SSC – DE-ESCALATION THERAPY

IN SEPSIS
Hadira Mutiara
Rupita Rendy
Putra Syahril
Gostry
SURVIVING SEPSIS
CAMPAIGN
 Infection is defined by the presence of microorganisms in
host tissue or the bloodstream. At the site of infection the
classic findings of rubor, calor, and dolor in areas such as the
skin or subcutaneous tissue are common.
 The systemic manifestations noted previously comprise the
systemic inflammatory response syndrome (SIRS).
 A documented or suspected infection with some of the
findings of SIRS define sepsis
Relationship of SIRS, SEPSIS, & Infection
 DEFINISI

 Sepsis is defined as the presence (probable or documented)

of infection together with systemic manifestations of
infection.
 Severe sepsis is defined as sepsis + sepsis-induced organ
dysfunction or tissue hypoperfusion
 Septic shock is defined as sepsis-induced hypotension
persisting despite adequate fluid resuscitation.
 Tn. Burhan siregar /♂ / 45 th/ RM : 25220
MRS : 16-09-2015 Jam : 22.09 WIB
INA-CBG : K-1-20-II
DPJP : Dr. Bambang A. S., SpB-KBD

KU : Nyeri seluruh perut

AK :
Sejak 3 hari SMRS pasien mengeluh nyeri di seluruh perut yang
dirasakan terus-menerus dan dirasakan semakin bertambah nyeri.
Keluhan nyeri awalnya dirasakan pada perut kanan bawah dan
kemudian menyebar ke seluruh perut. Keluhan disertai mual (+), muntah
(+), demam (+). Riwayat seperti kototran kambing (-), riwayat BAB
mencret 1 bulan, Riwayat BAB kehitaman (+), BAK tidak ada keluhan,
riwayat penurunan berat badan dalam 6 bulan teakhir (+)
Karena keluhannya pasien berobat ke RS al-islam, dan
kemudian di rujuk ke RSHS.
PEMERIKSAAN FISIK

Status generalis
KU : CM, tampak sakit sedang
T : 130/80 mmHg N : 108 x/mnt R : 24x/mnt S : 36.7oC

Status lokalis
a/r abdomen : Cembung, tegang, BU (-), NT (+), NL (+), DM (+),
pekak hepar menghilang (+)
RT : TSA lemah, mukosa licin, ampula tidak kolaps,
massa (-), NT (+) di seluruh lingkaran
ST : Feses (+), darah (-)
Foto klinis
Foto thoraks tegak
 LABORATORIUM

PT : 13 GDS : 154
INR : 1.17 Natrium : 142
APTT : 18.7 Kalium : 2,6
Hb : 14.5
Ht : 44 AGD
L : 18.900 pH : 7,119
Tr : 380.000 PCO2 : 59,1
Ur : 113 PO2 : 44,8
Kr : 3,20
HCO3 : 18,4
ALT : 21
Be : -11,9
AST : 12
SaO2 : 66,0
Alfa Amilase: 91
Lipase : 6,0 TCO2 : 39,4
FOBT : + Laktat : 2.
APAKAH DIAGNOSA PADA PASIEN INI?

APAKAH PADA PASIEN INI TERJADI

SEPSIS

SEVERE SEPSIS

SYOK SEPSIS

?????????????
Severe Sepsis Criteria
DK/
Peritonitis Difus (K65) ec suspek
perforasi organ hollow viscus +
severe sepsis (R65.2)
BAGAIMANA TERAPI SEVERE
SEPSIS PADA PASIEN INI?
MANAGEMENT OF
SEVERE SEPSIS
 A. Initial Resucitation

 During the first 6 hrs of resuscitation, the goals of initial

resuscitation of sepsis-induced hypoperfusion should include all
of the following as a part of a treatment protocol (grade 1C):
 a) CVP 8–12 mm Hg (12-15 mmHgin ventilated patients)
 b) MAP ≥ 65 mm Hg
 c) Urine output ≥ 0.5 mL/kg/hr
 d) Superior vena cava oxygenation saturation (Scvo2) or mixed
venous oxygen saturation (Svo 2) 70% or 65%, respectively.
 We suggest targeting resuscitation to normalize lactate in
patients with elevated lactate levels as a marker of tissue
hypoperfusion (grade 2C).
 B. Screening for Sepsis

 Rationale :
 early identification of sepsis and
implementation of early evidence-based
therapies have been documented to improve
outcomes and decrease sepsis-related
mortality
 C. Diagnosis

 We recommend obtaining appropriate culture before

antimicrobial therapy is initiated (grade 1C).  at least 2 sets
of blood cultures (both aerobic and anaerobic) with at least
one drawn percutaneously and one drawn through each
vascular access device
 Rationale : If the same organism is recovered from both cultures,
the likelihood that the organism is causing the severe sepsis is
enhanced.
 D. Antimicrobial Therapy

 The administration of effective intravenous

antimicrobials within the first hour of recognition of
septic shock (grade 1B) and severe sepsis without
septic shock (grade 1C) should be the goal of therapy.

 We recommend that initial empiric anti-infective

therapy include one or more drugs that have activity
against all likely pathogens (bacterial and/or fungal
or viral) and that penetrate in adequate
concentrations into the tissues presumed to be the
source of sepsis (grade 1B).
  Rationale :
 The most common pathogens that cause septic shock in hospitalized patients
are Gram-positive bacteria, followed by Gram-negative and mixed bacterial
microorganisms.

 The antimicrobial regimen should be reassessed daily for

potential de-escalation to prevent the development of
resistance, to reduce toxicity, and to reduce costs (grade
1B).

 Empiric therapy should attempt to provide antimicrobial

activity against the most likely pathogens based upon
each patient’s presenting illness and local patterns of
infection. (grade 2B)
 Combination therapy, when used empirically in patients with
severe sepsis, should not be administered for longer than 3 to 5
days.

 We suggest that the duration of therapy typically be 7 to 10 days

if clinically indicated; longer courses may be appropriate in
patients who have a slow clinical response, undrainable foci of
infection, bacteremia with S. aureus; some fungal and viral
infections, or immunologic deficiencies, including neutropenia
(grade 2C).
 Recommend that antimicrobial agents not be
used in patients with severe inflammatory
states determined to be of noninfectious
cause (UG).
 ANTIBIOTIK APA YANG DI PILIH
PADA PASIEN INI SEBAGAI TERAPI
EMPIRIS?
 Terapi Antibiotik Empiris

 Pemberian antibiotik tanpa menunggu hasil kultur,

diberikan lbh awal disesuaikan dgn pola kuman dan
resistensi dirs.
 Menurunkan resiko kematian
Tabel 1. Terapi Antibiotik berdasarkan tempat
terjadinya infeksi.
Tabel 2. Durasi pemberian terapi antibiotik berdasarkan
panduan Infectious Disease Society of America (IDSA)
 De-ekskalasi

 Dilakukan apabila pemeriksaan deinitif (hasil kultur)

telah menunjukan patogen apa.
 Antibiotik disesuaikan dgn hasil kultur
 Konsep de-eskalasi merupakan salah hal yang
terpenting untuk mencegah adanya pemanjangan
durasi pemberian antibiotik.
 De-ekskalasi

 Keuntungan
 meminimalisir biaya pengobatan
 mengurangi resiko munculnya efek samping obat
 mengurangi resiko munculnya patogen yang resistan.
 E. Source Control

 The principles of source control in the management of sepsis

include :
 a rapid diagnosis of the specific site of infection and
 identification of a focus of infection amenable

to source control measures (specifically the drainage of an

abscess, debridement of infected necrotic tissue, removal of a
potentially infected device, and definitive control of a source of
ongoing microbial contamination)
 F. Infection Prevention

 Careful infection control practices (eg, hand

washing, expert nursing care, catheter care,
barrier precautions, etc) should be instituted
G. Fluid Therapy
BAGAIMANAKAH TERAPI CAIRAN
PADA PASIEN INI?
 Dilakukan resusitasi cairan initial dengan menggunakan
kristaloid 30 cc/KgBB
H. Vasopressors
 APAKAH PASIEN INI
MEMBUTUHKAN VASOPRESSOR?
 Pemberian vasopresor dilakukan apabila resusitasi cairan
tidak dapat memenuhi kriteria EGDT : MAP ≥ 65 mmHg
 Vasopresor pilihan utama yang dianjurkan : Norepinephrine
 Why???
 Little change in heart rate / cardiac output
 Increased systemic vascular resistance
 I. Corticosteroid

 We suggest not using intravenous hydrocortisone as a treatment of adult

septic shock patients if adequate fluid resuscitation and vasopressor
therapy are able to restore hemodynamic stability (see goals for Initial
Resuscitation). If this is not achievable, we suggest intravenous
hydrocortisone alone at a dose of 200 mg per day (grade 2C).

 We suggest that clinicians taper the treated patient from steroid therapy
when vasopressors are no longer required (grade 2D).
J. Blood Product Administration
Grade B
 Red blood transfusion should occur only when
hemoglobin decreases to < 7 g/dL
 Once tissue hypoperfusion has resolved and in
the absence of extenuating circumstances
such as significant coronary artery disease,
acute hemorrhage or lactic acidosis
 Target hemoglobin of 7 – 9 g/dL
 Erythropoietin is not recommended for Grade B
specific treatment of anemia associated with
severe sepsis
 Unless septic patients have other accepted
reasons for administration of erythropoietin
 Routine use of fresh frozen plasma to correct Grade E
laboratory clotting abnormalities in the
absence of bleeding or planned invasive
procedures is not recommended
J. Blood Product Administration
(cont)
 It is not recommended to use antithrombin
Grade B
for the treatment of severe sepsis or septic
shock
 High dose antithrombin in a phase III trial
did not demonstrate a beneficial effect on
28-day mortality and was associated with
increased risk of bleeding when
administered with heparin Grade E
 Platelets should be administered when
platelet counts are < 5000/mm3 regardless of
apparent bleeding
 Platelet transfusion may be considered
when counts are 5000 - 30,000/mm3 and
there is a significant risk of bleeding
 Platelet counts  50,000/ mm3 are typically
required for surgery or invasive procedures
L. Sedation, Analgesia, and
Neuromuscular Blockade in Sepsis
Grade B
 Protocols should be used when
sedation of critically ill mechanically
ventilated patients is required
 The protocol should include the use of
a sedation goal, measured by a
standardized subjective sedation scale
Grade B
 Intermittent bolus or continuous
infusion sedation are recommended to
predetermined end points
 With daily interruptions/lightening of
continuous infusion sedation with
awakening and retitration, if necessary
Sedation, Analgesia, and
Neuromuscular Blockade in Sepsis
Grade E
 Neuromuscular blockers should be
avoided in the septic patient due to the
risk of prolonged neuromuscular
blockade
 If needed for more than the first hour
of mechanical ventilation, either
intermittent bolus as required or
continuous infusion with monitoring of
depth of block with train of four
monitoring should be used
M. Glucose Control
Grade D
 Following initial stabilization of patients
with severe sepsis, maintain blood glucose
to < 150 mg/dL
 Best results obtained when blood glucose
was maintained between 80 and 110
mg/dL Grade E
 Glycemic control strategy should include a
nutrition protocol with the preferential use of
the enteral route
 Minimize the risk of hypoglycemia by
providing a continuous supply of glucose
substrate
 Accomplished by using 5% or 10% dextrose
IV infusion and followed by initiation of
feeding preferably by enteral route
N. Renal Replacement
Grade B
Continuous venovenous hemofiltration
and intermittent hemodialysis are
considered equivalent in acute renal
failure (in the absence of hemodynamic
instability)
 Continuous hemofiltration offers easier
management of fluid balance in
hemodynamically unstable septic patients
 O. Bicarbonate Therapy
Grade C

Bicarbonate is not recommended for the purpose of

improving hemodynamics or reducing vasopressor
requirements for the treatment of hypoperfusion induced
lactic acidemia with pH  7.15

 No difference revealed in vasopressor requirements or

hemodynamic variables between bicarbonate and normal saline
for treating hypoperfusion-induced acidemia
 Effects of bicarbonate therapy at pH levels < 7.13 have not been
studied
 P. Deep Vein Thrombosis (DVT)
Prophylaxis
Grade A

DVT prophylaxis with either low-dose unfractionated

heparin or low molecular weight heparin should be used in
severe sepsis patients

 Use a mechanical prophylactic device or intermittent

compression in patients with contraindications to
heparin
 Use a combination of pharmacological and mechanical
therapy in very high risk patients (eg, severe sepsis and
history of DVT)
 Q. Stress Ulcer Prophylaxis
Grade A

Stress ulcer prophylaxis should be given to

all patients with severe sepsis

 H2 receptor blockers are more efficacious than sucralfate

and are the preferred agents
 Proton pump inhibitors compared to H2 blockers have not
been assessed
Th/
EGDT + LE

DO (dr. Avit Sp.B, dr.Irzal, dr.Nano, dr.Iyan) /17-9-

2015 :
• didapatkan pneumoperitoneum
•Ditemukan cairan peritoneum bercampur pus
dan enterik konten ± 1500 cc
•Ditemukan perforasi tumor diameter 0,5 cm,
tepi nekrotik di caecum
•Tidak ditemukan KGB di messocolon.
•Hepar licin, tidak ditemukan nodul.
•Hollow viskus lain intak
Diputuskan dilakukan hemikolektomi kanan
dengan ileostomi mucofistel.
 DK/
 Peritonitis Difus ec perforasi tumor caecum + Severe
sepsis yang telah dilakukan hemikolektomi dextra +
ileostomi mukofistel + peritoneal toilet.

INA CBG: K-1-20- PROSEDUR INTESTINAL KOMPLEKS Rp.

III (BERAT) 37.048.273