Sepsis dan Septik Syok

Rama andyatma 201310330311166

Pendahuluan- Sindroma respons inflamasi sistemik ( Systemic Inflammatory Response Syndrome = SIRS) Peradangan tidak spesifik yg disebabkan oleh infeksi maupun keadaan yg bukan infeksius seperti emboli paru, luka bakar dan infark jantung.

InfectionEndotoxin and other microbial toxinsProinflammatory state with cytokine release andOther proinflammatory mediatorsSepsis / SIRSShock and multiorgan dysfunction and possible deathOld paradigm of sepsisAdaptasi dari Bone, 1997, hlm 239

Initial insult (bacterial, viral, traumatic, thermal)New paradigm of sepsisAdaptasi dari Jacobi, 2002, suppl 5

SIRS: systemic inflammatory response syndromeMODS: multiple-organ dysfunction syndrome

Definitions used to describe the condition of septic patientsBacteriemiaPresence of bacteria in blood (positive blood cultures)SepticemiaPresence of microbes or their toxins in bloodSIRS 2 of these conditions: fever (oral temp. >380C) or hypothermia (24 breath/min); tachycardia (heart rate > 90 beats/min); leukocytosis (> 12.000/L); leukopenia (< 4.000/L) or > 10% bands; may have a noninfectious etiologySepsisSIRS that has a proven or suspected microbial etiologySevere sepsis= sepsis syndrome: sepsis with 0ne or more signs of organ dysfunction, e.g:Cadiovascular: arterial systolic blood pressure 90mmHg or mean arterial pressure 70mmHg that respons to administration of intravenous fluidRenal: urine output < 0,5mL/kg per hour for 1 h despite adequate fluid resuscitationRespiratory: PaO2/FIO2 250 or, if the lung is the only dysfunction organ, 200Hematologic: platelet count < 80.000/L or 50% decrease in platelet count from highest value ercorded over previous 3 daysUnexplained metabolic acidosis: a pH 7,30 or a base deficit 5,0mEq/L and a plasma lactate level > 1,5 times upper limit of normal for reporting labAdequate fluid resuscitation: pulmonary artery wedge pressure 12mmHg or CVP 8mmHgSeptic shockSepsis with hypotention (arterial blood pressure < 90mmHg systolic, or 40mmHg less than patients normal blood pressure) for at least 1 h despite adequate fluid resuscitation; or need for vasopressors to maintain systolic blood pressure 90mmHg or mean arterial pressure 70mmHgRefractory septic shockSeptic shock that last for > 1 h and does not respond to fluid or pressor administrationMODSDysfunction of mor than one organ, requiring intervention to maintain homeostasis

(Adaptasi dari Bone, 1997, hlm 238)TNF-IL-1IL-2IL-6IL-8IL-15Neutrophil elastaseIFN-Protein kinaseMCP-1*MCP-2Leukemia inhib.factor (D-factorThromboxanePlatelet activating factorSoluble Adhesion mol.Vasoactive neuropeptidesPhospholipaseTyrosine kinasePlasminogen activator inhib.-1Free radical generationNeopterinCD14ProstacyclinProstaglandinsIL-1 raIL-4IL-10IL-13Type II IL-1 receptorTransforming growth factor-EpinephrineSoluble TNF- receptorsLeukotriene B4-receptor antagonismSoluble recombinant CD-14LPS binding proteinMCP = monocyte chemoattractant proteinBerbagai jenis molekul pro- dan anti-inflamasiProinflammatory moleculesAnti-inflammatory molecules

Wenzell dkk definisi stadium sepsis :I. Systemic inflammatory response syndrome (SIRS) Dua atau lebih gejala berikut :1.Suhu > 38oC atau < 36o C2.Nadi > 90 x/menit3.Pernafasan > 20 x/menit4.Lekosit > 12 ribu mm3 atau < 4 ribu /mm3 atau ditemukan > 10% sel batangII. Sepsis SIRS disertai infeksi kuman yg dibuktikan dgn kultur.

III. Sepsis beratSepsis dgn disfungsi organ, hipotensi atau hipoperfusi asidosis laktat, oligouri, perubahan status mental akut.

IV. Syok septik.Sepsis berat dgn hipotensi yang tidak memberikan respon terhadap resusitasi cairan ( tekanan darah arteri < 90 mmHg atau turun > 40 mmHg dari tekanan darah yang normal dari pasien.

Patogenesis

Infeksi lokal bakteri aliran darah, bakteriemia toksin aliran darah. Endotoksin lipopolysaccharide ( LPS) yang berasal dari membran luar bakteri gram negatif. - LPS sirkulasi darah protein plasma LPS Binding Protein (LBP) LPS CD-14 (permukaan monosit, makrofag,netrofil memacu sel fagosit mononuklear mediator (Tumor necrosis factor (TNF), Interleukin-1 (IL-1), Interleukin-6 (IL 6), Interleukin-8 (IL-8) dan Platelet- activating factor (PAF)

Dikeluarkan Asam arakidonat dimetabolisir menjadi lekotrin, tromboksan A 2, prostaglandin E2 (PGE2) dan prostaglandin I2 (PGI2). - IL-1, IL-6 mengaktifkan sel T memproduksi interferon , IL-2, IL-4 dan Granulocyte colony stimulating factor (GCSF). Lanjutan ..

Bakteri gram positif menyebabkan sepsis melalui 2 mekanisme: eksotoksin sebagai superantigen dan komponen dinding sel yang menstimulasi imun

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