PENEGAKAN DIAGNOSA SEPSIS Franciscus Ginting - Sepsis PIN... · I. Introduction • Sepsis and septic shock high rates of morbidity and mortality. • United States, incidence of

Management Sepsis TerkiniPENEGAKAN DIAGNOSA SEPSIS

Dr. Franciscus Ginting, Sp.PD – KPTI

Outline

• Introduction

• Pathogenesis of sepsis

• SIRS, SOFA Score & qSOFA

• Cases

I. Introduction

• Sepsis and septic shock high rates of morbidity and mortality.

• United States, incidence of sepsis is 3 cases per 1000 population

with mortality of 28.6% (215,000 deaths from 750,000 patients

diagnosed) per year.

• Septicemia was listed as the 10th leading cause of death in the

United States in 2007.

• Early and appropriate antimicrobial therapy the predominant factor

for reducing mortality

• DATA FROM ADAM MALIK HOSPITAL (2016) : mortality rate 73%(Ginting F, ICID 2018, Vienna)

Definisi lama Sepsis

1991 : Sindrom respon inflamasi sistemik (SIRS) host terhadap infeksi

2001 : Kriteria diagnostik sepsis

suhu >38ºC atau <36 ºC

denyut jantung ≥ .90/men

pernapasan >20x/menit

PaCO2 <32 mmHg (4.3kPa)

Leukosit >12000/mm3 atau <4000/mm3 atau >10% immature bands

Infeksi+ ≥ 2 gejala SIRS Infeksi+ ≥ 2 gejala SIRS

Sepsis is now defined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection” (Singer et al., 2016)

…the host response resulting in organ failure from an infection is stressed, while the inflammation stage known as S I R S in sepsis-1 and -2 has been removed

S

S

C

2

0

1

6

Sepsis as infection and 2 or

more SIRS is now just an

infection

Severe sepsis is now sepsis Septic Shock: Subset of

sepsis with circulatory and cellular/metabolic dysfunction associated with higher risk of mortality : Blood

lactate > 2 mmol/L despite volume

resuscitation; Hypotension that persists

after fluid resuscitation and requires

vasopressors

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

II. PATHOGENESIS of SEPSIS

Patofisiologi Sepsis

‘Final common

for death from infection’

• Hotchkiss 2013

Infection

Inflammatory

Mediators

Endothelial

DysfunctionVasodilation

Hypotension Vasoconstriction Edema

Maldistribution of Microvascular Blood Flow

Organ Dysfunction

Microvascular Plugging

Ischemia

Cell DeathPathophysiology of Sepsis-

Induced Ischemic Organ

Injury

Patofisiologi SEPSISPatofisiologi SEPSIS

R,perempuan, 61 tahun

KU: penurunan kesadaran

Hal ini dialami secara perlahan lahan sejak 1 bulan yang lalu memberat dalam 2 hari

ini. Awalnya pasien masih bisa dipanggil dan membuka mata namun 2 hari ini pasien

sudah cenderung tidur. Riw kejang tidak ada, riw muntah menyembur tidak ada.

Kelemahan tungkai tidak ada. Demam dijumpai 2 hari ini. Pasien pernah rawat

sebelumnya dengan diagnosa NHL

Sesak nafas dialami 1 hari ini. Demam dijumpai 2 hari ini. Batuk dijumpai 1 minggu ini

namun dahak sulit keluar.

Riwayat pemasangan kateter dijumpai, riw urin keruh tidak ada

Luka di bokong dijumpai 2 minggu ini

RPT: DM (-) HT (-), NHL (+) RPO: kemoterapi

Pemeriksaan fisik

Sens: somnolen

TD: 90/50

HR: 102x/menit

RR: 28 x/menit

T: 38,3

Terpasang O2 2-4 liter via nasal canule

Mata:

Anemis (-/-), ikterik (-/-), pupil isokor

Thorax:

SP: bronkial

ST: ronkhi di seluruh lapangan paru

Abdomen: simetris, soepel, H/L/R ttb, peristaltik N

Posterior: dijumpai ulkus dengan diameter 3-5 cm, pus (-)

Ekstremitas: lateralisasi (-)

Jenis

Pemeriksaan

Satuan Hasil

Hb g/dl 8,7

Leukosit /μl 3650

Ht % 23

Trombosit /μl 125.000

AGDA Satu

an

Hasil Rujukan

pH 7,370 7,35 –

7,45

pCO2 mm

Hg

26 38 – 42

pO2 mm

Hg

140 85 -100

HCO3 U/L 12,7 22 – 26

Total CO2 U/L 13,4 19 – 25

BE U/L -8,9 -2 - +2

Saturasi

O2

% 99,0 95 - 100

Jenis

Pemeriksaan

Satuan Hasil

Ureum mg/dL 68

Kreatinin mg/dL 3,4

Natrium mEq/L 138

Kalium mEq/L 3,8

Klorida mEq/L 101

III.1

Sequential Organ Failure Assessment

(SOFA) Score

Sequential Organ Failure Assessment (SOFA) Score

The SOFA score predicts mortality risk for patients in the intensive care unit

based on lab results and clinical data on the degree of dysfunction of 6 organ

systems.

• The score is calculated at admission and every 24 hours until discharge

• The SOFA score is not designed to influence medical management

• An initial SOFA score of < 9 predicted a mortality of < 33%, SOFA > 11 predicted

mortality of 95%

• Adam Malik Hospital (2018) SOFA score >7, kematian >>(Andrew, Ginting F KONAS PETRI

2019)

Variable SOFA SCORE

0 1 2 3 4

Respiratory :PaO2/FiO2,

mmHG

> 400 ≤400 ≤300 ≤ 200 ≤ 100

Coagulation : Platelet x 103μl >150 ≤150 ≤ 100 ≤50 ≤20

Liver : Bilirubin, mg/dl <1,2 1,2 – 1,9 2,0 – 5,9 6.0 – 11,9 >12

Cardiovascular : Hypotension No

hypotension

MAP : <70

mmHg

DOP ≤ 5 or Do (

any dose)DOP >5, Epi ≤ 0,1,

or Nor - epi ≤ 0,1

Dop >15,

Epi >0,1 or

Nor – Epi

>0,1

Central Nervous System :

GCS Scale

15 13 – 14 10 - 12 6 - 9 <6

Renal :Creatinine/Urine

Output

<1,2 1,2 – 1,9 2.0 – 3,4 3,5 – 4,9 or UOP :

<500

>5 .0 or

UOP : <200

1

23

45

6

S

S

C

2

0

1

6

Why to UseThe SOFA score can be used to determine the level of organ dysfunction and

mortality risk in ICU patients.

When to Use

• The SOFA can be used on all patients who are admitted to an ICU.

• It is not clear whether the SOFA is reliable for patients who were transferred from

another ICU.

Instructions

Calculate the SOFA score using the worst value for each variable in the preceding

24-hour period.

“the major gap is the difficulty to apply current sepsis case definitions, especially in LMIC settings when

the main tests are not available”

“90% of cases with poor outcome in the Australian sepsis database, inadequate recognition was found

to be the most common feature”

The SOFA scoring system is useful in predicting the clinical outcomes of critically ill patients.According to an observational study at an Intensive Care Unit (ICU) in Belgium the mortality• least 50% when the score is increased regardless of initial score in the first 96 hours • 27% to 35% if the score remains unchanged• less than 27% if the score is reduced.

III.2.q SOFA

QSOFA

SSC 2016

The qSOFA • a rapid, bedside clinical score to identify patients with suspected infection

who are at greater risk for poor outcomes.

• The primary outcome was in hospital mortality, and the secondary outcome

was an ICU length of stay of ≥ 3 days.

• The qSOFA was meant to replace the systemic inflammatory response

syndrome (SIRS) criteria.

• qSOFA has also been found to be poorly sensitive for the risk of death with

SIRS possibly better for screening

• Sepsis HAM Hospital 2018: 16,7% under diagnose (Maruli,Ginting F, KONAS PETRI 2019)

-Angus, Derek C.; Seymour, Christopher W.; Coopersmith, Craig M.; Deutschman, Clifford S.; Klompas,

Michael; Levy, Mitchell M

.; Martin, Gregory S.; Osborn, Tiffany M.; Rhee, Chanu. Williams JM, Greenslade JH, McKenzie JV, et al. -

SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients

with infection. Chest 2017;151:586-596.

• The qSOFA score predicts mortality but does not diagnose sepsis

• no prospective studies have demonstrated that clinical decisions based

on the qSOFA lead to better patient outcomes.

The most recent Surviving Sepsis Campaign guidelines, published in March

2017, do not integrate the qSOFA into recommendations for screening or

diagnosis of sepsis.

Emergency Medicine Practice • October 2018

A positive qSOFA score clinicians to further investigate for the presence of organ

dysfunction or increase the frequency of patient monitoring.

III.3.

SIRS compare to SOFA score in sepsis

The SIRS Criteria definitions of sepsis • are being replaced as they were found too many limitations;

• the "current use of 2 or more SIRS criteria to identify sepsis was unanimously considered

by the task force to be unhelpful.”

Audit pasien sepsis Tahun 2016 RSUP HAM

• SSC 2012: 2 SIRS + infected Over diagnosed: 33,7%

• 78 data infection with SIRS < 2

• 75 data >2 SIRS without infection (Chronic disease)

• 30 data Increased Procalcitonin in CKD

• 124 data sepsis in resume medic only

(Ginting F, submitted journal process)

Only 94 out of 142 cases ( 66,2 %) were judged to meet the diagnosis criteria for sepsis.

Out of the 94 patients, 77 ( 82%) were appropriately classified for sepsis severity.

19 patients (20%) met criteria for severe sepsis/ septic shock.

Among critically ill patients with suspected sepsis, the predictive validity of the SOFA score for in- hospital mortality was superior to that of the SIRS criteria (area under the receiver operating characteristic curve 0.74 versus 0.64)

SIRS, qSOFA and new sepsis definition

Paul E. Marik, Abdalsamih M. Taeb

Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USACorrespondence to: Paul Marik, MD. Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk VA 23507, USA. Email: marikpe@evms.edu. Provenance: This is an invited Editorial commissioned by the Section Editor Zhongheng Zhang (Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China).Comment on: Williams JM, Greenslade JH, McKenzie JV, et al. SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients with infection. Chest 2017;151:586-596.

Submitted Feb 05, 2017. Accepted for publication Mar 06, 2017. doi: 10.21037/jtd.2017.03.125View this article at: http://dx.doi.org/10.21037/jtd.2017.03.125

Evaluated the presence of SIRS criteria in 109,663

patients with infection and organ failure. In this study,

12% of patients were classified as having SIRS-negative

sepsis (i.e. <2 SIRS criteria) Kaukonen KM, Bailey M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in de ning severe sepsis. N Engl J

Med 2015;372:1629-38.

Over diagnose

A new large retrospective cohort analysis among 184,875 patients in

182 Australian and New Zealand intensive care units (ICUs) found

SOFA score had superiority in prediction of in-hospital mortality but it

showed SIRS criteria has greater prognostic accuracy for in-hospital

mortality than qSOFA score

Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the sofa score, sirs criteria, and qsofa score for in-hospital mortality among adults with

suspected infection admitted to the intensive care unit. JAMA 2017;317:290-300.

The discrimination of in-hospital mortality for SOFA (75.3% AUROC; 99% confidence interval (CI): 0.750–0.757) was significantly higher than that of qSOFA (60.7% AUROC; 99% CI: 0.603– 0.611) or SIRS (58.9% AUROC; 99% CI: 0.585–0.593).

Of the study population, 90.1% (165,103 patients) had an increase in SOFA score from baseline to at leasttwo points; 86.7% (158,710 patients) met two or more SIRS criteria, and 54.4% (99,611 patients) had a qSOFA scoreof at least two points .

In adults admitted to the ICU with suspected infection, an increase in SOFA score of at least two points had superior prognostic accuracy for in-hospital mortality followed by qSOFA and finally SIRS criteria.With SOFA score demonstrating significantly greater discrimination for in-hospital mortality, the authors highlight that this may

suggest that SIRS criteria and qSOFA may have limited utility in predicting mortality in an ICU setting .

• The definition of SIRS, although sensitive to detect sepsis, was rather unspecific. • In addition, the SIRS criteria performed badly in identifying patients significant morbidity

and mortality.• These issues led to a recent new consensus definition for sepsis and septic shock• This international task force

o defined sepsis as ‘life-threatening organ dysfunction o Using large datasets (>1 million patient records), o increase in 2 points or more for a patient suspected to have infection using the

Sequential Organ Failure Assessment (SOFA) best predicted in-hospital mortality.• The SOFA is well known within the intensive care community, but is not so well known

generally. • The task force developed a simpler clinical screening tool that performed very well in

identifying adult patients with suspected infection who were likely to have poor outcomes, which they termed ‘quick SOFA’ (qSOFA).

• The definition of SIRS, although sensitive to detect sepsis, was rather unspecific. • In addition, the SIRS criteria performed badly in identifying patients significant morbidity

and mortality.• These issues led to a recent new consensus definition for sepsis and septic shock• This international task force

o defined sepsis as ‘life-threatening organ dysfunction o Using large datasets (>1 million patient records), o increase in 2 points or more for a patient suspected to have infection using the

Sequential Organ Failure Assessment (SOFA) best predicted in-hospital mortality.• The SOFA is well known within the intensive care community, but is not so well known

generally. • The task force developed a simpler clinical screening tool that performed very well in

identifying adult patients with suspected infection who were likely to have poor outcomes, which they termed ‘quick SOFA’ (qSOFA).

PPK SEPSIS PERMENKES 2017 - > SSC 2012

MENGHITUNG RASIO PAO2/ FIO2

Perhitungan rasio PaO2 / FiO2 dilakukan untuk mengetahui status oksigenasi pasien.• Rasio paO2 / FiO2 yang normal adalah > atau =300.• Apabila rasio paO2 / FiO2 < 300 maka pasien mengalami acute lung injury ( ALI) • Apabila rasio PaO2 / FiO2 < 200 maka pasien mengalami acute respiratory distress syndrome (ARDS)Cara menghitung rasio paO2 / FiO2 pasien diatas adalah:1. cari nilai FiO2: misal, pasien menggunakan O2: 3 l/mnt FiO2 adalah : 33% atau 0,322. hasil AGDA didapat paO2 pasien diatas adalah 82 mmHg3. masukan ke rumus berikut:PaO2 / FiO282 / 0,3 = 273,3

AO2 100% (l/mnt) FiO2

Kanul nasal Sungkup O2

1 0,24 5-6 0,40

2 0,28 6-7 0,50

3 0,32 7-8 0,60

4 0,36 Sungkup reservoar

5 0,40 6 0,60

6 0,44 7 0,70

8>= 0,80

qSOFA SSC 2016qSOFASOFA ScoreqSOFASOFA Score

STEP 1

Inflammation or infection?

• Leukocytosis : MCI, CHF, Pancreatitis, burn injury, post operative?

• SIRS not cause by infection

• Fever?

• SIRS correlation with infection? Acute?

Bacterial or viral?

• CRP, Procalcitonin(CKD?)

• Neutrophil/ limphocyt

• Total eosinophil

STEP 2• Sepsis (SSC 2016)

– Quick Sofa

The scoring/condition happened in acute condition and due to by infection

SOFA Score

dr. Fransiscus Ginting SpPD, K-PTI

Kasus Pasien Sepsis

Kasus 1

Tn E, Laki-laki 38 tahun

Anamnesa

Sesak nafas dialami 2 hari. Sesak nafas tidak berhubungan

dengan aktivitas dan cuaca, disertai batuk.

Demam dialami sejak 2 hari, sepanjang hari .Penurunan kesadaran

terjadi sejak 2 hari ini. Tidak ada riwayat trauma atau kejang.

Pasien sudah berbaring sejak > 1 bulan ini karena tangan dan kaki

pasien mengalami kelemahan. Pasien juga tidak dapat diajak

berbicara lagi.

pasien baru mengetahui menderita HIV selama 2 minggu.

Vital Sign

Sens : somnolen

TD : 90/60 mmHg

HR 104x/i RR : 24x/i T : 39

Pemeriksaan Fisik

Kepala : Konj palpebra anemis (-), sklera ikterik (-), oksigen terpasang

4 l/I nasal canul. NGT terpasang

Leher : TVJ R-2 Cm H20

Thorax : simetris, SF ki=ka. Sonor, SP: bronchial, ST : Ronchi basah

diseluruh lapangan paru

Abdomen : simetris, soepel, peristaltik N

Extremitas : oedema (-)

Apakah ini sepsis?

1.Fokus infeksi : paru2.Hasil scanning : Toxoplasma encephalopathy3.Quick sofa score = 3 (>2)• GCS : 5 ( <15)• RR : 24 ( >22x/i)• TD : 90/60 (<100)

Quick Sofa : 3

1 1 1

Laboratorium

Hb : 9,6

PLT : 22.000

WBC : 12.300

Ureum : 75

Creatinin : 1,63

Bilirubin total : 2,3

pH 7,46 IgG anti toxoplasma 157

pCO2 : 21 IgM anti toxoplasma 2,72

pO2 : 167

HCO3 : 14,9

Total Co2 : 15,5

Base Excess : -6,9

SO2 : 100

AGDA :

Natrium : 130

Kalium 3,2

Chlorida 102

Sofa score: 1. Kesadaran :

11

3

2. Tekanan darah

TD : 90/60 mmHgMAP > 70 (score = 0)

Pernafasan

0 1 2 3 4

>400 <400 >300 <200 <100

AO2 100% (l/mnt) FiO2

Kanul nasal Sungkup O2

1 0,24 5-6 0,40

2 0,28 6-7 0,50

3 0,32 7-8 0,60

4 0,36 Sungkup reservoar

5 0,40 6 0,60

6 0,44 7 0,70

8>= 0,80

167/0,36= 463PO2 : 167 FiO2:0,36

Trombosit : 22.000 ( score 3)Bilirubin : 2,3 ( score 2)

pO2/FiO2 : AGDA pO2 167/FiO2 0,36= 463 ( score : 0)Trombosit :22.000 ( score 3)Bilirubin : 2,3 ( score 2)MAP : 73 ( score 0)GCS :5 ( score 4)Creatinin : 1,63 ( score 1)Total Score : 10

DXSepsis ec pneumonia

Pneumonia HAP dd CAPHIV stadium IV

Toxoplasma Encephalopathy

K a s u s 2Tn L, pria 54

tahun

Anamnesa

Sesak nafas dialami sejak 1 hari sebelum rumah sakit. Sesak nafas memberat dengan aktivitas disertai dengan batuk. Pasien di diagnosa dengan acute lung oedema oleh dept cardiologi. Demam dialami sejak 4 hari dirawat di CVCU. Demam terjadi sepanjang hari .Pasien menggunakan ventilator sejak berada di cvcu.

Vital Sign

Sens : DPO TD : 90/60 mmHgDengan support norepinefrin

HR 54 x/i RR : 16x/I terpasang ventilator

T : 38,9

Pemeriksaan Fisik

Kepala : Konj palpebra anemis (-), sklera ikterik (-), terpasang ventilator. FiO2 50%Leher : TVJ R+3 Cm H20Thorax : simetris, SF ki=ka. Sonor, SP: bronchial, ST : Ronchi basah diseluruh lapangan paruAbdomen : simetris, soepel, peristaltik NExtremitas : oedema (-)

Diagnosa infeksi

Pneumonia HAP?

Quick Sofa : (sulit dinilai) untuk pasien rawat non ICU

RR : 20 x/I ( ventilator +)

Td : 100/80 (support norepinefrin)

Sens : DPO

? ? ? ?

Laboratorium

Hb : 12,3PLT : 206.000WBC : 17.440Ureum : 137Creatinin : 2,8Bilirubin total : 1,2

pH 7,42pCO2 : 32pO2 : 87HCO3 : 20,8Total Co2 : 21,8Base Excess : -2,9SO2 : 97%

AGDA : Natrium : 134Kalium 3,2Chlorida 107

SOFA SCOREpO2/FiO2 : 87 / 0,5 = 174 ( score : 3)Trombosit : 206000 ( score 0)Bilirubin : 1,2 ( score 1)MAP : support norepinefrin ( oleh karena penyakit jantung? Sepsis? )GCS : sulit dinilai. Pasien DPO ( score ?)Creatinin : 2,8 ( score 2)Total Score : 6

DX

Sepsis ec pneumonia VAP

Acute Lung Oedema

CAD 3 VD

DM tipe 2

time is my time

KASUS 3KASUS 3

S, perempuan, 42 tahunAnamnesis:• Sesak nafas, dijumpai sejak 4 hari SMRS, sesak tidak berhubungan dengan aktivitas dan

cuaca• Batuk dijumpai sesekali 3 minggu ini, dahak berwana kuning, riw batuk darah (-), penurunan

BB (-), keringatmalam (+), nyeri dada (-) demam (+) 3 hari SMRS.• Mual muntah (-) mata kuning dijumpai 2 hari SMRS. Nyeri perut tidak dijumpai • Riw sakit kuning sblmnya (-) riw alkohol (-)• BAK nyeri (+) 2 hari ini setelah pemasangan kateter, pada kateter dijumpai BAK sedikit keruh.

Volume BAK 1 liter/hari• BAB tidak ada keluhan• Pasien merupakan pasien konsul dan dirawat oleh TS Bedah dengan Diagnosa Reynoud

Disease.• RPT: DM (-) HT (-)

Pemeriksaan Fisik• Sens : CM• Vital Sign:

– TD 90/60, – HR: 107x/menit, – RR 32x/menit (terpasang simple mask 6 l/menit)– T: 37 C

• Mata: anemis (-/-), ikterik (+/+)• Thorax:

– SP: bronkial – ST: ronkhi (+/+) di lapangan atas kedua paru

• Abdomen: simetris, soepel, H/L/R ttb, peristaltik normal• Ekstremitas:

– Sup: menghitam pada digiti III dan IV manus sinistra– Inferior: edema (-/-)

Jenis Pemeriksaan Satuan Hasil Nilai Rujukan

Hb g/dl 11,2 12-16

Leukosit /μl 34.910 4,000-11,000

Ht % 33 39-54

Trombosit /μl 6000 150,000-450,000

MCV fL 87 81-99

MCH pg 29,2 27-31

MCHC g/dL 33,6 21-37

Neutrofil % 91,8 50-70

Limfosit % 4,0 20-40

Monosit % 3,6 2-8

Eosinofil % 0,3 1-3

Basofil % 0,3 0-1

Kesan : leukositosis, trombositopenia

Kimia KlinikJenis Pemeriksaan Satuan Hasil Rujukan

Ginjal

Ureum mg/dL 96 15-40

Kreatinin mg/dL 5,02 0.6-1.1

AGDA Satuan Hasil Rujukan

pH 7,370 7,35 – 7,45

pCO2 mmHg 22 38 – 42

pO2 mmHg 159 85 -100

HCO3 U/L 12,7 22 – 26

Total CO2 U/L 13,4 19 – 25

BE U/L -10,8 -2 - +2

Saturasi O2 % 99,0 95 - 100

Hasil

Bil. Total 20,70

Bil Direk 11,00

Apakah ini sepsis?Apakah ini sepsis?

1. Adakah fokal infeksi?1. Adakah fokal infeksi?

Diagnosa Infeksi

• Pneumonia dd/ TB Paru

• ISK

• Cholangitis (??)

2. Berapa qSOFA?2. Berapa qSOFA?

TDS 90 mmHg 1TDS 90 mmHg 1 RR 32x/menit 1RR 32x/menit 1

TOTAL SCORE : 2

SOFA score:

• AGDA PaO2/FiO2 159/0,5= 318 (<300) 1

• Platelet 6000 4

• Bilirubin 20 4

• Cardiovaskular MAP >70 0

• CNS GCS >15 0

• Renal Cr>5,00 4

• TOTAL SCORE 13

3. Berapa SOFA Score?3. Berapa SOFA Score?

TOTAL SCORE 14TOTAL SCORE 14

Diagnosis

• Sepsis ec dd/ pneumonia dd/urosepsis dd/ cholangitis

• Reynoud Disease

Treatment

• Cor NaCl 0,9% 30 cc/kgBB 1500 cc

• Kultur darah, sputum, urin

• Cek Procalcitonin 31,89

• Antibiotik Drip meropenem 1 gram/8 jam dalam 100 cc NaCl 0,9% habis dalam 3 jam

Hasil Kultur

• Darah : tidak ada pertumbuhan bakteri

• Urin : tidak ada pertumbuhan bakteri

• Sputum:

– Dijumpai batang gram (-)

– Bakteri aerob: Acinetobacter baumanii

• Sensitive: Amikasin, Tigecyline

• Resisten: Ampicillin Sulbactam, ceftazidime, ceftriaxon, cefepime, ciprofloxacin, gentamycin, meropenem, trimetropim/sulfametoxazole

NB: KULTUR SPUTUM DIAMBIL SETELAH PEMBERIAN ANTIBIOTIK

EVALUASI

Jenis Pemeriksaan Satuan Hasil Nilai Rujukan

Hb g/dl 7,7 12-16

Leukosit /μl 13.550 4,000-11,000

Ht % 24 39-54

Trombosit /μl 416.000 150,000-450,000

MCV fL 87 81-99

MCH pg 27,8 27-31

MCHC g/dL 31,8 21-37

Neutrofil % 75,2 50-70

Limfosit % 22,0 20-40

Monosit % 3,6 2-8

Eosinofil % 0,3 1-3

Basofil % 0,3 0-1

Kesan : leukositosis

Hematologi Rutin

PERBAIKANPERBAIKAN

Hasil

Bil. Total 2,4

Bil Direk 1,9

SGOT 105

SGPT 131

PERBAIKAN!Anjuran: USG ABDOMEN data tidak

ada

PERBAIKAN!Anjuran: USG ABDOMEN data tidak

ada

MENINGKATHasil Foto Thorax pasien menunjukkan

adanya TB paru dan diberikan OAT, sehingga OAT mungkin penyebab

peningkatan SGOT dan SGPT

MENINGKATHasil Foto Thorax pasien menunjukkan

adanya TB paru dan diberikan OAT, sehingga OAT mungkin penyebab

peningkatan SGOT dan SGPT