Intervensi Terapi Pada Sepsis PDF

Monitoring Therapeutic Interventions
in Critically Ill Septic Patients

Prof. Dr. H. Soegeng Soegijanto, dr., SpA(K), DTM&H
Introduction
In recent decades, the reported incidence of sepsis has increased
dramatically.
The management of patients with sepsis is based largely on treating
or eliminating the source of infection, the use of appropriate antimicrobial
agents, and hemodynamic and other physiologic supportive measures.
Nutrition support plays an important role in the management of
patients with sepsis.
Monitoring the progress and response to treatment is an integral
component of the management of critically ill septic patients.
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1. What is Critically ill septic patients ?
Sepsis is characterized by the excessive

production of pro-inflammatory cytokines and a
marked increase in the release of norepinephrine
and epinephrine and glucagon and growth hormone.
The metabolic response to sepsis includes a
dramatic increase in the basal metabolic rate,
occurrence of stress hyperglycemia, and proteolysis.
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Figure. 56.10 Cutaneous Changes in Meningococcal Infection
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Figure. 56.11 Cutaneous Changes in Toxic
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2. What kind of response to therapeutic
should be recognized ?
a). Hemodynamic response to therapy
White cell count are commonly used to monitor a
patient’s progress.
b). The use of global and regional markers of
tissue dysoxia as therapeutic end points in the
management of patients with sepsis
c). The use of specific biochemical market or “a
sepsis test” that reflects illness severity and the
response to treatment has attracted much attention.
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Global Indices of Tissue Dysoxia
a). Blood lactate concentration.
b). Unchanged lactate/pyruvate ratio (L/P).
C). Mixed venous oxygen suturation (SmvO2).
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Tissue Carbon Dioxide (CO2) Monitoring
1. Gastrointestinal dysoxia an “early warning of impending

trouble”.
2. Gastric tonometry and sublingual capnography are based on

the principle that tissue CO2 levels rise sharply in
conditions associated with poor tissue perfusion.
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Gastric Tonometry
Gastric intramucosal hypercarbia has been
demonstrated to be a marker of gastric mucosal dysoxia an a
reliable predictor of morbidity and mortality in critically ill
patients.
Sublingual Capnometry
Sublingual PCO2 (PslCO2) that was closely related to

decreases in arterial pressure and cardiac index during
circulatory shock produced by hemorrhage and sepsis.
PslCO2 correlated well with microvascular perfusion
and that in was more responsive to therapy than the gastric
intramucosal pCO2.
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Cytochrome aa3 Redox State and
Near-Infrared Spectroscopy
NIR spectrophotometry has been used to detect

tissue dysoxia in skeletal muscle, the brain, and
the liver.
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Biomarkers of Sepsis
C-Reactive Protein (CRP) and Procalcitonin
CRP is an acute-phase protein relesed by the liver after the onset

of inflammation or tissue damage.
CRP has both pro and anti-inflammatory effects. CRP plasma
concentrations >50 ml/L have been reported to discriminate the
inflammatory response to infection from other types of inflammation.
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PCT ( pro-calcitonin )
PCT demonstrates a closer correlation with the dynamically

changing clinical course of infection that does CRP.
PCT rises up to 20 hours earlier than CRP, and whereas PCT level
normalizes as the patients improves, the CRP level may remain
elevated for several days, even when the infection has resolved.
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Severity of Illness Scoring Systems
Severity of Illness Scoring Systems are frequently

used to monitor the progress of individual patients.
However, these scoring systems were not specifically

designed for this purpose, and their ability to track individual
patients or groups of patients over time has not been tested.
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Table 1
Comparison of the multipurpose severity of illness scoring systems used to
evaluate critically ill patients
APACE II APACHE III SAPS MPM
Total number of variables 14 19 17 15
Number of physiological variables 12 17 12 3
Age Yes Yes Yes Yes
Chronic helath variables Yes Yes Yes Yes
Disease-specific coefficients Yes Yes Yes Yes
RankingÌ 1 2 3 4
ÌBy number of citations (122).

ÌAPACHE, Acute Physiology and Chronic Health Evaluation; SAPS,
Simplified Acute physiology Score; MPM, Mortality Probability Model.
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Organ Failure Scores
The score that has been collected from data of the

sequential dysfunction and failure of several organ
systems.
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3. What is Multiorgan dysfunction syndrome
(MODS) ?
MODS of the critically ill is caused by

inadequate oxygen delivery, often exacerbated by
microcirculatory changes and increased tissue
metabolic demands.
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Table 2
The SOFA scoring system
SOFA Score 1 2 3 4
Respiration <400 <300 <200 <100
PaO2/FIO2 mm Hg With respitaroty With respiratory
support support
Coagulation <150 <100 <50 <25
Platelets x 103/mm3
Liver
Bilirubin mg/dl 1.2 – 1.9 2.0 – 5.9 6.0 – 11.9 >12
Cardiovascular Map <70 mm Hg Dopamine ≤5 or Dopamine >5 or Dopamine >15 or
Hypotension doburamine in any dose epinephrine ≤ 0.1 or norepinephrine >0.1 or
norepinephrine ≤0.1 norepinephrine >0.1
Central nervous system 13 – 14 10 – 12 6–9 <6
Glasgow Coma Scale
Score
Renal 1.2 – 1.9 2.0 – 3.4 3.5 – 4.9 >5.0
Creatinine mg/dl or Or <500 ml/day <200 ml/day
urine output
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Conclusion
A number of different tools should be used for

prognostication and monitoring their response to
treatment.
This should be include indices of tissue dysoxia,
“septic biomarkers”, and quantitative measures of organ
function.
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Monitoring Therapeutic Interventions

in Critically Ill Septic Patients

Sepsis is characterized by the excessive

a). Blood lactate concentration.

b). Unchanged lactate/pyruvate ratio (L/P).

C). Mixed venous oxygen suturation (SmvO2).

1. Gastrointestinal dysoxia an “early warning of impending

2. Gastric tonometry and sublingual capnography are based on

Sublingual PCO2 (PslCO2) that was closely related to

NIR spectrophotometry has been used to detect

C-Reactive Protein (CRP) and Procalcitonin

CRP is an acute-phase protein relesed by the liver after the onset

PCT demonstrates a closer correlation with the dynamically

Severity of Illness Scoring Systems are frequently

However, these scoring systems were not specifically

Total number of variables 14 19 17 15

Number of physiological variables 12 17 12 3

Age Yes Yes Yes Yes

Chronic helath variables Yes Yes Yes Yes

Disease-specific coefficients Yes Yes Yes Yes

ÌBy number of citations (122).

The score that has been collected from data of the

MODS of the critically ill is caused by

A number of different tools should be used for

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