Sepsis Puerpuralis A.Guntur H. Subbagian Alergi-Imunologi Tropik Infeksi Bagian Ilmu Penyakit Dalam Fak. Kedokteran UNS. / RSUD.Dr. Moewardi Surakarta
Introduction Generally, a measure used to assess the merits of the state of obstetric care (maternity care) within a country or region is maternal death (maternal mortality). According to the WHO definition of "maternal mortality is the death of a woman during pregnancy or within 42 days after the end of pregnancy in any way, regardless of the parents of pregnancy and the actions taken to terminate the pregnancy".
High mortality rates are generally half a century ago has three main reasons: • (1) is still a lack of knowledge about the causes and prevention of important complications in pregnancy, childbirth, and childbirth; • (2) lack of understanding and knowledge about reproductive health, and • (3) less prevalence of good obstetric care for all pregnant. One of which belongs to the important causes of maternal mortality is puerperal sepsis
Although Semmelweiss in 1874 already showed that puerperal sepsis caused by infection and that doctors and midwives are often the carriers of the infection in women who are birthing, but still a long way in the 20th century this has not been generally accepted among doctors.
Only after the advancement of microbiological sciences demonstrated that the main cause of the disease are different types of bacteria (streptococcus), that the germs are carried by a doctor, midwife, or other personnel who attended the delivery However, the occurrence of sepsis reduction is achieved with the discovery of new drugs that have antibiotic functions "Narrow Spectrum" and "Broad Spectrum."
Definition Puerperium is the period that begins after the placenta was born after 6 weeks (42 days) to return to normal reproductive or pre-pregnancy state.
(Patholgic change in the uterine cavity) • The uterine cavity is normally free of bacteria during pregnancy. • Approximately 48 hours postpartum, progressive necrosis of the endometrial and placental remnants produces a favorable intrauterine environment for the multiplication of aerobic and anaerobic bacteria.
Pathologic change in the uterine cavityEndomyoparametritis • Endomyoparametritis is a potentially life-threatening condition. • It commonly begins with: • Retention of secundines (placental and amniochorionic membrane fragments) that block the normal lochial flow, • Allowing accumulation of intrauterine lochia, • Which in turn changes the local BH. • And acts as a culture medium for bacterial growth.
The body's normal defense mechanisms that can prevent the occurrence of a progressive infection, but decreased defense mechanisms (imunocompromise) enables microorganisms (bacteria) to invasion into endometrium or myometrium. A rise of temperature of 100.4 ° F (38 ° C) or higher that lasts longer than 2 consecutive days (not including the first day postpartum) during the first 10 days postpartum.
further invasion into the lymphatics of the parametrium can cause: lymphangitis, pelvic cellulitis. Infection during childbirth have clinical manifestations increased body temperature (fever), and increased pain around the uterus and lower abdomen.
When developing these infections erratic body temperature, increased with fluctuations, it is a sign of Systemic Inflammatory Response Syndrome occurs (SIRS) onset of sepsis. Puerperal sepsis at the time was still significantly contribute to postpartum maternal morbidity and mortality.
Sepsis • Clinical syndrome that occurs by excessive body response due to stimuli Microorganisms products. • SIRS + Infection.
SIRS/SEPSIS : CLINICAL SYNDROM • 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 : • Hyperthermia/ Hypothermia (> 38,3 0C / < 35,6 0C ) • Tachypnoe ( resp > 20 / mnt ) • Tachycardia ( pulse > 100 / mnt ) • Leucocytosis >12000/mm atau Leucopenia < 4000/mm • 10% > immature cell 2. SEPSIS SIRS 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 mmHg). 5. SEPTIC SHOCK septic shock as subset of severe sepsis difined as sepsis-induced hypotension persistently despite adequate fluid resuscitation along with the presence of tissue hypoperfusion.
Diagnosis • Good ananemsa to eliminate other causes of fever are caused by the purpurium. • Physical examination. • Laboratory investigations: • Aerobic and anaerobic cultures should be obtained from the blood, endocervix, and uterine cavity, • Urine specimens for culture • Complete blood • CTS or abdominal pelvic ultrasound scan.
Management Sepsis di HCU (High Care Unit) Penyakit Dalam RSUD Dr.Moewardi Surakarta NONMEDIKAMENTOSA MEDIKAMENTOSA
NONMEDIKAMENTOSA Total bed rest, the position depending on the condition of the patient's illness Oxygenation 3-4 lt DC Plug If the patient is unconscious or inadequate intake and gastro intestinal massive bleeding, plug NGT for bleeding and evacuation sonde diet.
MEDIKAMENTOSA • Fluid resuscitation • Changes in sepsis hemodynamic • capillary permeability • Liquid come out interstitial space • Reduced intravascular fluid • Dilation of blood vessels resistance ↓ • decreased blood pressure shock • Restoration of intravascular volume • Colloid + crystalloid
Goal of fluid resuscitation: - Improvement of blood volume - Optimizing Cardiac Output - Reduce the risk of pulmonary edema - Correction of acidosis
Antibiotik SEPSIS • Cephalosphorin • Cephalosphorin + Lactam inhibit • Sesuai pola kuman dirumah sakit setempat Emperik Gram (+) Gram (-) Cephalosphorin C. Lactam inhibit 72 jam Aminoglycosida METRONIDAZOL 72 jam - Vancomycin - Teicoplanim Carbapenim Imepenim Sensitivitas Test Fungus : Fluconazol Parasite Virus Guntur, 2002
ANTIBIOTIC • 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 Culture Available Culture Not Available Deescalation Empirical Treatment broad spectrum antibiotics Combination Definite / Rational Therapy
III. NutrisiEnteral – IMUNONUTRISI • Imunonutrisi - omega 3 • - L. arginin • - Nukleutida • responsimun • perfusisplanikus Folat B12 Vit E MALT GALT
INSTALASI GIZI RSUD Dr. MOEWARDI SURAKARTA Tabel ZONDE LENGKAP Items analyzed : 150 gram wortel 150 gram tempekedelaimurni 40 gram hatisapi 40 gram tepungberas 90 gram tepungsusu skim 120 gram gulapasir 75 gram telurayam 20 gram margarine Code 298 111 139 49 365 393 147 369 Guntur, 2001
Weight : 685 Gram (24.2 oz) Calories 1515 Protein 81.7 G Carbohydrates 228 G Dietary Fiber G Fat-Total 343 G Fat-Saturated G Fat-Mono G Fat-Poly G Cholesterol Mg Vit A-Carotene RE Vit A-Preformed RE Vit A-Total 36710 RE Thiamin-B1 887 Mg Ribloflavin-B2 Mg Niacin-B3 Mg Water weight : 329 G Vitamin B6 Mg Vitamin B12 Mcg Folacin Mcg Pantothenic Mg Vitamin C 27.7 Mg Vitamin E Mg Calcium 1477 Mg Copper Mg Iron 21.8 Mg Magnesium Mg Phosphorus 1552 Mg Potassium Mg Selenium Mcg Sodium Mg Zine Mg Calories from protein : 21% Poly/Sat = 0.0 : 1 Calories from carbohydrates : 59% Sod/Pot = 0.0 : 1 Calories from fats : 20% Ca/Phos = 0.0 : 1 Guntur, 2001
IV. SUPLEMENTATIF THERAPY - Strategy and Anti Exotoxinendotoxin - Monoclonal antibody - Corticosteroids - Strategy Anti Mediator - Neutralization of NO - CVVH - Herbal Treatment - Intra Venus Immuno Globulin (IVIG)
APC LPS C3a, C5a IMUNOCOM SUPER ANTIGEN LPS bp CD 14 C7a MHC II TCR CD 4+ TLR 4 IL - 10 IL - 4 IL - 5 IL - 6 g IFN - TH - 1 TH - 2 TLR2 B cell CSF Ig IL 8 SEPSIS IL-2 IL 6 IL -1 N Compl. CD 8+ TNF - a NK MOD PAI-1 ICAM -1 PGE2 NO SHOCK SEPTIC (Guntur, 2006) Imunopatogenesis Kortikosteroid
Management Sepsis Underlying Treatment Better (+) • Resuscitation • AB + Underlying Diseases • Immunonutrition • Suplementatif Underlying Diseases + Sepsis Worst (-) MODS-MOF Septic-Shock 72% - 80% die > 72 hr 30% - 80% ARDS Guntur, 2000
Conclusions At purpuralis, frequent infections causing sepsis. Need to be careful, because it has a high mortality rate. Precision / accuracy for detecting "purpuralis infection" to sepsis. Immediately take action in accordance with a protocol that has been done as these above.