Sepsis Sepsis PuerpuralisPuerpuralis

A.Guntur H.A.Guntur H.

Subbagian Alergi-Imunologi Tropik Infeksi Bagian Ilmu Subbagian Alergi-Imunologi Tropik Infeksi Bagian Ilmu Penyakit DalamPenyakit Dalam

Fak. Kedokteran UNS. / RSUD.Dr. Moewardi SurakartaFak. Kedokteran UNS. / RSUD.Dr. Moewardi Surakarta

IntroductionIntroduction

Generally, a measure used to assess the merits of Generally, a measure used to assess the merits of

the state of obstetric care (maternity care) within a the state of obstetric care (maternity care) within a

country or region is maternal death (maternal country or region is maternal death (maternal

mortality).mortality).

According to the WHO definition of "maternal According to the WHO definition of "maternal

mortality is the death of a woman during mortality is the death of a woman during

pregnancy or within 42 days after the end of pregnancy or within 42 days after the end of

pregnancy in any way, regardless of the parents of pregnancy in any way, regardless of the parents of

pregnancy and the actions taken to terminate the pregnancy and the actions taken to terminate the

pregnancy".pregnancy".

High mortality rates are generally half a High mortality rates are generally half a

century ago has three main reasons:century ago has three main reasons:

(1) is still a lack of knowledge about the causes (1) is still a lack of knowledge about the causes

and prevention of important complications in and prevention of important complications in

pregnancy, childbirth, and childbirth;pregnancy, childbirth, and childbirth;

(2) lack of understanding and knowledge about (2) lack of understanding and knowledge about

reproductive health, andreproductive health, and

(3) less prevalence of good obstetric care for all (3) less prevalence of good obstetric care for all

pregnant. One of which belongs to the important pregnant. One of which belongs to the important

causes of maternal mortality is causes of maternal mortality is puerperal sepsispuerperal sepsis

Although Semmelweiss in 1874 already Although Semmelweiss in 1874 already

showed that puerperal sepsis caused by showed that puerperal sepsis caused by

infection and that doctors and midwives infection and that doctors and midwives

are often the carriers of the infection in are often the carriers of the infection in

women who are birthing, but still a long women who are birthing, but still a long

way in the 20th century this has not been way in the 20th century this has not been

generally accepted among doctors.generally accepted among doctors.

Only after the advancement of microbiological Only after the advancement of microbiological

sciences demonstrated that the main cause of the sciences demonstrated that the main cause of the

disease are different types of bacteria disease are different types of bacteria

(streptococcus), that the germs are carried by a (streptococcus), that the germs are carried by a

doctor, midwife, or other personnel who attended doctor, midwife, or other personnel who attended

the deliverythe delivery

However, the occurrence of sepsis reduction is However, the occurrence of sepsis reduction is

achieved with the discovery of new drugs that have achieved with the discovery of new drugs that have

antibiotic functions "Narrow Spectrum" and "Broad antibiotic functions "Narrow Spectrum" and "Broad

Spectrum."Spectrum."

DefinitionDefinition

Puerperium is the period that begins after Puerperium is the period that begins after

the placenta was born after 6 weeks (42 the placenta was born after 6 weeks (42

days) to return to normal reproductive or days) to return to normal reproductive or

pre-pregnancy state.pre-pregnancy state.

(Patholgic change in the uterine (Patholgic change in the uterine

cavity)cavity)

The uterine cavity is normally free of bacteria The uterine cavity is normally free of bacteria

during pregnancy.during pregnancy.

Approximately 48 hours postpartum, Approximately 48 hours postpartum,

progressive necrosis of the endometrial and progressive necrosis of the endometrial and

placental remnants produces a favorable placental remnants produces a favorable

intrauterine environment for the multiplication intrauterine environment for the multiplication

of aerobic and anaerobic bacteria. of aerobic and anaerobic bacteria.

Pathologic change in the uterine Pathologic change in the uterine

cavitycavity EndomyoparametritisEndomyoparametritis

Endomyoparametritis is a potentially life-threatening Endomyoparametritis is a potentially life-threatening

condition. condition.

It commonly begins with:It commonly begins with:

Retention of secundines (placental and amniochorionic Retention of secundines (placental and amniochorionic

membrane fragments) that block the normal lochial flow, membrane fragments) that block the normal lochial flow,

Allowing accumulation of intrauterine lochia,Allowing accumulation of intrauterine lochia,

Which in turn changes the local BH.Which in turn changes the local BH.

And acts as a culture medium for bacterial growth.And acts as a culture medium for bacterial growth.

The body's normal defense The body's normal defense

mechanisms that can prevent the mechanisms that can prevent the

occurrence of a progressive infection, occurrence of a progressive infection,

but decreased defense mechanisms but decreased defense mechanisms

(imunocompromise) enables (imunocompromise) enables

microorganisms (bacteria) to invasion microorganisms (bacteria) to invasion

into endometrium or myometrium.into endometrium or myometrium.

A rise of temperature of 100.4 ° F (38 A rise of temperature of 100.4 ° F (38

° C) or higher that lasts longer than 2 ° C) or higher that lasts longer than 2

consecutive days (not including the consecutive days (not including the

first day postpartum) during the first first day postpartum) during the first

10 days postpartum.10 days postpartum.

further invasion into the lymphatics of the further invasion into the lymphatics of the

parametrium can cause: lymphangitis, parametrium can cause: lymphangitis,

pelvic cellulitis. pelvic cellulitis.

Infection during childbirth have clinical Infection during childbirth have clinical

manifestations increased body manifestations increased body

temperature (fever), and increased pain temperature (fever), and increased pain

around the uterus and lower abdomen.around the uterus and lower abdomen.

When developing these infections erratic When developing these infections erratic

body temperature, increased with body temperature, increased with

fluctuations, it is a sign of Systemic fluctuations, it is a sign of Systemic

Inflammatory Response Syndrome occurs Inflammatory Response Syndrome occurs

(SIRS) onset of sepsis. (SIRS) onset of sepsis.

Puerperal sepsis at the time was still Puerperal sepsis at the time was still

significantly contribute to postpartum significantly contribute to postpartum

maternal morbidity and mortality.maternal morbidity and mortality.

Sepsis

Clinical syndrome that occurs by excessive body Clinical syndrome that occurs by excessive body

response due to stimuli Microorganisms products.response due to stimuli Microorganisms products.

SIRS + Infection.SIRS + Infection.

SIRS/SEPSIS : CLINICAL SIRS/SEPSIS : CLINICAL SYNDROMSYNDROM

Hyperthermi / Hypothermi (> 38,3 0C / < 35,6 0C ) Tachypneu ( resp > 20 / mnt ) Tachycardi ( pulse > 100 / mnt ) Leukocytosis > 12000 / mm Leukopenia < 4000 / mm 10% > cell immature Suspected infection Blood Glucose > 120 mg/dL (without

diabetes) Mental status disorders

Biomarker dini Pct dan Crp (ccm 2003)

Grade of Sepsis 1. SIRS, caracterized with two or more following symptom :, caracterized with two or more following symptom :

a.a. Hyperthermia/ Hypothermia (> 38,3 Hyperthermia/ Hypothermia (> 38,3 00C / < 35,6 C / < 35,6 00C )C )

b.b. Tachypnoe ( resp > 20 / mnt ) Tachypnoe ( resp > 20 / mnt )

c.c. Tachycardia ( pulse > 100 / mnt )Tachycardia ( pulse > 100 / mnt )

d.d. Leucocytosis >12000/mm atau Leucopenia < 4000/mmLeucocytosis >12000/mm atau Leucopenia < 4000/mm

e.e. 10% > immature cell10% > immature cell

2. SEPSIS

SIRS that has a proven or suspected infectionSIRS that has a proven or suspected infection

3. SEVERE SEPSIS

Sepsis with one or more sign of Multi Organ Disfunction syndrome (MODS)/ Multi organ Failure (MOF), Hypotension, oligouria or anuria.

4. SEPSIS with Hypotension

Sepsis with hypotension ( systolic blood Pressure (SBP) < 90 mmHg or reduced SBP > 40 Sepsis with hypotension ( systolic blood Pressure (SBP) < 90 mmHg or reduced SBP > 40 mmHg).mmHg).

5. SEPTIC SHOCK

septic shock as subset of severe sepsis difined as sepsis-induced hypotension persistently septic shock as subset of severe sepsis difined as sepsis-induced hypotension persistently despite adequate fluid resuscitation along with the presence of tissue hypoperfusion.despite adequate fluid resuscitation along with the presence of tissue hypoperfusion.

DiagnosisDiagnosis

Good ananemsa to eliminate other causes of fever are Good ananemsa to eliminate other causes of fever are

caused by the purpurium.caused by the purpurium.

Physical examination.Physical examination.

Laboratory investigations:Laboratory investigations:

Aerobic and anaerobic cultures should be obtained from Aerobic and anaerobic cultures should be obtained from

the blood, endocervix, and uterine cavity,the blood, endocervix, and uterine cavity,

Urine specimens for cultureUrine specimens for culture

Complete bloodComplete blood

CTS or abdominal pelvic ultrasound scan.CTS or abdominal pelvic ultrasound scan.

Management SepsisManagement Sepsis

di HCU (High Care Unit) Penyakit Dalam di HCU (High Care Unit) Penyakit Dalam RSUD Dr.Moewardi SurakartaRSUD Dr.Moewardi Surakarta

A.A. NONMEDIKAMENTOSANONMEDIKAMENTOSA

B.B. MEDIKAMENTOSAMEDIKAMENTOSA

NONMEDIKAMENTOSANONMEDIKAMENTOSA

Total bed rest, the position depending on the Total bed rest, the position depending on the

condition of the patient's illnesscondition of the patient's illness

OOxygenation 3-4 ltxygenation 3-4 lt

DCDC Plug Plug

If the patient is unconscious or inadequate If the patient is unconscious or inadequate

intake and gastro intestinal massive bleeding, intake and gastro intestinal massive bleeding,

plug NGT for bleeding and evacuation sonde plug NGT for bleeding and evacuation sonde

diet.diet.

MEDIKAMENTOSAMEDIKAMENTOSA

I.I. Fluid resuscitationFluid resuscitation Changes in sepsis hemodynamicChanges in sepsis hemodynamic capillary permeability capillary permeability Liquid come out Liquid come out interstitial space interstitial space Reduced intravascular fluidReduced intravascular fluid Dilation of blood vessels Dilation of blood vessels resistance resistance ↓↓ decreased blood pressure decreased blood pressure shock shock Restoration of intravascular volumeRestoration of intravascular volume Colloid + crystalloid Colloid + crystalloid

Goal of fluid resuscitation:Goal of fluid resuscitation:

        - Improvement of blood volume        - Improvement of blood volume

        - Optimizing Cardiac Output        - Optimizing Cardiac Output

        - Reduce the risk of pulmonary         - Reduce the risk of pulmonary

edemaedema

        - Correction of acidosis         - Correction of acidosis

EmperikEmperik

- CephalosphorinCephalosphorin- Cephalosphorin + Cephalosphorin + Lactam inhibit Lactam inhibit- Sesuai pola kuman dirumah sakit Sesuai pola kuman dirumah sakit

setempatsetempat

Gram (+)Gram (+) Gram (-)Gram (-)

72 jam72 jam

72 jam72 jam

CephalosphorinCephalosphorinC. C. Lactam inhibit Lactam inhibit

AminoglycosidaAminoglycosida

- Vancomycin- Vancomycin- Teicoplanim- Teicoplanim

METRONIDAZOLMETRONIDAZOL

Sensitivitas Sensitivitas TestTest

Carbapenim Carbapenim ImepenimImepenim

Fungus : FluconazolFungus : FluconazolParasiteParasiteVirusVirus

Guntur, 2002Guntur, 2002

Antibiotik

ANTIBIOTICANTIBIOTICANTIBIOTICANTIBIOTIC

Culture Not AvailableCulture Not AvailableCulture AvailableCulture Available

Empirical TreatmentEmpirical Treatmentbroad spectrum antibioticsbroad spectrum antibiotics

CombinationCombination

DeescalationDeescalation

Definite / RationalDefinite / RationalTherapy Therapy

Blood culture obtained prior to antibiotic administration From the time of presentation, broad spectrum antibiotics administered

within 3 hours for ED admissions and 1 hours for non-ED ICU admissions. Intensive Care Med (2010) 36:222–231

DOI 10.1007/s00134-009-1738-3

III. Nutrisi Enteral – III. Nutrisi Enteral – IMUNONUTRISIIMUNONUTRISI

• Imunonutrisi - omega 3 - L. arginin -

Nukleutida • respons imun

• perfusi splanikus

Folat

B12

Vit EMALT

GALT

INSTALASI GIZI RSUD Dr. MOEWARDI SURAKARTA

Tabel ZONDE LENGKAP

Items analyzed :Items analyzed :

  

150 gram wortel 150 gram wortel

150 gram tempe kedelai murni150 gram tempe kedelai murni

40 gram hati sapi40 gram hati sapi

40 gram tepung beras40 gram tepung beras

90 gram tepung susu skim90 gram tepung susu skim

120 gram gula pasir120 gram gula pasir

75 gram telur ayam75 gram telur ayam

20 gram margarine20 gram margarine

Code Code

  

298298

111111

139139

4949

365365

393393

147147

369369

Guntur, 2001

Weight : 685 Gram (24.2 oz)Weight : 685 Gram (24.2 oz)

Calories Calories 15151515

Protein Protein 81.781.7 GG

CarbohydratesCarbohydrates 228 228 GG

Dietary Fiber Dietary Fiber GG

Fat-Total Fat-Total 343 343 GG

Fat-SaturatedFat-Saturated GG

Fat-MonoFat-Mono GG

Fat-PolyFat-Poly GG

CholesterolCholesterol MgMg

Vit A-CaroteneVit A-Carotene RERE

Vit A-PreformedVit A-Preformed RERE

Vit A-Total Vit A-Total 3671036710 RERE

Thiamin-B1Thiamin-B1 887887 MgMg

Ribloflavin-B2Ribloflavin-B2 MgMg

Niacin-B3Niacin-B3 MgMg

Water weight : 329 GWater weight : 329 G

Vitamin B6 Vitamin B6 MgMg

Vitamin B12 Vitamin B12 McgMcg

Folacin Folacin McgMcg

Pantothenic Pantothenic MgMg

Vitamin C Vitamin C 27.7 27.7 MgMg

Vitamin E Vitamin E MgMg

Calcium Calcium 14771477 MgMg

Copper Copper MgMg

Iron Iron 21.8 21.8 MgMg

Magnesium Magnesium MgMg

Phosphorus Phosphorus 1552 1552 MgMg

Potassium Potassium MgMg

Selenium Selenium McgMcg

Sodium Sodium MgMg

ZineZine MgMg

Calories from proteinCalories from protein : 21%: 21% Poly/SatPoly/Sat = 0.0 : 1= 0.0 : 1Calories from carbohydratesCalories from carbohydrates : 59%: 59% Sod/PotSod/Pot = 0.0 : 1= 0.0 : 1Calories from fats Calories from fats : 20%: 20% Ca/PhosCa/Phos = 0.0 : 1= 0.0 : 1

Guntur, 2001

IV. SUPLEMENTATIF THERAPYIV. SUPLEMENTATIF THERAPY

- Strategy and Anti Exotoxin endotoxin- Strategy and Anti Exotoxin endotoxin

      - Monoclonal antibody      - Monoclonal antibody

      - Corticosteroids      - Corticosteroids

      - Strategy Anti Mediator      - Strategy Anti Mediator

      - Neutralization of NO      - Neutralization of NO

      - CVVH      - CVVH

      - Herbal Treatment      - Herbal Treatment

      - Intra Venus Immuno Globulin (IVIG)      - Intra Venus Immuno Globulin (IVIG)

LPS bpLPS bp

CD 14CD 14

IL 6IL 6

TNF -TNF -

IL -1IL -1

IL 8IL 8

APCAPC

CD 4CD 4++ TCRTCR

IFN - IFN -

SUPER ANTIGEN SUPER ANTIGEN

IL - 10 IL - 10 IL - 4IL - 4IL - 5IL - 5IL - 6IL - 6

IgIg

NONO ICAM -1ICAM -1

TH - 2TH - 2TH - 1TH - 1

B cellB cell

CD 8CD 8++

LPSLPSIMUNOIMUNOCOMCOM

SEPSISSEPSIS

MODMOD

SHOCKSHOCK

SEPTICSEPTIC

IL-2IL-2

CSFCSF

Compl.Compl.

N N

NKNK

(Guntur, 2006)

C3a, C5a

PGEPGE 22

TLR 4

TLR2

C7a MHC IIMHC II

PAI-1

Imunopatogenesis

Kortikosteroid

Underlying Diseases +

Sepsis

Better (+)

Worst (-)

Underlying Treatment

MODS-MOFSeptic-Shock

•Resuscitation

•AB + Underlying Diseases

•Immunonutrition

•Suplementatif

Management Sepsis

72% - 80% die > 72 hr72% - 80% die > 72 hr

30% - 80% ARDS30% - 80% ARDSGuntur, 2000

ConclusionsConclusions

At purpuralis, frequent infections causing At purpuralis, frequent infections causing

sepsis.sepsis.

Need to be careful, because it has a high Need to be careful, because it has a high

mortality rate.mortality rate.

Precision / accuracy for detecting "purpuralis Precision / accuracy for detecting "purpuralis

infection" to sepsis.infection" to sepsis.

Immediately take action in accordance with a Immediately take action in accordance with a

protocol that has been done as these above.protocol that has been done as these above.