sepsis puerpuralis
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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.
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