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Pretest Simposium Sehari:Stop Sepsis Save lives
1. Berikut ini merupakan tanda-tanda Systemic
Inflammatory Respons Syndrome (SIRS) kecuali :
A. Tekanan darah sistol <90 dan atau MAP <70
B. Laju jantung >90
C. Laju pernapasan >20 atau PaCO2<32
D. Suhu tubuh >38⁰C atau <36⁰C
E. Leukosit (WBC) >12.000/dLatau < 4000/dL atau
>10% neutrofil immatur
2. Sepsis dapat disebabkan oleh patogen dibawah ini
kecuali :
A. Bakteri
B. Parasit
C. Virus
D. Jamur
E. Semuanya benar
3. Seorang laki-laki 65 tahun masuk ke UGD dengan sesak
berat, laju napas 40/menit, tekanan darah 90/40 mmHg, nadi 125/menit, suhu 35 C. Pasien ada batuk sudah 3 hari dengan riwayat DM dan Hipertensi. Menurut saudara pasien ini mengalami :
A. Pneumonia
B. SIRS
C. Sepsis
D. Sepsis berat
E. Syok sepsis
4. Setelah menentukan diagnosa kasus pada soal no 3, Anda
melakukan resusitasi cairan. Berikut ini adalah cairan yang dapat anda gunakan kecuali :
A. NaCl 0.9 %
B. Hydrocyethyl starches
C. Ringer asetat
D. Ringer Laktat
E. Albumine 5 %
5. Kecepatan pemberian cairan resusitasi yang akan anda berikan pada pasien ini sesuai yang dianjurkan oleh Surviving Sepsis Campaign (SSC) 2012 :
A. 10 mL/Kg/jam
B. 20 mL/Kg/jam
C. 30 mL/Kg/jam
D. 40 mL/Kg/jam
E. 60 mL/kg/jam
6. Target resusitasi yang ingin di capai dalam 6 jam adalah :
A. Tekanan vena sentral (CVP) 8-12 mmHg dan
tekanan
darah rata-rata (MAP) ≥ 65 mmHg
B. Urine ≥ 0.5 mL/Kg/jam
C. Saturasi vena sentral 70% atau Saturasi vena
campur (Mixed vein) 65%
D. Normalisasi kadar laktat
E. Semuanya benar
7. Obat vasopressor yang menjadi pilihan pertama pada syok sepsis adalah :
A. Dopamine
B. Dobutamine
C. Efendrin
D. Noradrenalin
E. Adrenalin
8. Berikut ini merupakan target yang harus di kerjakan dalam 3 jam pertama dari Surviving Sepsis Campaign Bundles :
A. Mengukur kadar laktat
B. Mengambil kultur darah sebelum pemberian
antibiotik
C. Memberikan antibiotik spektrum luas
D. Memberikan kristaloid 30 ml/Kg pada hipotensi
atau laktat ≥ 4 mmol/L
E. Semua benar
9. Target gula darah pada pasien dengan sepsis berat/syok
sepsis :
A. ≤ 200 mg/dL
B. 100-120 mg/dL
C. ≤ 180 mg/dL
D. 120-150 mg/dL
E. Semua salah
10. Prinsip pemberian antibiotik pasien sepsis adalah
dengan memberian initial antibiotik spektrum luas
sesuai antibiogram setempat dan setelah ada hasil
kultur maka akan dilakukan:
A. Eskalasi
B. Deeskalasi
C. Empirik terapi
D. Kombinasi antibiotik
E. Dosis dikurangi
SELAMAT BEKERJA
•Understand immediate resuscitation
•Why it works
•Sepsis Bundle
•The Sepsis Six
Overview
Mortality increases with increasing organ failure
Hebert et al. Chest 1993;104:230-5
The Early demise curve
The Early demise curve
Ward Care HDU ICU
Reco
gnitio
n
The Early demise curve
Ward Care HDU ICU
Reco
gnitio
n
Sepsis Bundle
LOOK at the patient•MEWS Score, observations, clinical acumen ‘end of the
bed’ test
CHECK the facts•History, results, opinions
DO your ABCs
Remember the basics
SSC 2004
SSC 2008
SSC 2012
Pre and post-discharge
Hospitalization
24 hours
6 hours
Recognition
Resuscitation
Initial Management
Maintenance
Recovery
Initial ResuscitationSSC 2012
P (v-a)CO2E.Kipnis, et
al
Addressing circulation in sepsis
•Why is circulation affected in sepsis?• Dehydration• Loss of vascular tone• Loss of endothelial
integrity• Shunting• Occlusion• Decreased cardiac output
•How is circulation addressed in sepsis?• Replete intravascular
volume• Vasopressors• Interventions directed at
oxygen delivery:extraction balance
HEART
ARTERIESVEINS
ORGANS
O2
O2
O2
O2
O2
O2
O2
O2
HEART
ARTERIESVEINS
ORGANS
O2
O2
O2
O2
O2
O2
O2
O2
STEP 1: Make sure the pump is full
(volume depletion)
The C in the ABCs:Volume Resuscitation
Assess for Volume Depletion• History
• Exam - Organ perfusion – skin, brain, kidneys• Measure intravascular pressures – arterial, central venous
Administer a “Fluid Challenge”• 1000mL crystalloid OR 500mL colloid
• Intravenous over 30 minutes
See what happens• Blood pressure (mean arterial pressure
>65)• Central venous pressure 8-12
• Urine output 0.5 ml/kg/h• Heart rate
See what happens• Blood pressure (mean arterial pressure
>65)• Central venous pressure 8-12
• Urine output 0.5 ml/kg/h• Heart rate
SSC 2012
Fluid Resuscitation
HEART
ARTERIESVEINS
ORGANS
O2
O2
O2
O2
O2
O2
O2
O2
STEP 2: Make the train is on a fast track (vascular
tone)
STEP 1: Make sure the pump is full
(volume depletion)
The C in the ABCs:Vasopressors In Septic Shock
Heart Rate Contractility Vasoconstriction
Dopamine
Low dose 0 0 1-
Medium dose 2+ 2+ 0
High dose 2+ 2+ 3+
Dobutamine 1+ 4+ 1-
Norepinephrine 2+ 2+ 4+
Phenylephrine 2- 0 4+
Epinephrine 4+ 4+ 4+
Vasopressin* 0 1- 3+
Why Norepinephrine is a first line?
Why Norepinephrine is a first line?
•Dopamine tidak direkomendasikan sebagai vasopressor inisial pada syok sepsis•Kurang efektif dibanding NE•Mempengaruhi endokrin pd aksis hipotalamus-pituitari•Memiliki efek imunosupresif•Angka kejadian aritmia lebih tinggi•Angka mortalitas lebih tinggi
HEART
ARTERIESVEINS
ORGANS
O2
O2
O2
O2
O2
O2
O2
O2
STEP 2: Make the train is on a fast track (vascular
tone)
STEP 1: Make sure the pump is full
(volume depletion)
STEP 3: See if supply is keeping up with demand
Step 3: Is oxygen supply keeping up with demand?Central venous O2 saturation
Reflects oxygen extractionby tissue, relative to
oxygen delivery
Lactate clearanceReflects transitionfrom anaerobic to
aerobic metabolism
Oxygen delivery is determined by: Hemoglobin
Cardiac output Arterial oxygen saturation
Interventions to address oxygen delivery/consumption balance
Optimize venous filling pressures, arterial blood pressure
Imbalance between O2 delivery: extraction- ScVO2<70%
-Lactate clearance <10%
Hgb <10?
Dobutamine
Transfuse
Increase CO
YES
YESNO
EGDT – “Rivers” resulted in different care
Control EGDT p
Crystalloid, mean, L
0-<6h 3.5 5.0 <0.0001
6-72h 10.6 8.6 0.01
Vasopressors
0-<6h 30.3% 27.4% 0.62
6-72h 42.9% 29.1% 0.03
Dobutamine
0-<6h 0.8% 13.7% <0.0001
6-72h 8.4% 14.5% 0.14
PRCs
0-<6h 18.5% 64.1% <0.0001
6-72h 32.8% 11.1% <0.0001
N Engl J Med 2001;345:1368
Control EGDT P
Hospital mortality
46.5% 30.5% 0.009
28d mortality 49.2% 33.3% 0.01
60d mortality 56.9% 44.3% 0.03
Pre and post-discharge
Hospitalization
24 hours
6 hours
Recognition
Resuscitation
Initial Management
Maintenance
Recovery
+
Sepsis Care Bundles
IHI.orgInstitute for Healthcare
Improvement
EBM and Bundles
•Group of elements of care for a particular treatment
•Each component is from ‘good’ evidence
•Each component is not implemented very well currently
•To do so would make a difference
•The whole is greater than the sum of the parts
The New Bundles
2 bundle (2004-2008)
1 bundle (2012)
becomes...
The Sepsis Six
1. Give high flow oxygen via non-rebreathe bag
2. Take blood cultures
3. Give IV antibiotics
4. Start IV fluid resuscitation
5. Check haemoglobin and lactate
6. Accurate hourly urine output monitoring
... plus Critical Care support to complete EGDT
Within one hour
The Sepsis Six are the first steps towards completing
the Campaign’s Resuscitation Bundle
•Aim to give 100%
- In practice you can’t!- NRB with reservoir: 60-98%
•Needs regular review
•Care if using for more than few hours
•May still be appropriate in COPD!!- Monitor carefully
Step 1: Oxygen
Step 1: Oxygen
Oxygen delivery (DO2) is impaired
So, high flow oxygen maximises SaO2
‘Sats’ of 99% are better than 95% in sepsis!!
DO2 = CaO2 x CO
CaO2 = ([Hb] x SaO2)
Before starting antibiotics, take at least one blood culture:
•Percutaneously•AND at least one from each vascular access device (if > 48 hrs)
Other cultures:
•Urine•CSF•Faeces•Wound swabs•Sputum•other fluids from within cavities, e.g, intraperitoneal
Step 2: Blood Cultures
Whenever systemic infection suspected
Sterile precautions: 2% chlorhex/ 70% alcohol
Sterile needle to inoculate each bottle
10 mls per bottle at least
Lines: each lumen + peripheral
Transport immediately to laboratory incubator
Step 2: Blood Cultures
Within 6 hours source must be controlledWith cultures, consider:
Diagnostic imaging X rayUSSCTMRI
Discuss with radiologist/ surgeon if an enclosed collection suspected
Step 2b: Source Control
Start therapy as soon as possible and certainly in the first hour... ...preferably after taking blood cultures!!
Choice should include one or more with activity against likely pathogen
•Penetration of presumed source•Guided by local pathogens•Give broad spectrum till defined
Step 3: Give Antibiotics
Mortality increases with delay in antibioticsfollowing onset of septic shock
<2 2 to 3 3 to 4 4 to 5 5 to 6 6 to 9 9to12 12to24 24-36 >361
10
100
Delay following onset of shock (hours)
Odds ratio of death
(log)
Kumar A et.al. Crit Care Med 2006:34(6);1589-1595.
Step 3: Antibiotics
The ‘right’ antibiotic is crucial•Ensure the guidelines are used
Early antibiotic use means:•Prescribe it•Get it•Give it
Mort
alit
y (
%)
0
50
70
10
30
Appropriate initial
antibiotic
Inappropriateinitial
antibiotic
p<0.001
40
60
20
NOW!!!
Step 4: Fluids
Why?
To reduce organ dysfunction and multi-organ failure
•By optimising tissue oxygen delivery
•By increasing organ perfusion
Optimising oxygen delivery
DO2 = Oxygen delivery to the tissue
Fluid therapy improves cardiac output by increasing venous return to the heart
DO2 = CaO2 x CO
Improving organ perfusion
•Organs have their own resistance to blood flow•Perfusion depends therefore on pressure as well as flow•Mean arterial pressure (MAP) is the key
MAP = CO x SVRWhere SVR is Systemic Vascular Resistance
Goal MAP > 65 or Systolic > 90mmHg
An improved cardiac output gives a higher MAP
Fluid resuscitation
In the first hour:
•Fluids improve Cardiac Output (CO)•Better Cardiac Output gives
•Higher delivery of O2
•Higher MAP•This will reduce organ injury
How to fluid resuscitate
Judicious fluid challenges•Up to 60ml/kg in divided boluses (min. 30ml/kg in shock)• Crystalloid (500 ml boluses)• Colloid (250 ml boluses)
Reassess for effect after each challenge•HR, BP, capillary refill, urine output, RR
In patients with cardiac disease•Use smaller volumes•More frequent assessment•Early CVC
High lactate identifies tissue hypoperfusion inpatients at risk who have a normal BP
‘Cryptic shock’
Gives an overview of current tissue oxygen delivery
The GoalLactate to improve
as resuscitation progresses
Step 5: Measure lactate
Risk stratification by lactate
Series10
5
10
15
20
25
30
35
40Low (0 - 2.0)
Intermediate ( 2.1 - 3.9)
Severe (>4.0)
Lactate threshold
% in
ho
spit
al M
ort
alit
y
Trzeciak, S et al , Acad Emerg Med; 13, 1150-1151.
Step 6: Urine Output
Accurate hourly urine output monitoring
(for many, this will mean catheterisation)
The Goal> 0.5 ml/kg/hr
> 40 ml/hour in the average adult
STEP 6: Urine Output
Urine output is a direct measure of GFRGFR= Glomerular Filtration Rate
GFR is directly proportional to COKidneys receive 1/5 cardiac output (1 L/min)
CO falls UO falls
Therefore urine output in the early stages is a useful assessment of cardiac output
Effects of fluid resuscitation
So…
Fluid resuscitation can improve•Cardiac output (raises)•Blood pressure (raises)•Haematocrit (lowers)
… each of which will improve urine output
Goals for the first hour
Evidence of success:
•MAP >65mmHg•Improving capillary refill•Warming of extremities•Urine output >0.5 ml/kg/hr•Improving mental status•Decreasing lactate
1. Give high flow oxygen via non-rebreathe bag
2. Take blood cultures
3. Give IV antibiotics
4. Start IV fluid resuscitation Crystaloid or equivalent
5. Measure lactate
6. Monitor accurate hourly urine output
Summary: the Sepsis Six
Thank You