TERAPI GIZI PADA

INFEKSI - SEPSIS

dr. Dadang Arief Primana, MSc, SpKO, SpGK

KSM Nutrisi Klinik RS Immanuel
INTRODUKSI
Infeksi : fenomena mikrobiologi,
ditandai respons peradangan terhadap
bakteri patogen atau toksinnya.

Ketidak-mampuan tubuh
membasmi infeksi dan
predisposisi infeksi berakibat
komplikasi infeksi-- SEPSIS.
INTRODUKSI

Dengan perkataan lain,

SEPSIS : sindroma klinik akibat

komplikasi infeksi, ditandai
peradangan sistemik dan
penyebaran kerusakan jaringan.
INTRODUKSI

Severe Sepsis cases US Population

1800 600
1600 550
500
1400
450
1200
400
1000
350
800 300
600 250
2001 2025 2050
INTRODUKSI
Sepsis memengaruhi status gizi
pasien, menyebabkan malnutrisi.

Di sisi lain,
Malnutrisi menyebabkan
sepsis lebih berat dan
serius
DEFINISI

 A consensus conference defined

sepsis as
"the systemic inflammatory
response syndrome (SIRS)
that occurs during infection."

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and
organ failure and guidelines for the use of innovative
therapies in sepsis. Chest 1992;101:1644-1655.
DEFINISI

The systemic inflammatory

response syndrome (SIRS) is
the host’s nonspecific cascade of
inflammatory events that occur in
response to some type of insult
(infection, trauma, burns,
pancreatitis, or majo surgery).
PATOGENESIS SEPSIS

 Sepsis dimulai rangsangan

bakteri dan toksin terhadap
sistem immune mengakibatkan
aktivasi makrofag, komplemen,
neutrofil, sekresi sitokin dan
mediator lain.
 Patogenesis sepsis yaitu
infeksi dan inflamasi.
DEFINISI
DEFINISI
DEFINISI
Sepsis is SIRS that is due to infection
(the invasion of normally sterile tissues
by mo, their products, or both).

Severe sepsis is sepsis with at least

one SIRS-induced organ dysfunction.

Septic shock is severe sepsis that

requires medical support of blood
pressure in spite of the patient
receiving resuscitation.
DEFINISI
If more than one organ is dys-
functional, the term multiple
organ dysfunction syndrome
(MODS)

If organs are failing, the patient is

said to have multiple organ
failure syndrome (MOFS).
DEFINISI
Multiple Organ Failure Syndrome
Respiratory: Acute lung injury or
acute respiratory distress syndrome
(ARDS).

Renal: Oliguria in spite of “adequate”

volume replacement, or an acute rise
in serum creatinine.
DEFINISI
Multiple Organ Failure Syndrome
Central nervous system: Altered
mental status, or a Glascow coma
score of < 15.

Hepatic: Jaundice, or an acute rise in

liver enzymes.

Cardiovascular: Hypotension in spite

of “adequate” fluids
DEFINISI
Multiple Organ Failure Syndrome
Gastrointestinal: Stress ulcer bleeding.

Hematologic: Low platelet count, or an

increase in protime (PT), partial
thromboplastin time (PTT), or an increase in
Ddimer levels not explained by other
diseases.

Systemic: Lactic acid levels greater than

two times normal.
PATOGENESIS SEPSIS
PATOGENESIS SEPSIS

 Penyebab Sepsis :
- Bakteri gram-negatif
- Bakteri gram-positif

 Sepsis bisa terjadi akibat infeksi

jamur, mikobakterium, riketsia, virus
atau protozoa.
PATOGENESIS SEPSIS
Bakteri
Jamur
Virus
PATOGENESIS SEPSIS
PATOGENESIS SEPSIS
PATOGENESIS SEPSIS
Tissue inflammation, Early
SIRS organ failure and death
TNF, IL-
1, IL-6,
PRO

Inflammatory balance

IL-12, IFN,
IL-3

days weeks
ANTI

IL-10, IL-4, IL-

1ra, Monocyte Immunosuppression
HLA-DR
suppression 2nd Infections Delayed MOF
CARS and death
Insult Griffiths, R. “Specialized nutrition support in the critically ill: For
(trauma, sepsis) whom and when? Clinical Nutrition: Early Intervention; Nestle
Nutrition Workshop Series
PATOGENESIS SEPSIS
RESPON METABOLIK
Respon metabolik sepsis kompleks
RESPON METABOLIK
 Libarkan banyak metabolisme
 fase ebb dan fase flow.
RESPON METABOLIK
 banyak metabolisme
 fase ebb dan fase flow.
RESPON METABOLIK
Respons Respons fase flow
fase ebb Respons akut Respons adaptif

Syok Katabolisme dominan Anabolisme dominan

hipovolemik ↑ glukokortikoid Respons hormonal berkurang
↓ perfusi jaringan ↑ glukagon perlahan-lahan
↓tingkat metabolik ↑ katekolamin ↓ tingkat hipermetabolik
↓ konsumsi oksigen Pelepasan sitokin, Berhubungan dg pemulihan
↓ tekanan darah mediator lipid Penting utk pengmbalian
↓ suhu tubuh Produksi protein fase akut protein
↑ ekskresi nitrogen Penyembuhan luka tergantung
↑ tingkat metabolik asupan gizi
↑ konsumsi oksigen
Penggunaan bahan bakar
RESPON METABOLIK
Sitokin jg berperan pd perubahan
metabolik, respons fase akut
Pasien sepsis mengalami hiper
katabolism meningkatkan energy
expenditure -----
terjadi – glikolisis
- glukoneogenesis
- lipolisis
- proteolisis.
RESPON METABOLIK
Severe human sepsis is associated
w/ hypermetabolic stress response

Severe human sepsis affects

protein, carbohydrate and lipid
metabolism throughout the body.
1. Netea MG, Van der Meer JW, Kullberg BJ. Sepsis-theory and therapies.
N Engl J Med 2003; 348: 1600-1602
2. Douglas RG, Shaw JH. Metabolic response to sepsis and trauma. Br J Surg
1989; 76: 115)
RESPON METABOLIK

From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
RESPON METABOLIK

From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
RESPON METABOLIK
Fasting – Early Stage
Muscle

Alanine / Pyruvate
Glucos Brain
e
Glutamine
Glycerol Gluconeogenesis

Ketogenesis Ketones
Fat AGL Liver
Ureagenesis

Ketones Urea

NH3
Kidney
Intestine
RESPON METABOLIK
Fasting – Late Stage
Muscle

Alanine / Pyruvate
Glucos Brain
e
Glutamine
Glycerol Gluconeogenesis

Fat Ketogenesis Ketones

AGL Liver
Ureagenesis

Ketones Urea

NH3
Kidney
Intestine
RESPON METABOLIK

From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
RESPON METABOLIK
Perubahan Metabolisme Energi
SEPSIS --- Stress Metabolik

Hipermetabolisme tergantung beratnya

sepsis, puncak peningkatan metabolism
mencapai 50-60% di atas normal.
Laju metabolisme meningkat 10-13%
setiap peningkatan suhu tubuh 1
derajat C pada pasien sepsis.
RESPON METABOLIK
Perubahan Metabolisme Karbohidrat
Sepsis meningkatkan- glikolisis
- glikogenolisis
- glukoneogenesis
Glikolisis --- simpanan glikogen
menurun cepat
Glukoneogenesis sering membuat
pasien hiperglikemia karena
glukosa turn over meningkat,
glucose intolerance, insulin resisten
RESPON METABOLIK
Perubahan Metabolisme Protein
Sepsis meningkatkan proteolisis

Keadaan hipermetabolisme dan

hiperkatabolisme pada sepsis
menyebabkan pemecahan protein
otot dan pelepasan asam amino
perifer meningkat untuk diubah
menjadi energi
RESPON METABOLIK

Sepsis ---
proteolisis
naik
RESPON METABOLIK
Perubahan Metabolime Lemak
Sepsis meningkatkan lipolisis

Pasien sepsis menjadikan lemak

sebagai sumber energi utama
untuk metabolisme energi shg
oksidasi lemak meningkat
RESPON METABOLIK
Perubahan Metabolisme Vitamin
Sepsis dapat menyebabkan gangguan
metabolisme vitamin

Gangguan metabolisme vitamin pada

sepsis menyebabkan pembentukan
sistem immune terganggu
Pasien sepsis sering mengalami
defisiensi vit B kompleks, vit D
RESPON METABOLIK
Perubahan Metabolisme Mineral

Sepsis meningkatkan proteolisis

menyebabkan gangguan
metabolisme mineral
Proteolisis meningkatkan
pengeluaran fosfor, kalsium,
zinc dan magnesium melalui
urine
RESPON METABOLIK
Gangguan Kesimbangan Elektrolit
Sepsis sering menyebabkan
hipokalemia

Pengobatan sepsis sering diikuti

oleh pengeluaran potassium
melalui urin
RESPON METABOLIK
Gangguan Kesimbangan Air
Sepsis sering disertai demam tinggi

Demam tinggi pasien sepsis

menyebabkan kehilangan air
dan ganggu keseimbangan air
dan elektrolit.
RESPON METABOLIK
Water balance
Sources Losses
Water 1500 ml Urine 1500 ml

Food 800 ml Stool 200 ml

Oxidation 300 ml Skin 500 ml

Resp. 400 ml
Tract
Total 2600 ml Total 2600 ml
RESPON METABOLIK
Disturbances of water and
electrolytes have a more profound
immediate effect on health than
nutrients, and imbalances readily
result in dehydration or fluid overload.
Metabolic abnormalities such as acid-
base, fluid, electrolyte disturbances
are common in septic patient
TERAPI SEPSIS
Pasien sepsis
 Managemen shock
 Managemen multiple organ
dysfunction (MOD)
 Resusitasi cairan
 Monitor CVP (the central venous
pressure = oxygen saturation)
TERAPI SEPSIS
Pasien sepsis
 Segera dirawat di ICU
 Kontrol infeksi
 Cardiovascular support
 Respiratory support
 Renal replacement therapy
Pasien sepsis
 Glucose control
 Other supportive care
TERAPI SEPSIS
Other Supportive Care
 Sedation
 Analgesia and neuromuscular
blockade
 Deep-vein thrombosis prophylax
 Stress ulcer prophylaxis
 Blood product administration
 Nutritional support
TERAPI SEPSIS
TERAPI SEPSIS
 Cardiovascular support
 Hypotension is a hallmark of severe sepsis.
 Patients with severe sepsis have
intravascular volume deficits as a result of
hemodynamic alterations.
 Respiratory support
 Oxygenation and ventilation problems are
common in patients with severe sepsis.

 Renal replacement therapy

 Alterations in renal functioning can occur in
patients with severe sepsis due to hypotension
and hypoperfusion.
TERAPI SEPSIS, Glucose Control
 Hyperglycemia is common in severe
sepsis.
 Following initial stabilization of patients
severe sepsis, maintain blood glucose
< 140 mg/dL
 Best results obtained when blood glucose
was 80-110 mg/dL
 Continuous infusion of insulin and
glucose may be used to maintain
target blood glucose levels.
van den Berghe G. N Engl J Med 2001;345:1359-1367.
Nutrition Support
 First, fluid therapy/resuscitation and
treatment of cause of
hypermetabolism
 When hemodynamically stable, begin
nutrition support
 Nutrition support may not result in
+N balance – may slow loss of
protein
 Undernutrition can lead to protein
synthesis, weakness, MODS, death
Terima Kasih