ot
5%. P@ead to e*
dS lf sh6k
ped s.
2
2001
Sepsis Definitions Conference
FXRO staging system
proposed
'
Fredisposition: Genetics, Chronic
illness
.
fnsult:
Infection, Injury,
lschemia
.
Response:
Physiologic, Medrators, Markers
.
Organ Dysfunction: outcome, Organ dysfunction
To
be
pdi6hed
?00?
{vsd
ctrtucatid Mltchct
lry, sccM
?002)
pd,odto.ln
MEtuondwsWMEG.
m&oDhib.
Dlalel#
and endothelw
*aseswdos cyroknes lnd dhr
ftdato.E
tL€ [,a lL'10
9SF
Pded
Prdnftmd5ry
6trect
bdrop$ cturchdc ftdo.
Ms
Es
prun,
tudaie6
B and
T
ll4@yte
pDffie.ation,
iMbts
cytokn€
pdwliff.
id6$
immunos#€don
Ad€{ion
6nd
&gaouhfion
d
nedophb
Cyl& .. au@nb Eocurr
Fmeabifty
@dribde6
10
sto*
lNtud hbdlmsic ater.tons
olsqnc
€hock
Promde
sedqhil
and ftsodE$.
pW#
adMgon
ad che@ds
dBprciniammioy
ffied6
Enboe wc&r
Ffrls$Fty
and coddMec to
&ng
injq
hance
Mr4illaddhdia'
€n lilaadlm,
reg&te
Hksyle
doEtim
aod aft6€ioa. and
play
a
rc16
h
Fsogffijs
sf €psis
medtttrg
Litid
rudatoB
Pnorpirlipase A?
Ecdel6
kchidonic
aqld
mdabdlit6€
trds
m&cdes
Sl6din6
Ledocyte
idqdne
Flff6
l. Rocommddons
lor dwi$
f,a{6ll@ of hmodnmb
Wpd
h
itu6
affikn
*
gd6
ot
nd
pl1&n.nd ptun
prrBs6
(ms
d6dal
pr.ss
csMd
v6muc
pr6ssuo
lffAp
Cyq].
Prcc.ed
to n6xr
rr.p
il
sho*
p6Ehs
8/20/2019 02. Sepsis - Prof. Suharto [OBGYN]
3/8
uu2aL2
HTSTORY
I
Y
r---iNienve-runoNs
AND
--
-*l
i_
_enngrslqrgo1ygqEBEp
_-,]
o
Vasopressor therapy
as needed
(norepinephrine,
dopamine, vasopressin)
r.
lnotropic therapy (dobutamine or
a
combination
of
dobutamine and
a
vasopressor)as
indicated
s Steroids (hydrocortisone
with
or
without fludrocortisone,
dexamethasonel
s. Recombinant
nr*"n
activated
protein
C
(rhAPC)
ro.
Blood
produci
administration
{red
blood
eell
transfusion,
erfihropoietin,
fresh
fozen
plasma,
antithrombin*,
piatelets)
rr
Mechanical ventrlation
ofseDsis-induced acute luno
injury
(ALl)/adult
respiratory'
distress
svndrome
(A{DS
)
\
.6.4,:
s*rws/$s
r
,.,
S*,F*I#
{3$f :9J$r''l,,
i
tNfECtENfaoNs-AND-
---
l
l
L,_,_l8AqrpEg
qgugtp_E_REp,
__,
l
ra. Sedation,
analgesia,
and neuromuscuiar
blockade
rs.
Glucose control
r Renal replacement
{hemofiltration,
hemodialysis)
rs Bicarbonate thetapy*
ro
Deep vein thrombosis
(DW)
prophylaxis
(low-dose
unfractionated
heparin, low-molecular
weight heparin,
mechanical
prophylactic
devices)
rz.
Stress
ulcer
prophylaxis
{H2
receptor inhibitors)
re. Consideration for
limitation
of
support
rg
Pediatric
considerations
\.
-.:,.lrl-
#u.wv n*t
-"
SdpsJs
4i3or
r
4r
*
?grr
r
3
PATHOGENESIS
roasAr nr
o,frr
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i-
sPfl3 ru
n,ln
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iltJ
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rirnr ,d
f
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.,:
r\,
I a
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\:r'r-r
F'
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it't-/
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TABLE
1,
lEFNF$re
Of
SEF3HANS IIELATEO CdUTNS
it8S2.1S?);
FROTOS€O PIRO
cussFEATEil
WffiE
FOft
aEp93
IAOArE
FRil
?0Q3 cOflSHSUs
pApEF
:-llti-"-.ji-ii..-..-,,--...,-,
tnf
lamft
ery
R6.pon*
{$ts}
scDsi.:sIRs
+
id&n
'Qr*
sls)
HHrn
s.Ptdeft6k
$Fjs
xlb hy@rGid
dqlb
Abrd @*n fudon h an.cuhly lllFbntl
INTERVENTIONS AND
PRACTICES CONSIDERED
initial re$uscitation
Diagnostic studies,
as
indicated
l.lmaging studies, as indicated,
such as ultrasound
2" Blood cultures
and
culturee
from other sites, as
indicated, such
as urine, cerebrospinal fluid, wounds,
respiratory
secretions, or other body {luids
: Antibiotic therapy
r
Source
conkol
mea$ures
s Fluid therapy
1.
Natural or artificial colloids
or crystalloids
2.
Fluid
challenge in patients with suspected hypovolemia
\
"
ar,
"'
S {reiFrnSr
i
,r
sG/EsJs
Catt4t algt
t
8/20/2019 02. Sepsis - Prof. Suharto [OBGYN]
4/8
312/2AL2
i--
Anti6ibtiEThe-rapv
-
"t
L----,.,---
"
lntravenous
antibiotic
therapy should be stiarted
within
the
first
hour
of
recognition of
severe sepsis,
after appropriate
cultures
have
b*n
obtained. {
E
}
"
lnltial empidcal anli-infective theapy should
include
one
or
more
drugs
that have activity against the
likely
pathogens
{bacteriai
or
fungali
and
tha
pen€tate
into
the
prasumsd
soure of spsis.
The
choice
of
drugs
should
be
guided
bythe
(
O)
"
The
antimicrobial regimgn should always
b6
reassessed
ater 48-72
hrs
on
th6
basis
of microbiological and clinical
dala
wiih the
aim
of
using a
narow-spectrum aniibiotic to
prevent
the
development of
resisiance,
to
reduce toxicity, and
to
roduce
msts. Once
a
Gusatlve
pathogen
is
idedmed, ther€
rs
no
€lidenc€
that
combinalicn
th€tapy
is more etfectiv€
than monotherapy.
The
duration {d
therapy
should
iypicafiy
b€
7-1 Q
days
and
guid€d
by
clinical
response-
(E)
1
"4'ilsrviyrrr€
1
S
6Jt-+iat
*eur1:r ei91
I
i__- _4ii lib
L{F,[F'?
p[__
_ _,r
,
Some
experts prefer combination therapy
for
patients
with
Pseudomorlas infections,
(
E
)
"
Most experts would use
combination therapy for
neutropenic
patients
with
severe sepsis or 5eptic
shock. For
neutropenic
patients,
broad-spectrum
therapy usually
must
be continued for
the
duration
of the neutropenia.
Grade of
R€commendationr
(
E
)
"
If
the
presenting
clinical syndrome
is
determined
to be
due
to a noninfectious
cause, antimicrobial therapy
should be
stopped
promptly
to minimize the development
of resistant
pathoEens
and superinfection
with other
paihogenlc
organisms.
(
E
)
'
:i
.r
s.5psj*
S+rr;r*u'yr
r
SEP5IS MANAGEMENT
."
M].t'M
fhe
ooal
6
to
F{orr
al
,ndhted
tasis
fffor€
to ac@mplish lhese
goal6
should
b$rn
100rh
ot
rhe
r4e
dhin ihe
i.sr
6
n
of FTedr#rt.
biltfhese
ftems may be
conpieted
identification of
severe
gepsj9.
wiihin
:it
h
oi
prsanbtbn
for
palients
wfth severe
sepsis
ot s6ptic
ahock
M6SUre
$rum lac€te
Obbin hlmd c ltures
befo.e
antibidic
admin&{sn
Admrnisier
b16d-spedrum
antibroth
y?fr
hh
3 h d ED edmission end
wfrin
t h
of
dGntifrcation of 6epsis
on
the
hospltal fler
ln the
Mnt
of hypotens'on and/or
a serum
lachb
'4
mmol/L
Deltuer an
inthi
minimum
ol
20
hllko
cryslilloid
or
equvalen'l
Apply
€gopressors
ior
hyFtenston
not
respoh0rngto
initral
fluo
Resuscitatr
lo
maintain
MAP
>65
mmhg
ln
the event
oi
pe sEtent
hypotenglon
desprF
Adoquate
fluld
resuscitation
{septlc
ahock)
And/or
lachte
>4
mmolll
AchieveaCVPSmmhg
Achieve
an scvot
70% oasvoi 6i%
funm
ster
ltu-oosage
steroids
{or
gepr,c
sn@k ln
eodane*t\
a
shndardired CU
Fhc .
J
mt
adrnrnse.eo
then aocumeni
wly
the
pat,ent
dd
ndquallfy
for
l@-dosage
steroids besed oa
the
standa.dized
protocol
Administsr
rhapc-xigns
in rccordance
with
r
stanoamized'CU
polrcV,
f not
adnrnJftred,
then
documentwhy the
patient
did notqualfyfor ftapc
lvain?ain a median
lFp
30
cmhp fol
mechanically
ventiiated
patients
r
.::;":,:;,s{rrvryrns
'l
-/
: erl*i$
f*:-.rFai:ilrr
S€PSIS MANAG€MEN1:,
R6uicihtirn .nd Inl€dion
Esuacibtlon
(fid
6h6)
Cherk
4rum lr.tab
to aid in rEsus.ilalion
qoals
.
&din resu*lbtidn
'nrmdiarelv
rn DG { tr
h-,yDotension or elevated lact;c:
ilo
not
d6lay
psndrns
ICU adm,s5ron
(1C)
. cesuscibbon
s€ls
(1C)
a) flP
8-12,
b)
MAP
i 65mmHo: c) urine olbut :
0.5m
/kq/,hr
,
teln
cuitures
before
aillibiahcs
{1C)
a)
So
or more
rcs;
b)
one
or morc
should b€
Frcutaneous;
c) one
8C kom
6ach vascular
a..ess
device io
Dl..e >
4Ahrc;
dl .ulture
orh€r
siFs
as
cInicarly
lmadind *udier D.omorlv b coilfirm and
simulew sirce cit iifxtion
,f
sare b
ntibiod.
Thenpy
Beqln
orodd
sgedrum
IV abx w/rhrn the
fiEt
hour
oi
recoqnhinq
severc sepsrs
(1D)
and seDtic shock
{1Cl
L-€i f G?e
Ed@qt
q'
m-, .:l
.
Sourc€ idahtilEatior rdd aonkol
r
Esteblish
anltomjc
siie of infuction
ilC)
.
Implement
sou€e
control measures
(1C)
. R€move
inlEvasc0iar
a.ae5s
davices iF
potentially
inf€cted
ilC)
heeodvnamJc
Suppct trd Adiundive
FluidThcrepy
.
Fluid
aerusciule rsinc
crys6ilo,d5
o.
colloros
(18)
.'larsercVPre(lC)
.
Grve flu,o
challenag o'1L
crysbllords o 300.
500m1
of
collords over l0
rirns
(l
D)
.
Majnbin
UAP
>
85mmHg
.
NoreDineDhnf,e Bnd
domnrne
are the
'nitlal
aioDrisrs
or chorce
{
1C)
Va$Drsrn
0.03 uf,lts/mrfi
ma
be
sutiseqiently
aod€d {ir
andiipat,o.
of
al
effecL equ,valent to noreprnephflne alone
(2C)
.
b
not use low-dose dopamrne
for
renai
.
In
D6
,€dunrno insd
arteral
caherei
(1Dl
.
Rsssess abr dail/
to opllm,?e
effrc.c ,
Drevedt
rerbirce, avod to1i.itv,
Bnd
m rimiz€
cos6
{lc}
.
Consder
ombinabon
dreraev in
tueudomr$ rnfebors
(2b)
r Gmbination
thEraDv
31"5
dAVs and d€
lnotropic
tfi+rrpy
.
U5e dobuhmrne in
pE
wth
mytradr3l
dysluncuon
in
pts
wiffi
low CO
{1C)
. Do not
in.rsse radlac
index to
4
8/20/2019 02. Sepsis - Prof. Suharto [OBGYN]
5/8
Consroer
lv hydrocodsone
when
hvmbnsron
r€soonds Doorlv b flurd resuEcrtatlon and
vasopressbE
{lc)
,r
acTH stimulation
test
not
reommerded
(28)
hvorocodsone
D,eled€d b apxamethd50ne
128)
.
nrorocorlrr.ne do €
shodld
be
sl00
mq/day
{1a)
Rssmbinlrt
humin
6b Bd
p@ir
C
CoilsrderhAPc
In
pb
wldl
sFsr5-induced
oroan d/sfLncUon
*;Ur
cll&caJ
as*ssqenr
oflrdh isk
o
d€ad
f thera aru no
(ont;arndrcat,ons
(28,
2C
for
pstop€ralive
Ftiens
Oth6r SuFpoftka
TherrFy
glood
Produclg
.
6rve RBCa whe4 Ho < 7 ro
Hroet
Ho
ci
7 0-
I
0
{18).
A
hrqhelr Hr
may b€
req-uired in
5p*Ltsl.rrcumstincs
(€.9
myGadial
lschem)a,
*vere
tryFxefrra,
{cure
h€morhdg€,
q4nohc
head
disa*,
or
Lo noi
uF
e.ythropolebn
to
treat *psrs.
r€iaEd anemia, lt
mat
be u*d
for
dh€r
acc€pEd Easo4s
(16)
F
not
Jse
f+ b
corr€(t
laboratory
ilottug
ahn6rmalt,ec unlF
r2@;tr
t,.,
i.00i
/Lror*i :
riri
in'r.u,€ bNe
lrirft
C{eicrya
p,a(€ i
>
I
50:bove ihc,o,,iil
viile
PbrnF
r,o.iJrtroni.
>
2 SD
ibcve ftc roil.il litic
s'{ok ul*i
p,.${€
<
c0
n\.i H€o.
*in
1
rura
br@d
pr.n,'.e
tsi:.d
ve.orr
axtEan
3r.rEr6n
>
704
Cndri( iter
>
3.5 L,rnin H
1r
O4r,
dtsfunaz{ 4.dier
Ur&. qu
<
0.5
sL:kB' irrcr r
t
'nrol
HrFe.hdilqn,a
>
I mfto/L
ha
B
od
v,
am
Ic
cI
stqbe
@,
w8
alyslbrtlgh or t/66w
I
Ert6io, alromslltr*
Research article
serum
procalcitonin
elEvation in
critielly ill
Fati€nts
at the
onset
of
bacteromiacausd
by
elihrr
gram
negative or
gram
positive
bact€rla
Conclusion: In a critically ill
patient
with clinical
sepsis, GN bacteremia could be associated
with
higher
PCT
values
than those found
in
GP
bacteremia, regardless of the severity of
the
disease.
i
Sepsisi
t
.
Vasodilatation
.
Distributive
shock
ri
.,
1
N
Enql
Jil6d
?0tr,351i1594
5
8/20/2019 02. Sepsis - Prof. Suharto [OBGYN]
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The localizing symptom$
referable to organ
systems may
provide
useful clues to the etiology of
sepsis and are as
follows:
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Head
and neck infections
-
Ear*che,
sor€ throat, sinus
pain,
or swollen lymph
glands
.
Chest
and
pulmonary
infectlons
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(especially
if
productive), pleurltlc
chest
pain,
and dyspnea
r Abdominal and cI infectlons
-
Abdominal
pain.
nausea,
vomiting, and
diarrh€a
. Pelvlc and oenitourinarv lnf€ctiong
-
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vaginal or
irethral
discharge, and urlnary frequency and
urgency
.
Bone
and soft tlssue lnfections
-
Localized
llmb
paln or
tenderness,
focal
erythema,
edema, and
swollenJoint
Empirical antimicrobial therapy
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lnie€lloft
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and Some o{ lhe
Follwlng
TABLE 1.
I
c*;rr"t
"*irfi;-
DTAGNOATIC CRITERIA
FOn SEPSTS
ACCORDING
10
THE
$EPSIS
D€FIHIlIONS
CONFgnErilcE
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or
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Ileo,
Hyrrbilitobincmit
Silt*flr
EFKS
TABLE2.
THE PIRO
CONCEPT
I
Clinical
I
OtherTests
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R
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Malaise
temmmrure
heart
rale.
,
WBc cRP
pcl
modrfied
respimtoryrate
iAPTT
{oroan
dysfunction}
I
Artedal
pressur€,
urine output,
I
Paor/F,",
creatinine,
Giasgow coma score
]
Dilirubrn.
plaielets
8