Diagnostic and manajement

SEPTIC SHOCK therapy

ach. Najich rf ,md
SHOCK
Sindrom klinis yang terjadi akibat perfusi jaringan yang tidak adekuat dalam
memenuhi kebutuhan oksigen dalam jaringan

Manifestasi Klinis:
a.Akral Dingin, Pucat basah
b.Nadi >100 x/ menit
c.TD <90 mmHg
JENIS SHOCK
Hipovolemic Shock
Cardiogenic Shock
Neurogenic Shock
Septic Shock
 Sirkulasi / hemodinamik
normal

Venous Return Cardiac Output

A V
VR CO

4800 = 60 x 80 cc
Perfusion

VR setara CO
CO = frek x Stroke Volume
 Shock hypovolemic =
masalah pada volume darah

Venous Return Cardiac Output

A V
VR CO

Perfusion

4800 = 60 x 80 cc
VR turun, CO turun
CO = frek naik x Stroke Volume turun
perdarahan
4800 = 120 x 40 cc
 Shock obstructive =
masalah pada aliran darah

Venous Return Cardiac Output

A V
VR CO

Perfusion

VR turun (congestion) CO ikut turun

CO = frek naik x Stroke Volume turun
 Shock cardiogenic =
masalah pada jantung
infarct, myocarditis, Hypertensive Heart Disease dll

Venous Return Cardiac Output

A V
VR CO

Perfusion

VR normal > CO turun (congestion)

CO = frek naik x Stroke Volume turun
 Shock distributive =
masalah mal-distribusi aliran darah
sepsis dll

Venous Return Cardiac Output

A V
VR CO
Vaso
Shunting or pooling dilatasi
Perfusion

VR turun CO ikut turun

CO = frek naik x Stroke Volume turun
PERBANDINGAN JENIS SHOCK
Type Of Shock CVP and PCWP Cardiac Output Systemic Vascular Venous O2
Resistance Saturation
Hypovolemic Turun Turun Naik Turun
Cardiogenic Naik Turun Naik Turun
Septic Turun Turun/Naik Naik/Turun Naik
Neurogenic Turun Turun Turun Turun
SIRS (SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME)
Consesus ACCP/ SCCM (2002)
1. Temperature <360 C or > 380 C
2. Heart Rate >90 bpm
3. Respiratory Rate > 20 bpm or PaCO2 > 32mmHg
4. WBC <6.000/µL or > 12.000/µL
SEPSIS
Definition :

Criteria
 Parasite

Virus
Severe
Infection Sepsis SIRS
Sepsis
Fungus
shock Severe
SIRS Trauma
Bacteria
BSI
Burns

Adapted from SCCM ACCP Consensus Guidelines

Epidemiology
 WHERE’S THE INFECTION ?
Abdomen
15%
Urine
10%

Other
Lung 8%
47%
Culture
Negative
20%

Bernard & Wheeler NEJM 336:912, 1997

WHAT’S THE INFECTION?
Pure isolates, total n = 444 pts, 61% micro documented
80
70
60
50
40 Early
Late
30
20
10
0
Gram pos Gram neg Fungal

Cohen et al, J Infect Dis 1999 180:116

Cohen, Nature: 2002 420:885
 Immune activation and immunosuppression in sepsis

Hotchkiss et al, NEJM 2003 348:138

SEPTIC SHOCK
Definition:

Criteria
MANAJEMENT
EARLY GOAL DIRECTED THERAPY
INTERNATIONAL MANAGEMENT
RECOMENDATIONS
NOREPINEFRINE (NE)
Mekanisme : NE disintesin dari Dopamin oleh enzim b- hidroksilase, bersifat agonis
pada reseptor alfa-1.
Sifat : Vasopressor , Inotropik Negatif
Efek Samping : Bradikardia, Aritmia, Iskemik,
Dosis : 0.05 µg/kg , dosis dititrai dinaikan perlahan
DOPAMINE
DOBUTAMINE
 INOTROPIC / VASOPRESSOR AGENTS
Dopamine
 Low dose (2-3 g/kg/min) – mild inotrope
plus renal effect
 Intermediate dose (4-10 g/kg/min) –
inotropic effect
 High dose ( >10 g/kg/min) – vasoconstriction
 Chronotropic effect

SHK 26
®
 INOTROPIC AGENTS
Dobutamine

5-20 g/kg/min
Inotropic and variable chronotropic effects
Decrease in systemic vascular resistance

SHK 27
®
 INOTROPIC / VASOPRESSOR AGENTS
Epinephrine
Both  and  actions for inotropic and
vasopressor effects
0.1 g/kg/min and titrate
Increases myocardial O2 consumption

SHK 28
®
DAFTAR PUSTAKA