The document discusses early treatment for sepsis patients. It summarizes that early and appropriate antimicrobial therapy is key to reducing mortality from sepsis. It then discusses definitions of sepsis that have evolved over time from 1991 to 2016. The Sequential Organ Failure Assessment (SOFA) score and quick SOFA (qSOFA) score are introduced to better predict mortality risk and identify organ dysfunction in sepsis patients compared to the previous systemic inflammatory response syndrome (SIRS) criteria. The SOFA score is shown to have superior predictive validity for in-hospital mortality compared to SIRS criteria or qSOFA score.
2. I. Introduction
• Sepsis and septic shock high rates of morbidity and mortality.
• United States, incidence of sepsis is 3 cases per 1000 population
with mortality of 28.6% (215,000 deaths from 750,000 patients
diagnosed) per year.
• Septicemia was listed as the 10th leading cause of death in the
United States in 2007.
• Early and appropriate antimicrobial therapy the predominant factor
for reducing mortality
• DATAFROM ADAM MALIK HOSPITAL (2016) : mortality rate 73%
(Ginting F
, ICID 2018, Vienna)
3.
4. Definisi lama Sepsis
1991 : Sindrom respon inflamasi sistemik (SIRS) host terhadap infeksi
2001 : Kriteria diagnostik sepsis
suhu >38ºC atau <36 ºC
denyut jantung ≥ .90/men
pernapasan >20x/menit
PaCO2 <32 mmHg (4.3kPa)
Leukosit >12000/mm3 atau <4000/mm3 atau >10% immature bands
Infeksi+ ≥ 2 gejala SIRS
5. The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock
Systemic Inflammatory Responds Syndrome
SIRS criteria
-Temp >96.8o or >100.4oF
-HR > 90
-RR >20 or PCO2 <32mmHg
-WBC <4 or >12 or bands > 10%
Bone et al. Chest 1992;101:1644
6. The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock
Systemic Inflammatory Responds to Infection
-Suspected or confirmed infection
-2 or more SIRS criteria
Bone et al. Chest 1992;101:1644
7. The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock
Sepsis plus organ dysfunction
Bone et al. Chest 1992;101:1644
8. The continuum of Sepsis
SIRS Sepsis Severe sepsis Septic shock
Bone et al. Chest 1992;101:1644
Severe sepsis and hypotension
Hypotension that does NOT
respond to fluid (30ml/kg bolus)
11. Sepsis as infection and 2 or
more SIRS is now just an
infection
Severe sepsis is now sepsis
Septic Shock: Subset of
sepsis with circulatory and
cellular/metabolic
dysfunction associated with
higher risk of mortality : Blood
lactate > 2 mmol/L despite volume
resuscitation; Hypotension that persists
after fluid resuscitation and requires
vasopressors
JAMA 0. doi:10.1001/jama.2016.0287
16. R,perempuan, 61 tahun
KU: penurunan kesadaran
Hal ini dialami secara perlahan lahan sejak 1 bulan yang lalu memberat dalam 2 hari
ini. Awalnya pasien masih bisa dipanggil dan membuka mata namun 2 hari ini pasien
sudah cenderung tidur. Riw kejang tidak ada, riw muntah menyembur tidak ada.
Kelemahan tungkai tidak ada. Demam dijumpai 2 hari ini. Pasien pernah rawat
sebelumnya dengan diagnosa NHL
Sesak nafas dialami 1 hari ini. Demam dijumpai 2 hari ini. Batuk dijumpai 1 minggu ini
namun dahak sulit keluar.
Riwayat pemasangan kateter dijumpai, riw urin keruh tidak ada
Luka di bokong dijumpai 2 minggu ini
RPT: DM (-) HT (-), NHL (+) RPO: kemoterapi
17. Pemeriksaan fisik
Sens: somnolen
🞑 TD: 90/50
🞑 HR: 102x/menit
🞑 RR: 28 x/menit
🞑 T
: 38,3
🞑 Terpasang O2 2-4 liter via nasal canule
Mata:
🞑 Anemis (-/-), ikterik (-/-), pupil isokor
Thorax:
🞑 SP: bronkial
🞑 ST: ronkhi di seluruh lapangan paru
Abdomen: simetris, soepel, H/L/R tidak teraba, peristaltik
Normal
Posterior: dijumpai ulkus dengan diameter 3-5 cm, pus (-)
Ekstremitas: lateralisasi (-)
18. Jenis
Pemeriksaan
Satuan Hasil
Hb g/dl 8,7
Leukosit /μl 3650
Ht % 23
Trombosit /μl 125.000
AGDA Satu
an
Hasil Rujukan
pH 7,370 7,35 –
7,45
pCO2 mm
Hg
26 38 – 42
pO2 mm
Hg
140 85 -100
HCO3 U/L 12,7 22 – 26
Total CO2 U/L 13,4 19 – 25
BE U/L -8,9 -2 - +2
Saturasi
O2
% 99,0 95 - 100
Jenis
Pemeriksaan
Satuan Hasil
Ureum mg/dL 68
Kreatinin mg/dL 3,4
Natrium mEq/L 138
Kalium mEq/L 3,8
Klorida mEq/L 101
20. Sequential Organ Failure Assessment (SOFA) Score
The SOFA score predicts mortality risk for patients in the intensive care unit
based on lab results and clinical data on the degree of dysfunction of 6 organ
systems.
• The score is calculated at admission and every 24 hours until discharge
• The SOFA score is not designed to influence medical management
• An initial SOFA score of < 9 predicted a mortality of < 33%, SOFA> 11 predicted
mortality of 95%
• Adam Malik Hospital (2018) SOFAscore >7, kematian >>(Andrew, Ginting F KONAS PETRI
2019)
21. 4
5
S 1
S 6
C
2
0
1 3
6 2
Variable SOFA SCORE
0 1 2 3 4
Respiratory :PaO2/FiO2,
mmHG
> 400 ≤400 ≤300 ≤ 200 ≤ 100
Coagulation : Platelet x 103μl >150 ≤150 ≤ 100 ≤50 ≤20
Liver : Bilirubin, mg/dl <1,2 1,2 – 1,9 2,0 – 5,9 6.0 – 11,9 >12
Cardiovascular : Hypotension No
hypotension
MAP : <70
mmHg
DOP ≤ 5 or Do (
any dose)
DOP >5, Epi ≤ 0,1,
or Nor - epi ≤ 0,1
Dop >15,
Epi >0,1 or
Nor – Epi
>0,1
Central Nervous System :
GCS Scale
15 13 – 14 10 - 12 6 - 9 <6
Renal :Creatinine/Urine <1,2 1,2 – 1,9 2.0 – 3,4 3,5 – 4,9 or UOP : >5 .0 or
22. Why to Use
The SOFA score can be used to determine the level of organ dysfunction and
mortality risk in ICU patients.
When to Use
• The SOFA can be used on all patients who are admitted to an ICU.
•It is not clear whether the SOFA is reliable for patients who were transferred from
another ICU.
Instructions
Calculate the SOFAscore using the worst value for each variable in the preceding
24-hour period.
“the major gap is the difficulty to apply current sepsis case definitions, especially in LMIC settings when
the main tests are not available”
“90% of cases with poor outcome in the Australian sepsis database, inadequate recognition was found
23. The SOFA scoring system is useful in predicting the clinical outcomes of critically ill patients.
According to an observational study at an Intensive Care Unit (ICU) in Belgium the mortality
• least 50% when the score is increased regardless of initial score in the first 96 hours
• 27% to 35% if the score remains unchanged
• less than 27% if the score is reduced.
27. The qSOFA
• a rapid, bedside clinical score to identify patients with suspected infection
who are at greater risk for poor outcomes.
• The primary outcome was in hospital mortality, and the secondary outcome
was an ICU length of stay of ≥ 3 days.
• The qSOFA was meant to replace the systemic inflammatory response
syndrome (SIRS) criteria.
• qSOFA has also been found to be poorly sensitive for the risk of death with
SIRS possibly better for screening
• Sepsis HAM Hospital 2018: 16,7% under diagnose (Maruli,Ginting F
, KONAS PETRI 2019)
-Angus, Derek C.; Seymour, Christopher W.; Coopersmith, Craig M.; Deutschman, Clifford S.; Klompas,
Michael; Levy, Mitchell M
.; Martin, Gregory S.; Osborn, Tiffany M.; Rhee, Chanu. Williams JM, Greenslade JH, McKenzie JV, et al. -
SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients
with infection. Chest 2017;151:586-596.
28. • The qSOFA score predicts mortality but does not diagnose sepsis
• no prospective studies have demonstrated that clinical decisions based
on the qSOFA lead to better patient outcomes.
The most recent Surviving Sepsis Campaign guidelines, published in March
2017, do not integrate the qSOFA into recommendations for screening or
diagnosis of sepsis.
Emergency Medicine Practice • October 2018
A positive qSOFAscore clinicians to further investigate for the presence of organ
dysfunction or increase the frequency of patient monitoring.
30. The SIRS Criteria definitions of sepsis
• are being replaced as they were found too many limitations;
• the "current use of 2 or more SIRS criteria to identify sepsis was unanimously considered
by the task force to be unhelpful.”
Audit pasien sepsis Tahun 2016 RSUP HAM
• SSC 2012: 2 SIRS + infected Over diagnosed: 33,7%
• 78 data infection with SIRS < 2
• 75 data >2 SIRS without infection (Chronic disease)
• 30 data Increased Procalcitonin in CKD
• 124 data sepsis in resume medic only
(Ginting F
, submitted journal process)
31. Only 94 out of 142 cases ( 66,2 %) were
judged to meet the diagnosis criteria for
sepsis.
Out of the 94 patients, 77 ( 82%) were
appropriately classified for sepsis
severity.
19 patients (20%) met criteria for severe
sepsis/ septic shock.
32. ⦁ Among critically ill patients with suspected sepsis, the
predictive validity of the SOFA score for in- hospital mortality
was superior to that of the SIRS criteria (area under the
receiver operating characteristic curve 0.74 versus 0.64)
⦁ SIRS, qSOFA and new sepsis definition
⦁ Paul E. Marik, Abdalsamih M. Taeb
⦁ Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
Correspondence to: Paul Marik, MD. Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk VA 23507, USA. Email:
marikpe@evms.edu. Provenance: This is an invited Editorial commissioned by the Section Editor Zhongheng Zhang (Department of
Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China).
Comment on: Williams JM, Greenslade JH, McKenzie JV, et al. SIRS, qSOFA and organ dysfunction: insights from a prospective database of
emergency department patients with infection. Chest 2017;151:586-596.
⦁ Submitted Feb 05, 2017. Accepted for publication Mar 06, 2017. doi: 10.21037/jtd.2017.03.125
View this article at: http://dx.doi.org/10.21037/jtd.2017.03.125
33. 12% of
Evaluated the presence of SIRS criteria in 109,663
patients with infection and organ failure. In this study,
patients were classified as having SIRS-negative
Engl J
sep
Kaukone
Med 2015
sis (i.
n KM, Bailey
;372:1629-3
e. <2 SIRS criteria)
M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in de ning severe sepsis. N
8.
Over diagnose
34. A new large retrospective cohort analysis among 184,875 patients in
182 Australian and New Zealand intensive care units (ICUs) found
SOFA score had superiority in prediction of in-hospital mortality but it
showed SIRS criteria has greater prognostic accuracy for in-hospital
mortality than qSOFA score
Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the sofa score, sirs criteria, and qsofa score for in-hospital mortality among adults with
suspected infection admitted to the intensive care unit. JAMA 2017;317:290-300.
35. The discrimination of in-hospital mortality for SOFA (75.3% AUROC; 99% confidence interval (CI): 0.750–0.757) was significantly
higher than that of qSOFA (60.7% AUROC; 99% CI: 0.603– 0.611) or SIRS (58.9% AUROC; 99% CI: 0.585–0.593).
Of the study population, 90.1% (165,103 patients) had an increase in SOFA score from baseline to at least
two points; 86.7% (158,710 patients) met two or more SIRS criteria, and 54.4% (99,611 patients) had a qSOFA score
of at least two points .
In adults admitted to the ICU with suspected infection, an increase in SOFA score of at least two points had superior prognostic
accuracy for in-hospital mortality followed by qSOFA and finally SIRS criteria.
With SOFA score demonstrating significantly greater discrimination for in-hospital mortality, the authors highlight that this may
suggest that SIRS criteria and qSOFA may have limited utility in predicting mortality in an ICU setting .
36. • The definition of SIRS, although sensitive to detect sepsis, was rather unspecific.
• In addition, the SIRS criteria performed badly in identifying patients significant morbidity
and mortality.
• These issues led to a recent new consensus definition for sepsis and septic shock
• This international task force
o defined sepsis as ‘life-threatening organ dysfunction
o Using large datasets (>1 million patient records),
o increase in 2 points or more for a patient suspected to have infection using the
Sequential Organ Failure Assessment (SOFA) best predicted in-hospital mortality.
• The SOFA is well known within the intensive care community, but is not so well known
generally.
• The task force developed a simpler clinical screening tool that performed very well in
identifying adult patients with suspected infection who were likely to have poor
outcomes, which they termed ‘quick SOFA’ (qSOFA).
43. MENGHILANGKAN / MENDRAINASE SUMBER
INFEKSI
DRAINASE SUMBER KUMAN
Contoh : Abses, Cairan Peritoneum, Pleura, dll
GANTI INFUS SET KULTUR KANULA
GANTI KATETER URIN
GANTI NGT
PERHATIKAN APAKAH ADA SINUSITIS BILA ADA INTUBASI
CEGAH / RAWAT DEKUBITUS
44. 6 Pilar penanganan sepsis
1. Lactat measure
2. Fluid resuscitation
3. Blood culture, dari dua tempat yang berbeda dan culture dari sumber
infeksi
4. Antibiotic empiric
5. Norepinephrine: pada kasus sepsis syok
6. Lactate remeasure: untuk mengevaluasi terapi pada jam jam awal
54. Anamnesa
Sesak nafas dialami 2 hari. Sesak nafas tidak berhubungan
dengan aktivitas dan cuaca, disertai batuk.
Demam dialami sejak 2 hari, sepanjang hari .Penurunan kesadaran
terjadi sejak 2 hari ini. Tidak ada riwayat trauma atau kejang.
Pasien sudah berbaring sejak > 1 bulan ini karena tangan dan kaki
pasien mengalami kelemahan. Pasien juga tidak dapat diajak
berbicara lagi.
pasien baru mengetahui menderita HIV selama 2 minggu.
