MANAGEMENT OF

SEPSIS IN COMBAT
INJURY PATIENTS IN
I.C.U R.S.P.A.D
Chris A Johannes
Head of Intensive Care Unit
Central Army Hospital Gatot
Subroto
JAKARTA

ACCP/SCCM Consensus
Definitions

Infection

Systemic Inflammatory
Response Syndrome
(SIRS)

Inflammatory response to
microorganisms, or
Invasion of normally sterile
tissues

Systemic response to a variety

of processes

Sepsis

Infection plus
2 SIRS criteria

Bone RC et al. Chest. 1992;101:1644-55.

Severe Sepsis

Septic shock

Sepsis
Organ dysfunction
Sepsis
Hypotension despite fluid
resuscitation

Multiple Organ
Dysfunction Syndrome
(MODS)

Altered organ function in an

acutely ill patient
Homeostasis cannot be
maintained without intervention

BACTERIEMIA

OTHER

FUNGEMIA

INFECTION

SIRS

PARASITEMIA

TRAUMA

SEPSIS

VIREMIA
OTHER

BURNS

PANCREATITIS

The interrelationship between SIRS, sepsis, and infection

Chest 1992;101:1645

Sepsis: A Complex Disease

This Venn diagram

provides a conceptual
framework to view
the relationships
between various
components
of sepsis.

The inflammatory
changes of sepsis are
tightly linked to
disturbed hemostasis.

Adapted from: Bone RC et al. Chest. 1992;101:1644-55.

Opal SM et al. Crit Care Med. 2000;28:S81-2.

SIRS: More Than Just a Systemic

Inflammatory
Response
SIRS: A clinical response

arising from a nonspecific

insult manifested by
2 of the following:

Temperature
38C or 36C
HR 90 beats/min
Respirations 20/min
WBC count 12,000/L or
4,000/L or >10% immature
neutrophils

Recent evidence indicates

that hemostatic changes are
also involved

Adapted from: Bone RC et al. Chest. 1992;101:1644-55.

Opal SM et al. Crit Care Med. 2000;28:S81-2.

Sepsis: More Than Just

Inflammation
Sepsis:

Known or suspected
infection
Two or more
SIRS criteria

A significant link

to disordered
hemostasis

Adapted from: Bone RC et al. Chest. 1992;101:1644-55.

Severe Sepsis: Acute Organ

Dysfunction and Disordered
Severe Sepsis:
Hemostasis
Sepsis with signs of
organ dysfunction in 1
of the following
systems:

Cardiovascular
Renal
Respiratory
Hepatic
Hemostasis
CNS
Unexplained metabolic
acidosis

Adapted from: Bone RC et al. Chest. 1992;101:1644-55.

Identifying Acute Organ

Dysfunction as a Marker of
Severe Sepsis
Altered
Consciousness
Confusion
Psychosis

Tachycardia
Hypotension
CVP
PAOP

Tachypnea
PaO2 <70 mm Hg
SaO2 <90%
PaO2/FiO2 300

Oliguria
Anuria
Creatinine

Jaundice
Enzymes
Albumin
PT

Platelets
PT/APTT
Protein C
D-dimer

Severe Sepsis: A Complex and

Unpredictable
Clinical
Syndrome

High mortality rate

(28%-50%)

Systemic
Inflammation

Heterogeneous
patient population

Unpredictable
disease progression

Unclear etiology
and pathogenesis

Angus DC et al. Crit Care Med. 2001; (In Press).

Zeni F et al. Crit Care Med. 1997;25:1095-100.
Wheeler AP et al. N Engl J Med. 1999;340:207-14.

Impaired
Fibrinolysis

Coagulation

Sepsis: Defining a Disease Continuum

Insult

SIRS

Sepsis

Severe Sepsis
Sepsis with 1 sign of organ
failure
Cardiovascular (refractory
hypotension)
Renal
Respiratory
Hepatic
Hematologic
CNS
Metabolic acidosis

Shock

Bone et al. Chest. 1992;101:1644; Wheeler and Bernard. N Engl J Med. 1999;340:207.

Effective Therapy in Sepsis ?

One Therapy for All

Menu of therapy

Presence of inflammatory, severity of disease

Corticosteroid th/, enteral feeding, type of iv
solution, low tidal volume in ARDS, protein C,
hemoperfusion column, early goals directed th/,
tight control blood sugar, anti endotoxins, anti
inflammatory th/ etc

Index
Blood Product Administration

Initial Resuscitation

Diagnosis

Antibiotic therapy
Source Control

Fluid therapy
Vasopressors

Inotropic Therapy

Steroids

Recombinant Human Act

ivated Protein C (rhA

PC)
[drotrecogin alfa
(activated)]

Mechanical Ventilation
Sedation, Analgesia, and Neuromuscular
Blockade in Sepsis
Glucose Control
Renal Replacement
Bicarbonate Therapy
Deep Vein Thrombosis Prophylaxis

Stress Ulcer Prophylaxis

Limitation of Support

Dellinger, et. al. Crit Care Med 2004, 32: 858-873.

Antibiotics in sepsis; Intensive Care Med

(2001) 27: S33-S48
Does appropriate antimicrobial therapy improve the
outcome of patients with bloodstream infections and
severe sepsis or septic shock in patients with Grampositive bacteriemia ?

YES

Antibiotics in sepsis; Intensive Care Med

(2001) 27: S33-S48
The mortality directly attributable to infection was
lower in the AB group (25%) than in the control group
(40%), suggesting that appropriate antibiotics reduced
mortality (p=0,27)

Antibiotics in sepsis; Intensive Care Med

(2001) 27: S33-S48
Are there clinical conditions justifying the use of
empirical anti-Gram-positive therapy in patients with
severe sepsis ?

YES

Causes of Nosocomial Bacteremia

(M.B Edmond, et al, 1999 , SCOPE Project)

Microorganism

Gram-positive organism
Gram-negative organism
Fungi

64,4
27,0
8,4

Immunoglobulin in Sepsis
21 patients received Pentaglobin (IgM

enriched immunoglobulin) for 3 days

No change in organ dysfunction, septic
shock or mortality in sepsis patients
Critical Care 2002;6:357-362

IVIG in Sepsis
Meta analysis (N=91) from Cochran review

group concluded that polyclonal

immunoglobulin results in improved mortality
(relative risk 0.3 (CI 0.9 to 0.99)
Results less clear for monoclonal
immunoglobulin
Alejandria et al Cochrane Database Rev 2002

IVIG in Sepsis
Rendomized, Double Blind, Control Study ( N=

56 ) set in medical/surgical ICUs of seven teaching

hospital, Pt with severe sepsis and septic shock of
intra Abdominal Origin admitted to the ICU within
24 h after the onset of symptoms were included in
the study. Intra venous polyclonal immunolobulin (
IVIG ) at a dosage of 7 ml/kg/day , and equal
amount of 5% human albumin ( Control Group )
was randomized

Shock : Volume 23(4) April 2005 pp 298 - 304

IVIG in Sepsis
The overall mortality rate was 37, 5%. Twenty pts

had shock and 36 pts had severe sepsis ( the

mortality rate was 55% and 25%). In the intent to
treat analysis, the mortality rate was reduced from
from 48.1% in pts treated with ATB plus albumin
to 27,5% ( p = 0.06% ) for pts with ATB plus
IVIG.
Shock: Volume 23(4) April 2005 pp 298 - 304

IVIG in Sepsis
Conclusion:

IVIG administration when use in

combination with ATB, improved the
survival of surgical ICU patients with intra
Abdominal sepsis.
Shock: Volume 23(4) April 2005 pp 298 -304

CASE REPORT
During January July 2005.
12 young men pts ( 23 38 years old ) were

evacuated to ICU RSPAD from the conflict

area.
They admitted to ICU because of severe sepsis
and septic shock e.c. gun shoot.

Location of gun shoot

N
--------------------------------------------------------------1.
Abdomen
6
2.
Thorax
2
3.
Thoraco Abdominal
1
4.
Head
2
5.
Musculosceletal
1
-------------------------------------------------------------Total
12

Clasification of Sepsis
N
--------------------------------------------------------------1. Sepsis
3
2. Severe Sepsis
4
3. Septic Shock
5
-------------------------------------------------------------Total
12

Isolated micro organism from blood

1. Klebsiella sp ( 4 pts )
2. Enterobacter sp ( 2 pts )
3. Pseudomonas aerogenosa ( 2 pts )
4, Escheria coli ( 1 pts )

 On Ventilator : 8 pts. ( e.c. ARDS )

All pts we give Fluid. ( Crystalloid an Colloid)
Antibiotic : Meropenem
Cefipime
Source Control
Glucocorticoid if there any indication.
Glucose Control
Nutrition Therapy

 Polyclonal IVIG
Tight Monitoring.

- Hemodynamic monitoring.
- SaO2
- BGA
- Blood Glucose.
- Urine Output

RESULT
8 pts ( 66,6 % ) survived
4 pts ( 33,3 % ) died.

CONCLUSION
IF WE USE THE GUIDELINES FROM

SURVIVING SEPSIS CAMPAIGN, THE

MORTALITY IN SEPSIS COULD BE
DECREASED.

THANK YOU
( bertjohn27@yahoo.com )