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