MENCEGAH TERJADINYA DISFUNGSI ORGAN

DAN GAGAL ORGAN GANDA DI RUMAH SAKIT

DENGAN FASILITAS TERBATAS

Warko Karnadihardja
Bag Bedah RSHS/FKUP
Bandung
Konsensus "the American College of Chest Physicians
and the Society of Critical Care Medicine" (1991)

 SIRS =
Systemic Inflammatory Response Syndrome
Terdapat 2 atau lebih tanda berikut :
 Temperatur > 380C atau < 360C
 Denyut Jantung > 90
 Frekuensi pernafasan > 20
 Lekosit > 12 x 109/L atau < 4 x 109/L
atau 10% bentuk immature
 Sepsis =
SIRS + Infeksi yang dibuktikan dengan kultur
Konsensus "the American College of Chest Physicians
and the Society of Critical Care Medicine" (1991) (2)

 Sepsis Berat
 Sepsis + disfungsi organ, hipotensi atau hipoperfusi
(termasuk laktat asidosis, oliguria atau perubahan status
mental akut)
 Syok Septik
 Hipotensi (meskipun dengan resusitasi cairan) +
abnormalitas hipoperfusi
Wittman ,et al, Annals of Surgery, 1996, Vol. 22: 6
Hubungan SIRS, Sepsis, & Infeksi (ACCP-SCCM - Consensus
Conference Chest, 1992 : 1001 - 1004 )

Lain2
Bakteremia

Infeksi
Fungiemia Sepsis SIRS Trauma

Parasitemia

Viremia Luka Bakar

Lain2
Pankreatitis
KASUS 1

 Ny.H (54 thn)

 Masuk rawat : 25 Februari 2004
 Diagnosa :
 Peritonitis difusa e.c perforasi duodenum
Onset of pain 3 hari. Tanda-tanda sepsis
 DM
 Terapi :cito laparotomy
(beberapa jam setelah
masuk RS)
 Tindakan operasi :
 Eksisi tepi ulkus
 Pyloroplasty
Postop
 Somnolent – soporocomateus
 Ventilator
 Hb 7,8, PCV 25, Leuko 5500,
Trombosit 84.000
Ureum 112, Kreatinin 2.5,
Temp 36.6, GDS 250-330,
albumin 1.6
 Infus sesuai CVP
 Diagnosa (28Feb04) : Suspek
leakage anastomosis duodenum
 Tindakan :
 KU tak memungkinkan operasi
lagi
 TPN + bedside upper
endoscopy oleh Dr. Reno untuk
memasukan Flo-care ke
jejunum melalui daerah
kebocoran duodenum
KASUS 2

 Ny TL (60 thn)
 Ca gaster daerah antrum.
Obstruksi total pylorus
 Cachexia
 Regurgitasi, choking
 Rencana : subtotal
gastrectomy paliatif
Preop

 TPN ( 26-3-2004 s/d 6-4-2004)

 Hb 5.8, Ht 22, Prot total 4.8, albumin 2.7, globulin 2.1
Operasi I (subtotal gastrectomy – 6-4-2004)
Postop I

 Tgl 19-4-2004 :
 persiapan pulang,
KU baik
 Makan peroral
 Tiba tiba nyeri
abdomen akut
 Foto kontras oral :
leakage !
Operasi II ( 20-4-2004 )

 Reparasi + jejunostomy feeding

 Hernia ventralis
incarcerata
 Laparotomi
 Strangulasi (usus nekrosis)
 Reseksi usus (source
control)
 Baru terjadi gangren, belum
sepsis
Gagal Organ Pasca Bedah [1]

 Dapat singel atau multipel

 Kematian tinggi 50-100%

 Istilah
 Primary Organ Failure
 Secondary Organ Failure
Gagal Organ Pasca Bedah [2]

 Kematian pasca bedah disebabkan gangguan

fisiologik yg dapat
 diidentifikasi
 diterangkan
 diperkirakan akan terjadi
 Sehingga
 DAPAT DICEGAH (preventable death)
 Kematian dapat diturunkan s/d 30%
Inflammatory and organ failure responses to
injury

Primary Secondary organ failure

organ
failure

Progressive organ failure

Response

Systemic inflammatory response syndrome

Shock

Resuscitation

Recovery

Recovery

1 3 10 14 21
Injury Days after injury
Stress induced organ injury

Initial Second
Insult Insult

Primary Host Secondary

Multiple Organ Stress Multiple Organ
Dysfunction Response Dysfunction

 Demling et al. Surg Clin North Am 74(3); 1994.

 Host Stress Response to Injury

Modulation by CNS
Afferent Arc Efferent Arc

Local Endocrine
Wound Response

Systemic Inflammation

Systemic Response
Demling et al. Surg Clin North Am 74(3); 1994.
 Release of Mediators
Systemic Activation of
“First Hit” POST INJURY “Second Hit”
Inflammatory Cells
Primed
Lung Inflammatory
INITIAL INSULT Cells
Primed
Liver
Local Activation of Systemic Release WBCs
Inflammatory Cells of Cytokines Primed
Gut
WBCs

Other Primed
LOCAL
Organs WBCs
TISSUE
RESPONSE
SYSTEMIC RELEASE OF
TOXIC MEDIATORS
Demling et al. Surg Clin North Am 74(3); 1994. GENERALIZED TISSUE INJURY
Major issues in restoring & maintaining perfusion after initial
insult
Insult Insult

Primary Systemic Secondary

Multiple Organ Stress Multiple Organ
Dysfunction Response Dysfunction
What Endpoints?
What Fluids?
When Inotropes?
When Blood?
What Results?
Demling et al. Surg Clin North Am 74(3); 1994.
Factors Influencing Duration of
Metabolic Responses to Stress
Gagal Organ Pasca Bedah [3]

 Tindakan yg dapat meningkatkan survival

Urutan Prioritas

 A-B-C-nya resusitasi
 Menghilangkan sumber penyakit
 Memulihkan transport oksigen
 Membantu perbaikan metabolisme
Early Goal-Direct Therapy in the Treatment of
Severe Sepsis and Septic Shock

Rivers E, Nguyen B, Havstad S.

N Engl J M 2001; 345: 1368-1377
Background

Cardiac Cardiac Cardiac

preload after load contractility

Balance between DO2 and VO2

Resuscitation end points

SvO2 Lactate Base deficit pH

Surrogate for Target for

cardiac index hemodynamic
Value of SvO2

Mixed venous oxygen saturation (SvO2)

O2 remaining in venous blood

after extracting by tissue

Global Tissue Oxygenation

VO2 ≈ DO2
Objective

Early goal-directed therapy before admission to the ICU

Reduce of multi organ dysfunction

Reduce incidence of mortality

Study design
SIRS criteria
SBP < 90 mmHg
Lactate > 4 mmol/L

Assessment and consent

Standard Therapy Randomization (n=263) Early goal-directed

in ED (n=130) therapy (n=133)

Vital sign, Lab data, cardiac

monitoring, pulse oximetry,
Urinary catheterization,
arterial and venous CVP 8-12 mmHg
CVP 8-12 mmHg catheterization
MAP ≥ 65 mmHg
MAP ≥ 65 mmHg Standard care Continuous SvO2
monitoring and Urine ≥ 0.5 cc/kg/min
EGDT for 6 hours
Urine ≥ 0.5
cc/kg/min ScvO2 ≥ 70%
Hospital admission

SaO2 ≥ 93%

Vital sign, lab data, Hematocrit ≥ 30%

obtained every 12 hour
for 72 hour
Cardiac index

Did not complete Did not complete VO2

6 hour (n=14) Follow up 6 hour (n=13)
Protocol for Early Goal-Directed Therapy
Supplement O2
Endotracheal intubations
Mechanical ventilation

Central venous and

arterial catheterization

Sedation, Paralysis
(if intubated), or both

Crystalloid
< 8 mmHg
CVP
Colloid
8 – 12 mmHg

< 65 mmHg
MAP Vasoactive agents
> 90 mmHg

65 – 90 mmHg

≥ 70%
< 70% Transfusion of RC
ScvO2 < 70%
until Ht ≥ 30%

≥ 70% Inotropic agents

No Goal Yes
achieved Hospital admission
 Early Goal Directed Therapy
in Emergency Department

Hospital mortality

Standard Early Goal

Therapy Directed Therapy

56,8% 42,3%

↓ 25%

Rivers et all. N Engl J Med 2001; 345: 1368-77

Conclusion

Goal-directed therapy at earliest stage

of severe sepsis and septic shock

Significant short term and long term

benefits

Identification at Therapeutic
high risk for intervention
cardiovascular
collapse
Balance between
DO2 and VO2
Source Control

 Laki-laki Kol. AD 52 thn

 Paraanal abscess yang
dirawat konservatif ( > 7
hari )
 Sepsis  MODS
Source Control

 Konsul bedah
 Insisi
 MODS dan rawat ICU (3
minggu, 8 hari dng
ventilator)
 Continuing sepsis
Source Control

 Minggu ke-4 dikonsulkan

bedah
 Abses + fistula sudah
sampai scrotum kanan
 Fistulotomy  baik
Source Control
 Abses paraanal dengan sepsis
 Hari ke-4 dari onset of pain
pasti sudah ada abses dan
phlegmon fluktuasi tak
teraba o/k abses pararectal /
tinggi
 Segera insisi di RS dengan NU
 Debridement + drainase yang
baik
 Jangan membuat perforasi ke
rectum
 Kesimpulan [1]

 Gagal Organ, Gagal Organ Multipel dan Kematian

Pasca Bedah dapat dicegah dan dikurangi
karena
 Data-data menunjukkan bahwa kematian pasca
bedah disebabkan oleh gangguan fisiologik yg
dapat diidentifikasi, diterangkan, diprediksi dan
dicegah
Kesimpulan [2]
 Kunci Keberhasilan

 A-B-C resusitasi
 Source Control
 Pemulihan Transport Oksigen
 Metabolic Support
 Monitoring
 Tune-Up Prabedah
Kesimpulan [3]

 Kemampuan seorang dokter dalam menegakan

diagnosa kegawatan bedah mempengaruhi reputasi
dokter tersebut di masyarakat
 Sebaiknya dokter jangan terlambat bertindak