Sepsis: Fajar Yuwanto SMF Penyakit Dalam RS Abdul Moeloek

SEPSIS
Fajar Yuwanto
SMF Penyakit Dalam
RS Abdul Moeloek
19/10/2019 1
Sepsis vs Stroke/STEMI
Sepsis Mortality
Sepsis Mortality
• SIRS = 7%
• Sepsis Syndrome = 16%
• Severe Sepsis = 20%
• Septic Shock = 46%
• Once hypotension occurs  50% mortality!!!!

Sepsis at a Glance
Sepsis is a medical emergency . . .
minutes matter
Every hour a patient in
septic shock doesn't
receive antibiotics,
the risk of death
increases by 7.6%.
Source: Advisory Board Company: “Why sepsis screening isn't one-size-fits-all” Expert Insight | December 11, 2013
Speed is Important
Time is Tissue!
Would you wait an hour to treat a stroke? Heart attack?
Mortality rates increase as the number of failing organs increase.

Emerg Med J. 2009
• “In time critical conditions such as AMI or stroke,

specific interventions by prehospital practitioners
make a significant difference to mortality.”
Definition of shock
An abnormality of the circulatory system that results

in inadequateorgan perfusion
and tissue oxygenation
Circuit diagram of cardiovascular
system
Organ Perfusion and Tissue Oxygenation
Depend on
Blood FLOW i.e. cardiac output

&
Blood PRESSURE
Control of cardiac output
Cardiac Output
Heart Rate
X Stroke Volume
Parasympathetic Sympathetic End diastolic

Tone Tone volume
Venous return
Blood Pressure
Mean Arterial Pressure =
Cardiac Output X Total

Peripheral Resistance
Causes of Shock
•Hypovolaemic
haemorrhagic or non haemorrhagic
•Cardiogenic
•Tension pneumothorax
•Neurogenic
•Vasogenic
septic
anaphylactic
SEPTIC SHOCK
BACK GROUND
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BURDEN SEPSIS
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DEFINITION OF
SEPSIS-3
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DEFINITION OF SEPSIS-3
“life-threatening organ dysfunction caused by a
dysregulated host response to infection”
(Singer M et al. JAMA. 2016; 315[8]: 801- 810)
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New Definition of Septic Shock
Septic shock is a subset of sepsis in which underlying
circulatory and cellular/metabolic abnormalities are
profound enough to substantially increase mortality.
Need Vassopressor to
maintain MAP ≥ 65
Persisting hypotension mmHg
despite adequate fluids
Serum lactat level > 2
resuscitation mmol/L (18 mg/dL)
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Sepsis Pathophysiology
22
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DIAGNOSIS SEPSIS
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DIAGNOSIS SEPSIS
• Clinically sometimes difficult to diagnose
• Delay to diagnose and treatment  bad prognosis
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DIAGNOSIS SEPSIS
• Criteria Inside ICU : Using SOFA

score or LODS score
• Criteria Outside of the ICU :

• There is an increasing focus
on early recognition of
sepsis.
• Using quick SOFA (qSOFA)
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Sepsis : qSOFA

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SOFA SCORE
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LODS SCORE
JAMA 1996:276:802-10
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Screening patients likely to have sepsis
Sepsis
From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8):801-810.
doi:10.1001/jama.2016.0287
TREATING OF SHOCK
SEPTIC
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TREATING SEPSIS : THE
LATEST EVIDENCE
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The Sepsis Bundle
Per the New Core Measure Requirement!
Treating Severe Sepsis & Septic Shock
1. Implement the Sepsis Protocol
a) Blood Culture X 2 sets = 4 bottles
b) Stat Serum Lactate and repeat Lactate if >18mg/dL
2. IV Broad spectrum antibiotics
3. IV fluid bolus of 30mL/kg (minimum) if patient has-
• SBP<90 or >40 below baseline or MAP <65
OR
• Initial Lactate ≥36mg/dL
Fluid bolus must
be completed
within hours
from time of
presentation
Severe Sepsis/Septic Shock
Bundle
Activate Within ONE hour of presentation
• Blood cultures x 2 sets
• Drawn before antibiotic and within 1 hr after TOP (time of presentation)
• 4 bottles total with minimum 8-10 mL/bottle
• IV Broad Spectrum Antibiotic
• Start within 1 hr after TOP unless given within past 24 hours
• Lactate
• Drawn within 1 hr after TOP
• Require 2-5mL blood in GREY top tube: Immediately put sample on ICE &
transport to lab for analysis.
• If initial Lactate >18, then repeat within 3 hrs after 1st lactate draw
• IV fluid bolus (0.9% NS or LR) Physician needs to
document when the
• Min 30 mL/kg only if Septic Shock present treatment is
• Start within 1 hr after TOP and complete within 3 hrs contraindicated or
patient refused.
37
(Vincent JL, 2011).
Rhodes A et al, 2017
Dellinger RP, et al 2017
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AGGRESSIVE FLUID STRATEGIES
ADVERSELY AFFECT EVERY
SYSTEM AND ORGAN
THE KIDNEY PARADOX;
(oliguria worsened by
Tissue Edema fluid challenge)
Diffusion Distance
Celullar damage
(ORGAN DYSFUNCTION)
FLUID ACCUMULATION AND MULTI ORGAN
DYSFUNCTION
Prowle JR et al. Nat Rev Nephrol 2010;6:107
Fluid in – fluid out
100
BW when admitted
ANTIBIOTICS
Early administration
(within1 hour)
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Antibiotics
Appropriate
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Appropriate antibiotics
 Appropriate = in vitro activity against
pathogen
 Route of administration
 Dose and frequency
 Penetration
 Cidality
 Pharmacodynamics and
Pharmacokinetics
Crit Care Clin 2011;27:53-76

Effect of inappropriate antibiotics
on survival
Appropriate Inappropriate
OR (95% CI)
(n=4579) (n=1136)
Survived 52 10.3 9.45 (7.74 – 11.54)
P value
Immuno-
15 19.8 < 0.05
suppressed*
COPD 13.6 14.1 < 0.05
Dialysis 7.3 10.7 < 0.05
All numbers expressed as % unless otherwise specified
* Immunosuppression = chemotherapy or chronic steroids (>10mg prednisone daily)
Chest 2009;136:1237-48
Carbapenemen
Aminoglikosida
Betalactams
(RSCM, 2017)
(RSS)
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Surviving sepsis campaign 2016
• We suggest against using IV hydrocortisone to treat septic shock patients
if adequate fluid resuscitation and vasopressor therapy are able to
restore hemodynamic stability. If this is not achievable, we suggest IV
hydrocortisone at a dose of 200 mg per day
• No ACTH stimulation tests or serum cortisol testing
• No additional mineralocorticoid
• 7 days
• Taper
TO SAVE LIVES.....
Early identification
Early fluid resuscitation Early antibiotics

Thank You !
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Sepsis: Fajar Yuwanto SMF Penyakit Dalam RS Abdul Moeloek

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SEPSIS

• Once hypotension occurs  50% mortality!!!!

Mortality rates increase as the number of failing organs increase.

• “In time critical conditions such as AMI or stroke,

An abnormality of the circulatory system that results

Blood FLOW i.e. cardiac output

Parasympathetic Sympathetic End diastolic

Cardiac Output X Total

• Criteria Inside ICU : Using SOFA

• Criteria Outside of the ICU :

(Singer M et al. JAMA. 2016; 315[8]: 801- 810)

(Singer M et al. JAMA. 2016; 315[8]: 801- 810)

Crit Care Clin 2011;27:53-76

Early fluid resuscitation Early antibiotics

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