Penatalaksanaan Syok Sepsis dengan Penyulit Cedera Ginjal Akut pada Pasien Peritonitis Sekunder

Masriani Najamuddin, Haizah Nurdin, Faisal Muchtar

Abstract


Peritonitis akibat infeksi intraabdominal, khususnya peritonitis sekunder merupakan salah satu penyebab syok sepsis dengan tingkat morbiditas dan mortalitas yang tinggi. Perkembangan dalam pemahaman fisiologi, pemantauan, dan tunjangan sistem kardiopulmonal, serta penggunaan obat-obat baru secara rasional membuat mortalitas stabil pada kisaran 30%. Kasus ini mengenai seorang pasien perempuan usia 67 tahun masuk rumah sakit dengan diagnosis peritonitis generalisata karena suspek perforasi Hollow viscous. Setelah menjalani operasi laparatomi untuk source control, pasien dirawat di ICU selama 5 hari. Selama perawatan pasien mengalami edema paru, sepsis, anemia, hipokalemia, hipoalbuminemia, serta acute kidney injury (AKI). Pada pasien dilakukan tindakan ventilasi mekanik selama 4 hari yang diiringi dengan pemantauan analisis gas darah arteri dan furosemid untuk tata laksana edema paru dan fluid overload. Resusitasi dan pemeliharaan cairan sambil memantau hemodinamik konvensional dan melalui ICON, balance kumulatif, fluid overload, tekanan vena sentral, serta urine output. Terapi antimikrob diberikan berdasar atas pedoman terapi infeksi intraabdominal dan antibiogram ICU rumah sakit. Kondisi perfusi dipantau dengan kadar laktat dan SCVO2. Respons antibiotik dan perbaikan sepsis dipantau dengan pemeriksaan prokalsitonin dan leukosit. Perbaikan AKI dipantau dengan produksi urine serta kadar ureum dan kreatinin. Penatalaksanaan peritonitis sekunder dengan komplikasi sepsis dengan penyulit AKI telah berhasil dilakukan di ICU. Peritonitis sekunder memiliki tingkat mortalitas yang cukup tinggi, namun dengan source control yang adekuat dan manajemen di ICU yang agresif maka diperoleh hasil yang baik seperti pada kasus ini.

Management of Septic Shock with Acute Renal Failure Complications in Secondary Peritonitis Patients

Peritonitis due to intraabdominal infection, especially secondary peritonitis is one of the major causes of septic shock with high morbidity and mortality. Developments in understanding the physiology, monitoring and supportive therapy for cardiopulmonary system and rational use of new drugs, make mortality stable at around 30%. A 67-year-old female patient was hospitalized with generalized peritonitis due to suspected Hollow Viscous perforation. After undergoing laparotomy for source control, the patient was treated in the ICU for five days. During treatment, the patient experiences pulmonary edema, sepsis, anemia, hypokalaemia, and hypoalbuminemia, and acute kidney injury (AKI). The patient received mechanical ventilation intervention for four days accompanied by monitoring of arterial blood gas analysis and furosemide administration for pulmonary edema and fluid overload management. Fluid resuscitation and maintenance are monitored by conventional hemodynamic monitoring and through ICON, and by cumulative balance calculation, fluid overload calculation, central venous pressure, and urine output. Antimicrobial therapy is given based on guidelines for intraabdominal infection therapy and antibiogram at the hospital ICU. The condition of perfusion is monitored by examination of lactate and SCVO2 levels. Antibiotic response and improvement in sepsis are monitored by examination of procalcitonin and leukocytes. AKI improvement is monitored by urine production, and urea and creatinine levels. Management of secondary peritonitis with complications of sepsis and AKI has been successfully carried out in the ICU. Secondary peritonitis has a fairly high mortality rate, but with adequate source control and aggressive management in the ICU, good results are obtained as in this case.


Keywords


Cedera ginjal akut, peritonitis, peritonitis sekunder, syok sepsis

References


Xu Z, Cheng B, Fu S, Liu X, Xie G, Li Z et al. Coagulative biomarker on admission to the ICU predict acute kidney injury and mortality in patients with septic shock caused by intra-abdominal infection. Infection and drug resistestence 2019;12:2755-64.

Kopitko C, Medve L, Gondos T. The value of combined hemodynamic, respiratory and intra-abdominal pressure monitoring in predicting acute kidney injury after major intraabdominal surgeries. Renal failure 2019;41(1):150-8.

Mureșan MG, Balmoș IA, Badea I, and Santini A. Abdominal Sepsis: An Update. The Journal of Critical Care Medicine 2018;4(4):120-5.

Dugar S, Chaudhary C, Duggal A. Sepsis and septic shock: Guideline-based management. Cleveland clinic journal of medicine. 2020;87(1):53-61.

Gyawali B, Ramakrishna K, Dhamon AS. Sepsis: The evolution in definition, pathophysiology, and management. SAGE open medicine. 2019;7:1-13

Peerapornratana S, Caballero CL, Gomes H, Kellum JA. Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney Int. 2019;96(5): 1083-99.

Montomoli J, Donati A, Ince C. Acute kidney injury and fluid resuscitation in septic patients: are we protecting the kidney?. Nephron 2019;143:170-3.

Olesen MW, Moller MH, Johansen KK, Aasvang EK. Effects of post-operative furosemide in adult surgical patients: a systematic review and meta-analysis of randomised clinical trials. Acta anaesthesiol scand 2020;64:282-91.

Steinbach CL, Topper C, Adam T, Kees MG. Spectrum adequacy of antibiotic regimens for secondary peritonitis: a retrospective analysis in intermediate and intensive care unit patients. Ann Clin Microbiol Antimicrob 2015;14:48.

Montravers P, Dufour G, Guglielminot J. Dynamic changes of microbial flora and therapeutic consequences in persistent peritonits. Crit Care 2015;19:7.

Waele JJ, Tellado JM, Weiss G, Alder J, Kruesmann F, Arvis P, Hussain T, et al. Efficacy and safety of moxifloxacin in hospitalized patients with secondary peritonitis: pooled analysis of four randomized phase III trials. Surg Infect 2014;15:567–75.

Augustin P, Dinh AT, Valin N, Desmard M, Crevecoeur MA, Muller C, et al. Pseudomonas aeruginosa post-operative peritonitis: clinical features, risk factors, and prognosis. Surg Infect 2013;14:297–303.

Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect 2017;18(1):1-76.

Singer M, Deutschman CS, Seymour CW, Shankar M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801–10.

Divatia JV, Amin PR, Ramakrishnan N, Kapadia FN, Todi S, Sahu S, et al. Intensive care in India: The Indian intensive care case mix and practice patterns study. Indian J Crit Care Med 2016;20:216–25.

Simpson SQ. New sepsis criteria: a change we should not make. Chest 2016;149:1117–8

Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013:369 (21):2063

Poston JT, Koyner JL. Sepsis associated acute kidney injury. BMJ 2019;364:k4891.

KDIGO Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2:1-138.

Kellum JA, Lameire N. KDIGO AKI guideline work group diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary. Crit Care 2013;17:204.




DOI: https://doi.org/10.15851/jap.v8n3.2174



 

This Journal indexed by

                               


 
Creative Commons License
JAP is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

 



View My Stats