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Aries Budianto

Divisi Bedah Digestif Departemen Bedah


RSUD Saiful anwar fk. Universitas brawijaya
Old definition :
SIRS + SEPTICHEMIA

Currently :
Shift of foccus from Inflamation to Organ Dysfunction
Sindrom Klinis
Respon Host terhadap
Infeksi
Proses Sistemik
Melibatkan Multi Organ
Sepsis : life-threatening organ dysfunction due to a dysregulated host response to
infection
Severe Sepsis : as sepsis plus sepsis-induced organ dysfunction or tissue
hypoperfution
Septic Shock : a subset of sepsis in which underlying circulatory and celluler/metabolic
abnormalities are profound enough to substantially increase mortality
as sepsis induced hypotension persisting despite adequate fluid
resuscitation, and having serum lactate level >2 mmol/Lgggg
Mortality > 40 %

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)JAMA. 2016;315(8):801-810.
What differentiates sepsis from infection is an aberrant or
dysregulated host response and the presence of organ
dysfunction
Organ dysfunction can be idetified as an acute change in total
SOFA Score >/= 2 points consequent to the infection
A SOFA score >/= 2 reflect ,
Bacterial Product
And Component
Activation of Coagulation
And Complement TNF a
System IL-1
IL-6
Tissue Factor Release
PAF
Fibrinolytic acitvity Macrophage NO
etc

Neutrophyl Metabolism of T cell Release


Activation Platelet Arachidonic Acid
Activation Of IL-2
Agregation Release of IFN gamma
Degranulation Aggregation Tromboxane A2 GM-CSF
Release of O2 PGS, LTS
Radical and
Proteases
Endothelial Damage

Tissue Injury

Organ Dysfunction Source : Medscape.com


IDENTIFYING ACUTE ORGAN
DYSFUNCTION AS A MARKER OF
SEVERE SEPSIS
Altered Tachycar
Conscious dia
ness Hypotens
Confusion ion
Psychosis CVP
Oliguria
Tachypnea
Anuria
PaO2< 70

mm Hg
Creatinin
SaO2 < 90%
e

Jaundice
Platelets
Enzymes
Albumin PT/APTT
PT Protein
C
D-dimer
Titrate oxygen to a saturation target of 94%
Take blood cultures.
Administer empiric intravenous antibiotics.
Measure serum lactate and send full blood
count.
Start intravenous fluid resuscitation.
Commence accurate urine output
measurement.
Give 3 Take 3
1.OXYGEN: Titrate O2 to saturations 1. CULTURES: Take blood cultures
of 94 -98% or 88-92% in chronic lung before giving antimicrobials (if no
disease. significant delay i.e. >45 minutes)
and consider source control.

2. FLUIDS: Start IV fluid 2.BLOODS: Check point of care


resuscitation if evidence of lactate & full blood count. Other
hypovolaemia. 500ml bolus of tests and investigations as per
isotonic crystalloid over 15mins & history and examination.
give up to 30ml/kg, reassessing for
signs of hypovolaemia, euvolaemia,
or fluid overload.

3. ANTIMICROBIALS: Give IV 3. URINE OUTPUT: Assess urine


antimicrobials according to local output and consider urinary
antimicrobial guidelines. catheterisation for accurate
measurement in patients with severe
sepsis/septic shock.
Following initial stabilization, patients with severe sepsis and
hyperglycemia who are admitted to the ICU receive intravenous insulin
therapy to reduce blood glucose levels (grade 1B).
Validated protocol for insulin dose adjustments and targeting glucose
levels to the <150 mg/dL range (grade 2C).
We recommend that all patients receiving intravenous insulin receive a
glucose calorie source and that blood glucose values be monitored every 1-
2 hrs until glucose values and insulin infusion rates are stable and then
every 4 hrs thereafter (grade 1C).
We recommend that low glucose levels obtained with point-of-care testing
of capillary blood be interpreted with caution, as such measurements may
overestimate arterial blood or plasma glucose values (grade 1B).
1. Insulin sc
2. Insulin drip target GD <150
mg/dL
3. Insulin drip target 150-200mg/dL
Terima Kasih
10 Maret 2017
Nama : Sriah (58 thn)
Ruangan : R.13

No.RM : 11245970

Keluhan Utama : benjolan pinggang kiri

Diagnosa :

Urosepsis + Abses Flank S + DM Type II +


Azotemia + Hypoalbuminemia + Single
Kidney
Perkembangan Pasien 9/3/17
7/3/17 Dx : Urosepsis + Abses
Urinalisis 8/3/17 Retroperitoneal + insisi Drainasie
Kekeruhan Jernih day1 + DM Type II + HT on Tx +
Warna Kuning Operasi : Insisi Drainase Abses
Hypoalbumin + Single Kidney
BJ 1,020
Glukosa Trace
Protein 1+ 8/3/17 9/3/17
Lekosit 1+
Kirim Pus ke Mikrobiologi Luka Rembes Bekas Operasi
10X : Epitel 8,9 Vit K + Kalnex
40X : Eritrosit 5,7
Lekosit 11,3
Bakteri 237,9 8/3/17 9/3/17 TD 100/70;
TD 120/80; N 96; RR 20 Tax 37,2C; N 90; RR 20

MRS
7/3/17
8/3/17 Profilaksis : 9/3/17
Cefoperazon 2 x 1 g Cefoperazon 2 x 1 g
7/3/17
Hematologi Metronidazol 3 x 500 mg
HGB 11,6
8/3/17
RBC 3,97
Hematologi
WBC 21,48 9/3/17
HGB 8,3
PLT 424 Hematologi
RBC 2,83
Eos 0,2 HGB 8,5
WBC 14,48
Baso 0,2 RBC 2,92
PLT 356
Neutro 91,8 WBC 15,28
Eos 0,1
Limfo 4,3 PLT 316
Baso 0,3
Mono 3,5 Eos 0,5
Neutro 92,9
Immatur Granulosit Baso 0,2
Limfo 4,8
0,64 (3%) Neutro 85,3
Mono 1,9
Ur/Cr 101,8/2,05 Limfo 10,4
Immatur Granulosit
CRP Kuanti 25,55 Mono 3,6
0,63 (4,4%)
POCT (15:13) 346 Immatur Granulosit
Ur/Cr 101,8/2,05
POCT (23:33) 299 0,88 (5,8%)
POCT (22:13) 304
As. Laktat 1,2
POCT (04:02) 268
PPAM = Cipro + Genta

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