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DIAGNOSIS DAN PENATALAKSANAAN SEPSIS

26 Juni 2012, 10:11, dibaca 22500 kali


 DIAGNOSIS DAN PENATALAKSANAAN SEPSIS

Soroy Lardo SpPD FINASIM
Sub SMF Penyakit Tropik dan Infeksi
Departemen Penyakit Dalam RSPAD Gatot Soebroto

 

PENDAHULUAN

Sepsis merupakan reaksi inflamasi dan infeksi pada tubuh yang disebabkan oleh adanya patogen dan toksin masuk kedalam sirkulasi darah. Angka kejadian sepsis pada pasien di rumah sakit, khususnya di rumah sakit rujukan cukup tinggi. Hal ini disebabkan pasien yang datang, sudah ditandai dengan berbagai komorbid penyakit atau MODS (Multiorgan Dysfunction Syndrome). 1,2 Kejadian Sepsis di RSPAD Gatot Soebroto terutama di Ruangan Perawatan Umum, berdasarkan penelitian Pola Kuman di Ruangan Perawatan Umum tahun 2008 yang dilakukan oleh T Zulfikar dkk didapatkan kasus sepsis sebanyak 35,4 %.3
Diagnosis Sepsis ditegakkan berdasarkan adanya suatu gejala SIRS disertai dengan infeksi organ yang menjadi sumber infeksi sebagai respons inflamasi sistemik. Yaitu mencakup dua atau lebih : 1) Suhu > 38 ° C atau < 36 ° C, 2) Frekuensi jantung > 90 X /menit, 3) Frekuensi nafas > 20 kali/menit atau PaCO2 < 32 mmHg , 4) Lekosit darah > 12.000/mm3 , < 4000 /mm3 atau adanya netrofil batang > 10 %. 1,2,4
Klasifikasi Sepsis terdiri dari SIRS (Systemic Inflammation Respons Syndrome), Sepsis. Sepsis Berat yaitu sepsis yang disertai dengan hipoperfusi, oliguria, laktat dan penurunan kesadaran. Sepsis dengan hipotensi jika ditemukan tekanan darah sistolik < 90 mmHg atau penurunan TD diastolik > 40 mmHg dan tidak ditemukan penyebab hipotensi lainnya. Renjatan septik adalah sepsis dengan hipotensi, walaupun sudah diberikan resusitasi cairan secara adekuat dan pemberian vasopressor.1,2,4
Perjalanan Sepsis memiliki variasi yang sangat luas. Tingkat kesembuhan ataupun mortalitas ditentukan oleh waktu pasien masuk ke rumah sakit, tingkat dan gejala klinik, jumlah organ yang terlibat dan yang terpenting tersedianya ”cost” yang cukup untuk suportif dan pengobatan pasien.

PATOGENESIS

Patogenesis sepsis diawali dengan adanya fokus infeksi jaringan sebagai bakteriemia sekunder. Sepsis dapat disebabkan oleh bakteri gram negatif dan bakteri gram positif. Bakteri gram negatif akan menstimulasi toksin dengan Lipopolisakaraida (LPS) dan bersama dengan antibodi dalam serum darah penderita membentuk Lipopolysaccharide binding protein (LBP). LBP yang berada dalam darah penderita akan bereaksi dengan makrofag melalui TLRs4 (Toll Like Reseptor) sebagai reseptor transmembran dengan perantaraan reseptor CD14+ dan makrofag yang mengekspresikan sebagai imunomodulator. Bila penyebabnya bakteri gram positif, maka eksotoksin akan dikeluarkan. Eksotoksin, parasit dan virus dapat berperan sebagai superantigen setelah difagosit oleh monosit atau makrofag yang berperan sebagai Antigen Processing Cell yang ditampilkan dalam Antigen Presenting Cell (APC). Antigen ini membawa muatan polipeptida spesifik yang berasal dari Major Histocompatibility Complex (MHC). Antigen yang bermuatan peptida MCH kelas II akan berikatan dengan CD4 (Limfosit Th1 dan Th2) dengan perantaraan TCR (T Cell Receptor).1,2,4
Proses dari tubuh selanjutnya adalah peran limfosit T mengeluarkan substansi Th1 yang berfungsi sebagai imunomodulator yaitu : IFN , IL-2 dan GM-CSF (Granulocyte macrophage colony stimulating factor). Limfosit Th2 akan mengekspresikan IL-4, IL-5, IL-6 dan IL-10. IFN  merangsang makrofag mengeluarkan IL-1 dan TNF α yang merupakan sitokin proinflamatori dan meningkat pada keadaan sepsis. Beberapa penelitian sebelumnya mengungkapkan, peningkatan TNF α dan IL-1  berkorelasi dengan tingkat keparahan penyakit terhadap kematian, tetapi disisi lain IL-2 dan TNF α selain merupakan reaksi terhadap sepsis, dapat pula merusak endotel pembuluh darah. IL-1  sebagai imunoregulator utama memiliki efek terhadap sel endotelial termasuk didalamnya pembentukan prostaglandin E2 (PG-E2) dan merangsang ekspressi intracelluler adhesion molecule-1 (ICAM-1). Sehingga netrofil yang telah tersensitisasi oleh GM CSF akan mudah mengadakan adhesi, interaksi endotel dengan neutrofil.1,2,4
Rangkaian lebih lanjut adalah : Adhesi netrofil dan endotel menstimulasi lisosim menyebabkan dinding endotel lisis. Superoksidan dan radikal bebas yang dibawa netrofil mempengaruhi oksigenisasi pada mitokondria dan siklus GMPs sehingga endotel menjadi nekrosis dengan akibat kerusakan pembuluh darah yang diakhiri dengan terjadinya gangguan vaskuler

(vaskuler leak). Menurut pendapat Bone dan Cohen pada kondisi tersebut sudah terjadi kelainan organ multipel yang disebabkan oleh infeksi, inflamasi sistemik, sitokin mediator, trombosis dan koagulasi pembuluh darah kecil yang dapat menyebabkan syok septik dan berakhir dengan kematian. Pasien dengan kerusakan lebih dari tiga organ memiliki angka kematian sangat tinggi. Dalam suatu penelitian, angka kematian syok septik adalah 72 % dan 50 % penderita meninggal bila terjadi syok lebih dari 72 jam, 30 % - 80 % penderita dengan syok septik menderita ARDS (adult respiratory distress syndrome). Yang perlu menjadi perhatian adalah penderita immunocompromise seperti diabetes melitus, sirosis hati, gagal ginjal kronik dan usia lanjut. Kondisi tersebut lebih mudah menderita sepsis dan umumnya sering terjadi komplikasi yang berat yaitu syok septik dan berakhir dengan kematian. Untuk mencegah terjadinya sepsis yang berkelanjutan, Th-2 mengekspresikan IL 10 sebagai sebagai sitokin anti inflamasi yang akan menghambat ekspresi IFN  , TNF α dan fungsi APC. IL -10 juga memperbaiki jaringan yang rusak akibat peradangan. Apabila IL-10 meningkat lebih tinggi, kemungkinan kejadian syok septik pada sepsis dapat dicegah.1,2,4

PENDEKATAN DIAGNOSIS


Pendekatan diagnosis pasien sepsis didasarkan pada perjalanan penyakit, gejala klinik , pemantauan terhadap perkembangan sepsis yang didasarkan oleh PIRO . PIRO merupakan istilah yang uraiannya sebagai berikut : P : predisposisi dan perubahan fisiologis. Predisposisi tersebut mencakup penyakit yang mendasari, genetik dan interaksi diantara patogen dan pejamu. I : Infeksi yang didapatkan sebagai penyebab sepsis. Terdiri dari kultur patogen, kontrol sumber infeksi, LPS dan faktor-faktor virulen. R : Respon akibat infeksi.Terdiri dari SIRS, syok, CRP, IL-6, TNF alfa, Procalcitonin. O : Organ failure yaitu tidak ada kegagalan organ atau skor terkompensasi, apoptosis, hipoksia sitopatik dan stres sel. Jika berpegang dari akronim tersebut mengingatkan kita bahwa sepsis sebagai suatu kontinum, dari faktor yang merupakan predisposisi sepsis sampai komplikasi yang mematikan. Pendekatan lebih lanjut adalah mengenal secara dini tanda-tanda dari MODS (Multi Organ Disfunction Syndrome) dengan komplikasi yang terjadi yaitu : Sindrom distres pernafasan pada dewasa, koagulasi intravaskular, gagal ginjal akut, perdarahan usus, gagal hati, disfungsi sistem saraf pusat, gagal jantung dan kematian. Penelitian Guntur Hermawan dkk (2004) pada penderita sepsis yang dirawat dibangsal penyakit dalam Rumah Sakit dr Moewardi Surakarta terhadap 89 pasien. Sepsis terjadi pada usia lanjut  60 tahun (38 %), 41-59 tahun (34%) dan  40 tahun (28 %). Dengan komorbid dan penyakit penyerta yang menyebabkan sepsis adalah diabetes melitus (35 %) , Gagal Ginjal Kronik (15,7 %), Penyakit hati kronis (18 %), Infeksi Saluran Kemih (6.7 %), anemia (5,6 %), kardiovaskuler (4,5 %), penyakit paru (4,5 %), gastrointestinal (4,5 %), keganasan (2,3%), HIV (1,1 %) dan thypoid (1,1 %). 1,2,4
Diagnosis Sepsis ditegakkan dengan mengenal tanda-tanda SIRS dalam perjalanan infeksi pasien, pemeriksaan fisik secara menyeluruh terutama pasien neutropenia, pemeriksaan laboratorium yaitu darah lengkap dengan hitung diferensial, urinalisis, gambaran koagulasi, glukosa, urea darah, nitrogen, kreatinin, elektrolit, uji fungsi hati, kadar asam laktat, gas darah arteri, elektrokardiogram, ronsen dada, biakan darah, sputum, urin dan tempat lain yang diduga sebagai tempat infeksi. Pemeriksaan penting lainnya adalah Pro Calcitonin untuk penanda beratnya sepsis secara serial, D Dimer jika sudah didapatkan adanya trombositopenia dengan perpanjangan waktu trombin. 1,2,4,5

PENATALAKSANAAN


Penatalaksanaan Sepsis berdasarkan kemampuan untuk mengatasi infeksi dan mempertahankan homeostasis.
Pengelolaan tersebut meliputi : pengobatan penyakit dasar, pemberantasan sumber infeksi, pemberian antibiotika, support respirasi, sirkulasi dan hemodinamik dan pemberian cairan. Jika terjadi syok septik sudah harus dilakukan perawatan di ruang intensif. 1,2,4,5
Tingkat kesembuhan penanganan pasien sepsis tergantung kepada keberhasilan dalam mengatasi infeksi dasar, mempertahankan sirkulasi dan hemodinamik/perfusi jaringan agar mendapatkan oksigenisasi yang cukup. 1,2,4,5
Beberapa tahap penatalaksanaan sepsis adalah (1) Terapi cairan. Pada pasien sepsis akan terjadi kekurangan cairan intravaskular relatif sampai berat terutama pada syok septik. Pada awalnya tubuh mempertahankan perfusi organ vital terutama otak dan ginjal dengan mengadakan vasokontriksi pembuluh darah viseral dan mengurangi aliran darah kekulit. Jika upaya mempertahankan perfusi organ gagal, tekanan arteri sentral akan menurun. Untuk itu maka (a) Cairan resusitasi segera diberikan dengan cairan yang ada. (b) Cairan koloid lebih dianjurkan untuk resusitasi awal karena mempunyai efek hemodinamik segera. (c) Infus cairan selanjutnya dapat memakai koloid dan atau kristaloid. Pemberian cairan dekstrose 5 % tidak dipakai untuk resusitasi, karena akan disebar segera ke rongga intraseluler. Pada syok septik dianjurkan pemberian cairan bolus 1000 ml cairan kristaloid atau 500 ml koloid dalam 20-30 menit. Pemberian cairan berikutnya dilihat dari respon klinik, pemeriksaan auskultasi paru untuk mendengarkan ronchi, pengukuran ventricular filling pressure dan bila mungkin penilaian oksigenisasi.
Penilaian terapi cairan dianggap cukup jika dicapai tekanan darah sistolik 90 mm Hg dengan perbaikan perfusi. Pada pasien tua atau dengan penyakit jantung iskemia atau penyakit cerebrovaskular perlu tekanan darah > 100 mmHg. 6 (2) Pemberian Antibiotika pada keadaan sepsis pada prinsipnya sudah berlaku pemberian antibiotika kombinasi rasional sesuai dengan hasil kultur dan uji sensitivitas. Sebelum adanya hasil kultur maka pengobatan empirik dilakukan berdasarkan penyakit dasarnya. Pemberian antibiotika secara empiris adalah Cephalosporin generasi III atau IV karena mempunyai efek terhadap bakteri gram (+) dan gram (-). Dan kombinasi Cephalosporin dengan betalaktam. Dalam pemberian terapi jangan dilupakan pemberian adanya mikroorganisme lain sebagai penyebab sepsis yaitu parasit, jamur dan virus. 1,2,4,5 Menurut Cunha 2010 pemberian antibiotika pada sepsis adalah sebagai berikut 7 :



 

(3) Terapi Suportif . Terapi suportif merupakan terapi pendukung yang penting dalam perbaikan kondisi sepsis. Salah satunya adalah pemberian imunonutrisi kumpulan beberapa nutrient spesifik seperti arginin, glutamin, nukleotida dan asam lemak omega 3. Pemberian imunonutrisi ini memberikan pengaruh terhadap parameter imunologik dan inflamasi terutama memperbaiki GALT (Gut Associated Lymphoid Tissue). Diharapkan dengan pemberian imunonutrisi terjadi perkembangan penyakit yang membaik, penurunan komplikasi, jangka waktu perawatan dan kematian. (4) Terapi Suplementasi. Merupakan terapi spesifik pada sepsis yang sampai saat ini masih dalam penelitian. Misalnya pemberian antibodi monoklonal sebagai antiendotoksin, pemberian steroid, strategi anti mediator, netralisasi NO, hemofiltrasi, fitofarmaka dan Intravenous Imunoglobulin. Penelitian tersebut masih memerlukan metanalisis dengan jumlah populasi peneletian yang banyak sehingga dapat diberikan berdasarkan Evidence Base Medicine.1,2,4


KESIMPULAN


Sepsis merupakan reaksi inflamasi dan infeksi pada tubuh yang disebabkan oleh adanya patogen dan toksin pada sirkulasi darah yang dapat berakibat terjadinya MODS. Pengenalan dan penanganan awal berdasarkan EGDT (Early Goal Directed Therapy) menjadi kunci utama . Perbaikan keadaan umum ( Resusitasi), Pemberian Antibiotika yang adekuat dan appropiate serta Terapi suportif menjadi tumpuan utama penatalaksanaan sepsis

DAFTAR PUSTAKA

1. Guntur H. A. SIRS, Sepsis dan Syok Septik (Imunologi, Diagnosis dan Penatalaksanaan. UPT Penerbitan dan Percetakan UNS (UNS Press) 2008. h. 1-35
2. Soewondo ES. Kontribusi Proses Inflamasi dan Infeksi Pada Patogenesis Sepsis dan Syok Septik Serta Penatalaksanaannya. Airlangga 2002. H. 86-98
3. Zulfikar T, Lardo S, Sunarti. Pola Kuman Terhadap Pseudomonas Aeruginosa di Ruangan Perawatan Umum RSPAD Tahun 2008. Dipresentasikan dalam Indonesia Antimicrobial Watch PAMKI . Jakarta 2009
4 Jagneaux T, Taylor DE, Kantrow SP. Sepsis. In : Slaven AM, Stone SC, Lopez
FA (Eds) : Infectious Diseases Emergency Department Diagnosis & Management 1st Edition. Mc Graw Hill 2007.pp. 215 -25
5 Ramphal R MD. Sepsis Syndrome. In Southwick F Ed : Infectious Diseases A
Clinical Short Course. Mc Graw Hill 2007. Pp. 57- 65.
6. Suharto. How Is The Role Of Maintenance Fluid Therapy To Treating Serious
Infections. Dalam U Hadi U, Nasronudin, Bramantono, Triyono EA, Soewandojo
et. Al. Simposium Nasional Penyakit Tropik dan Infeksi dan HIV & AIDS 2008.
h.137-148
7. Cunha BA (Ed) . Antibiotika Essential 9th Edition. Physicians Press 2010. pp 148 -156

 

 

 

 

 

 

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(?????? ????)- ????? ???????, ?????????????????? ? ???????????, ??????? ???????????, ?????????? ? ???????????. ?????? ?? ????? ?????? ??? ?????????? ?? ??????? ?????, ??????? ? ????? ????????????? ???????????, ? ?????? ?? ????? ?????????, ??????? ?????? ? ??????? ? ????????????? ?? ????????. ??????????? #1 ???????: mim10 (25 ??????? 2016 19:13. lisi4ka: ?????? ????? ???????? ? ???????. ? ???? ?? ?????????. ??????????? ???????????????? ?????, ???. ???????? ????? ? ??????. [b]"????? 2017" ?????? ?????? ????? 2017. ????? 2017 ????. 07/06/2017 ????? 2017[/b] ??????? ?????? ??????. ??????????? ???????? ??? ?????? ?? ???????????? ?????????????? ?????? ????? ? ????????????? ?????? ??????? ????????? ? ???????????? ????????? ????? ???????????????? ???? ?????????? ??????. ??????????? ??? ?????? ? ?????????, ??????????? ? ????????? ??????? ??????? ??????? ? ??????? ??????, ????? ? ?????? ????????? ? ?????, ? ???? ????? ?? ???????? ?? ??????? ???. ?? ???? ???? ?????????, ??? ??????? ? ?????????, ??????????? ????????????, ??? ?? ???????????? ??? ?????????? ?????, ??????? ???? ??????????? ??????????? ???? ?? ???. ?????????? ?? ???? ????????? ???????? ????? ?????????? ?????? ??? ???????? ? ????. ?????? ?????, ?? ????????? ?? ???? ?????????? ?????????? ? ????????? ??????? ? ????? ??????????. ?? ????????? ?????? ????? ???? ??????? ?????? ?? ????. ??????? ????? ? ???????? ? ??? ?????? ???????? ???????, ?? ???????? ???????? ????????? ???????? ???? ???????????? ????. ????????? ?? ??????? ??????, ???????? ??????? ???, ??????????????? ???????? ? ??????? ??? ? ????????? ????????. ???????, ??? ??? ????? ???????????, ?????? ????? ????????? ???????????? ??????? ? ???????????? ????? ??????? ?? ????? ? ?????????? ?? ????????, ?????? ?? ??? ?????. ???????? ?????? ????? (2017) ?????? ????? ? ??????? ???????? HD. ????? (2017) ???????? ??????. ?????? ?????????? ????: ???????? ?? ???????????? ??????. ????? ??????. ????? ?? ?????? ? ???, ??? ??????? ?????????? ??????? ???????? ?????? ??????????? ??????? ??????. ?????? ??????????? ??? ????????? ? ??? ??? ? ?????? ?????????? ??????? ??, ??? ?? ????? ??????????? ??. ????? ????? (2017) ??????? ?? ??????? ??????? ?????? ?? ????? ?????. ???????: ?????, ????????, ????????, ?????????. ??????? ???????. ???????????: ????????????? - ????????. ????? ????? (2017) ? ??????? ????????. ??? ????????? ?????? ????? ????? (2017) ?????? ????? ? ??????, ?? ???????? ??????? ????????? ???????? HD 480, HD 720, HD 1080 ?????. ?????????? ???????? ?????? ?????????, ??? ????? ????????, ??? ????????? ???????? ????????. ??? ?? ??? ????? ???????? ?? ???????, ????? ? ????? ?????? ?????. [b]"????? 2017" ??????? ????? 2017. ????? ????? 2017. 07/06/2017 ????? 2017[/b] [b]"????? 2017" ????? ????? 2017 720. ??????? ????? 2017. 07/06/2017 ????? 2017[/b] ??????? ???????. ???? ?? ?????? ??? ????????, ?????? ? ?????? IP-?????? ????????? ???????? ????? ????????. ??????? ?????? ?? ??????? ??????, ??? c ??????? IP ??????? ???????????? ?????????????, ? ?????????? ??????. ????? ??????. ???????? ????? ? ??????. ????? ????? 2017 ???????? ?????? ?????? ????? ? ??????? ???????? hd 720 ? ?????????? ???????? ? ????????. ? ??????: ? ???????????? ?????? - ?????? ?????? ??? ???? ??????? ???????????? ???????, ????????? ??????? ??????? ? ?????? ?????????? ???????????. ??? ???????? ???? ????????? ????????, ??? ?????? ?????? ???? ??????? ? ?????? ????? ?????, ? ??????? ????????, ??? ?? ???? ?? ??? ?? ???? ??? ???????????, ? ??????? ????????? ????? ?????????? ????? ??? ?????????? ?????? ?????? ? ?????? ????, ????? ????? ????? ???? ?? ???????????????. ????? ????????????? ???????? ???? ??????, ? ? ??????????? ????? ???????? ? ?? ????????????, ????????????? ????? ????????? ????????, ? ?? ???????? ???????? ???????????? ? ?????? ??????????, ??????? ???????????? ??????? ? ???????. ??? ??????? ?????????? ???????? ?? ?????????? ??????, ?????? ??? ??????? ???????? ????? ??????????? ???????. ??? ?????? ????? ????? ????????? ?????????? ????? ?????? ???????? ? ????? ???????????? ????????, ???? ??? ? ????? ?????? ?????? ???? ??????, ??? ?? ? ???? ?????? ?????? ???????? ????? ???????. ??????? ?? ????? ?????????? ?? ?????? ?? ??, ??? ????? ??????? ?????????, ? ?????? ????????? ?????? ??????? ???, ????? ??????? ??? ??, ??? ?? ?? ????? ?????????? ???????????. ? ??? ?? ?? ??? ?? ???????????, ???? ?? ??????? ????. ????? ?????????? ? ??? - ????? ? ???????. ? ???-????. ????? (2017) ???????? ??????. ????? ?????. ????????: ???? ???????, ???? ?????, ??? ??????. ???????? ? ????????. 28.05.2017 ???????? ?????! ?? ???? ???????, ???. ????? ? ?????????????. [b]"????? 2017" ????? 2017 ??????? ??????? . ????? 2017. 07/06/2017 ????? 2017[/b] ???????? ?????? ???????. ????-??????? (2017. ????? 2017 ???????? ??????. ????? ?????. ??????????? ???????? ??? ?????? ?? ???????????? ?????????????? ?????? ????? ? ????????????? ?????? ??????? ????????? ? ???????????? ????????? ????? ???????????????? ???? ?????????? ??????. ??????????? ??? ?????? ? ?????????, ??????????? ? ????????? ??????? ??????? ??????? ? ??????? ??????, ????? ? ?????? ????????? ? ?????, ? ???? ????? ?? ???????? ?? ??????? ???. ?? ???? ???? ?????????, ??? ??????? ? ?????????, ??????????? ????????????, ??? ?? ???????????? ??? ?????????? ?????, ??????? ???? ??????????? ??????????? ???? ?? ???. ?????????? ?? ???? ????????? ???????? ????? ?????????? ?????? ??? ???????? ? ????. ?????? ?????, ?? ????????? ?? ???? ?????????? ?????????? ? ????????? ??????? ? ????? ??????????. ?? ????????? ?????? ????? ???? ??????? ?????? ?? ????. ??????? ????? ? ???????? ? ??? ?????? ???????? ???????, ?? ???????? ???????? ????????? ???????? ???? ???????????? ????. ????????? ?? ??????? ??????, ???????? ??????? ???, ??????????????? ???????? ? ??????? ??? ? ????????? ????????. ???????, ??? ??? ????? ???????????, ?????? ????? ????????? ???????????? ??????? ? ???????????? ????? ??????? ?? ????? ? ?????????? ?? ????????, ?????? ?? ??? ?????. ????? ????? (2017) ???????? ?????? ?????? ?????. ??????????? #1 ???????: mim10 (25 ??????? 2016 19:13. ??????? ???? ?????? ? ???? ?????????? ?????????, ??????????? ?????????????? ????? ? ?????? ?????????????????? ???????. ?????? ??????????? ??????, ???????? ?? ??????????? ??????, ??? ????? ?? ????? ????????? ?????? ????, ????????? ? ???????? ?????????. ????????, ????? ??? ? ?? ?????, ????? ??????? ??????? ?????? ????????? ?????????? ???????? ????????, ??????? ??????????? ?????? ???????????. ??????????? ????????, ???????? ?? ?????????? ??????, ???????? ??????? ??? ??? ?????? ?????, ?? ????????? ???????????? ? ????????????? ???????. ????? ??????. ????? (2017) ???????? ?????? ?????? ?????. ????? ????? ???????. ?????? ?????????????? ? ??????, ??????? ???? ?????????? ?? ?????? ?????????? ?????????, ?????????? ??????? ?????? ??????????? ???????. ??????? ?? ?? ???????????? ??????? ?????????? ???????. ??? ??????? ? ?????? ???? ??????? ? ????????, ?? ????? ???????? ?????? ??????? ?????. ?????? ????????? ????? ? ?????? ????? ??????????? ?????????? ????. ???????? ??? ????????? ?????? ??? ???????. ????? ??????????? ?????????????? ???????? ???? ????????? ????????, ??? ????? ?????? ???????. ????? ????, ??? ????? ????? ?????, ??????? ????????? ?????????????. ??? ???????????? ? ???????? ????????? ? ??? ?????, ????? ??????? ???? ??, ??? ? ??? ????????.

the-mumia-2017-hd

08 Juni 2017, 08:42

[b]"????? 2017" ???????? ????? 2017 ? ????? ??????. ????? 2017 ??????? ??????? . 07/06/2017 ????? 2017[/b] [url=http://hdkinokrad.ru/film/16459/][img]http://i.piccy.info/i9/fbfe5b1e2263df304661298513fea063/1496841864/141567/1152218/Mumyia_2017.jpg[/img][/url] [b]"????? 2017" ????? ????? 2017 ? ???????? Hd 720. ????? 2017. 07/06/2017 ????? 2017[/b] [url=http://hdkinokrad.ru/film/16459/][img]http://i.piccy.info/i9/fbd4c42a166f3b6d85e9fd5e2cbc10fb/1496841929/65046/1152218/Mumyia_2017_2.jpg[/img][/url] [b]"????? 2017" ???????? ????? ????? 2017 ??? ???? . ??????? ????? 2017 ????? ???????. 07/06/2017 ????? 2017[/b] ??? ?????? ????? ????? - ??? ????????? ??????, ??????? ???????? ????, ???????? ?? ???????? ??????. ????? ??????, ??????????? ?? ????????? ???????, ?? ???????????, ? ???? ???????? ?????????? ? ??????. ????????? ?????? ??????????? ? ??????? ?? ??????? ???????, ??????? ???????? ?? ?????????? ? ???????, ? ????? ??????, ??????????, ??? ????? ??????, ????? ?? ??????. ?? ???? ????????????????? ?? ????????? ?? ????? ???????. ???? ????????? ???, ????????? ???????????, ? ?????? ?? ???? ????????. ????? ???????????? ?????? ????? (2015. ????? ?????? ????? (2016. ???????? ????? ????? 2017 ?????? ?????? ????? ? ??????? ????????. ???????? 8 ???? 2017. ????? ??????????, ??????????, ??????? ??????? ? ???????? ? ???? ????? ? ??????? ?????????. ????? ??????. ???????? ????? ? ??????. ???????? ? ????????. ????? ???????? ?????????? ?????? ?? ??????????? ?? ??????????? ??????, ? ?????????? ? ????? ? ????????? (??????? ???????), ???????????, ?????? ? ?????????? ????????, ??????? ??????????? ?????? ??????????? ???????? ? ??? ????????????. ?? ?????????? ???? ??? ?? ???????, ? ?????? ?? ??????????? ? ???????? ??????, ?????? ??? ????????? ??? (?????? ????)- ????? ???????, ?????????????????? ? ???????????, ??????? ???????????, ?????????? ? ???????????. ?????? ?? ????? ?????? ??? ?????????? ?? ??????? ?????, ??????? ? ????? ????????????? ???????????, ? ?????? ?? ????? ?????????, ??????? ?????? ? ??????? ? ????????????? ?? ????????. ????? ??????? ??????????? ?????? ????? ???? ????? ??????? ?????? ????? ???????? ? ??????? ????????, ??????? ????? ????????? ???? ??? ??? ?????? ????? ??????? ????. ???? ?? ???? ???? ?????????? ???????? ??? ??????, ?? ??? ?????? ???????? ? ?????????? ??? ?????? ????????? ?? ??? ????????????? ??????? ? ??????? ??? ????????. ?????? ?????? ??? ? ???? ?? ??? ??????????????? ????? ??????? ?????? ????????, ? ??????? ?????????? ???? ?????? ?? ????? ??????? ???????? ??? ?????? ?, ???? ???????? ?????? ?????? ????? ????? ? HD ????????, ?? ????? ?????? ??????????? ????? ???????????. ? ? ??? ??????, ????? ??? ?????????? ?? ?? ????????, ? ?? ??? ?????? ???? ??????? ?????, ??????? ??????? ?????? ????????, ? ?? ????? ??????. ????? ????? ???????? ?????? ? ??? ??????????? ? ?????, ???? ?????? ??? ???????, ???? ?? ???????? ???????? ???? ???????. ? ????? ?? ????? ?? ?????, ?? ??????? ??? ???? ???? ??????, ???????, ? ???? ???? ????????? ? ??????? ?????. ?? ????? ?? ?????, ??? ??????? ????????? ????????? ?? ??????? ? ????? ?????????? ??? ?????. ?????? ???? ???? ????????, ??????? ?? ???? ?????? ??????? ? ???? ??????? ? ??? ?????, ? ???? ?? ????? ?????????? ??? ???. ???????????? ????????? ? ????????? ???????? ????? ????? ????????? ?????? ????? ? ??????? ???????? ??. ? ??????? ?? ????????. [b]"????? 2017" ????? ????? 2017 ??? ????. ????? ????? 2017 720. 07/06/2017 ????? 2017[/b] ????? ??????? ? ???????? (2017. ????? ????? 2017. ? ????? ??????: ????? ???????, ??? ????, ????????? ??????, ?????? ????, ????? ???????????, ????? ???????, ?????? ?. ????, ?????? ?????, Noof McEwan, ?????? ???????. lisi4ka: ??? ???? ??????? ???? ????? ?????????. ????? ?? ? ????? ?? ????????? ????????? (????? ???? ?????. ???? ??????. ????? ????????? ?????? ? ????? ????? (2016. 30 ???? ????: ?????? ???????. ????? ????? ?????? (2016. ????? ???????????? ?????? ????? (2015. ?????? ??????????? ???????? ???? ???????? ? ?????? ?????? ??????? ? ??????????????? ????????? ????????. ???????? ?????? ????, ????? ??? ???? ????? ? ???? ????? ????. ??????? ??????? ??????????? ???? ??????? ??????? ???????????, ????? ??????? ???????? ???????????? ?????, ??? ????????? ?? ????????? ?????? ???? ???-?? ???????. ???? ?????? ????????? ??????? ? ????? ??????? ????? ??? ????????. ???????????????? ?????? ?????????, ?? ??? ???????? ??????????????? ?? ????? ???????? ??????? ????? ???????????, ? ?????? ????????. ??? ???? ??????? ??????????? ?? ?????? ??????? ????? ?????? ?????????? ??. ??? ????????? ? ???? ???, ???? ??????? ???? ???? ????? ??????? ??????????? ?? ?? ???? ???????. ??????????????? ?????????? ? ?????????? ?????? ????? ?????? ??????? ? ?????? ??????? ? ?????? ????? ????? ???????. ?????? ??????????? ????????? ? ??????? ??????? ?? ?????????, ???????? ??? ??????, ???????? ???? ????? ?? ???????? ??????? ????? ??????, ??????? ??????????? ???? ? ?? ??????????? ????. ????? ????? ??????? ?????? ????? ??????????? ????????????: ? ?????? ?????? ????????? ????????? ????? ??????????????, ??????? ????????? ??????, ?? ??? ?? ??????? ???? ????? ?????? ?????????, ??? ????? ? ??????? ??????: ??????? ?????, ????????-??????? ? ?????? ??????? ?????, ?? ??? ??????? ????????? ????? ??????????. ??????? ????? ????? ???????? ?????????? ? ??????? ??????????, ?? ??? ?? ????? ? ????? ????????. Outlast 2 [v 1.0.17517] (2017) PC | RePack ?? xatab. [b]"????? 2017" ????? 2017 ????. ????? ????? 2017 ???????? ??????. 07/06/2017 ????? 2017[/b] ????? ????? 2017. ??????????? ??????????. ????????????: ??? ???????? (???): 22 ??? 2017 ???????? (??): 8 ???? 2017. ????? ??????. ???? ?????? ? ?? >8 ???? 2017. ????? ????? ???????. ?????? ???????????? ?????????? ????????????? ? ?????????? ??????? ??? ?????????? ???????? ?? ???????? ????????????????? ????????. ????????? ????????? ???????, ??????? ?? ??????? ??? ?? ????? ????? ????, ???? ? ??????? ??????????? ?????????? ??????? ????????. ?????? ?????????????? ? ??????, ??????? ???? ?????????? ?? ?????? ?????????? ?????????, ?????????? ??????? ?????? ??????????? ???????. ??????? ?? ?? ???????????? ??????? ?????????? ???????. ??? ??????? ? ?????? ???? ??????? ? ????????, ?? ????? ???????? ?????? ??????? ?????. ?????? ????????? ????? ? ?????? ????? ??????????? ?????????? ????. ???????? ??? ????????? ?????? ??? ???????. ????? ??????????? ?????????????? ???????? ???? ????????? ????????, ??? ????? ?????? ???????. ????? ????, ??? ????? ????? ?????, ??????? ????????? ?????????????. ??? ???????????? ? ???????? ????????? ? ??? ?????, ????? ??????? ???? ??, ??? ? ??? ????????. ????? 2+1 (2016. ??????? ? ??????: ????? ???? ????-?????????? ?????? ?????? ?? ???? ????????? ??????? ????????, ??? ?????? ????? ?? ??????? ???????? ? ????????? ????? ???? ?????????? ????????. ?? ????????????? ??????? ?? ???? ?? ???? ?????? ??????, ???? ??????? ?? ????? ???????? ? ???, ??? ??????????? ????? ?????? ??????: ?????, ??????? ????????? ??????? ??????? ??????. lisi4ka: ??? ???? ??????? ???? ????? ?????????. ????? ?? ? ????? ?? ????????? ????????? (????? ???? ?????. ????????? ??????????? ????? ?????? ?????????????????? ????????????. [ ??????????? | ????. [b]"????? 2017" ????? ????? 2017 ??????. ???????? ????? ????? 2017 ? ?????. 07/06/2017 ????? 2017[/b] ??? ????? ??????. ?????? ?????. ??? ???????: 2017 ??????????: 30674. ????????? ????????????? ?????????? ??????????? ?????? ????? ????? (2017) ???????? ?????? ?????? ????? ? ??????? ???????? hd 720-1080 ?? ??????? ?????, ?????? ????? ? ????????????? ??????? ????????? ?????? ?????. ??????? ?????? ?????????????, ??????? ?????? (???????), ?????????? ???????? ??????????? ? ??????????? ????????, ?? ?? ????? ?????????? (?????????? ?????). ????????????? ??????????????????? ???????????? ?? ??????? ???????? HD ????? ? ????????????? ?????, ? ????? ???????? ?????? ????? ?? ????????? (???????) ???????? / ???????? ??? ??????????? Android, ?? iPad / iPhone ?? ???? iOS, PS4, ?? ????? ??????? ??? ??????????. ??????? ?????? ???? ? ???? ?????? ????????, ?? ????, ???? ????, ????? ????????? ???????????? ??? ????????????, ?????? ?????????? ?????????? ?????. ? ?????? ????? 2017 ????, ?????? ????? ???????????? ? ????, ?? ??????? ?????? ? ??????? ??????-??????? ??? ???. ? ??????? ?????? ???????????, ?????? ???????????? ???????? ??????. ?? ??? ?????????????? ?????????? ????????? ?????? ???. ??????????? ????, ?? ?????, ??? ??????????? ??? ???, ?? ???? ???-??? ??????, ? ?????? ??????? ????????. ??????????? ??????? ??????? ???????? ? ????????? ? ??????? ??? ?????????? ???????????????. ?????????? ?????????? ????? 2017 ???? ?? ????? ?????. ????? ?????? ?????? ????? ? ??????? ???????? hd ?????? ?????. ??? ??, ?????? ?????? ????????? ?? ?????? ??????? ????? ?????? ????? ????? ?? ??????????????? ??????? ? ?????????? ?????? ??????? ??????. ????? ?????? ?????? ?????????? ??????? ?????? ???????? ???????, ??????? ??? ???????? ????????? ??????????? ?????. ?????? ??? ?? ????????? ?? ????????? ?????? ???? ?????? ????????, ??????? ????? ? ??? ?? ??????????. ??? ???? ?? ??? ???, ???? ?? ????????? ?? ???????? ????? ??????, ??????? ??? ???????? ???????? ?? ??, ????? ???-???? ????? ??? ????? ????????, ???? ?????? ?? ????????? ??????? ??? ??????. ?? ???? ????? ? ???? ??? ???????? ????????? ???? ????????, ???????? ?????????? ?? ? ????????? ?????????. ?????????? ?????????? ????? 2017 ???? ?? ????? ?????. ????? ?????? ?????? ????? ? ??????? ???????? hd ?????? ?????. ??? ??, ?????? ?????? ????????? ?? ?????? ??????? ????? ?????? ????? ????? ?? ??????????????? ??????? ? ?????????? ?????? ??????? ??????. ???????? ????? ??????. ?????: ??????????? (2014. ????? ? ????? ?????? 2017 ????? ???????? ?????? ?? ?????????. ??????: ??? ????, ?????? ????, ????????? ??????, ????? ???????, ????? ???????, ?????? ?. ????, ?????? ???????, ?????? ???????, ?????? ???????, ?????? ?????. [b]"????? 2017" ????? 2017 ???. ????? 2017 ?????? ? ??????? ????????. 07/06/2017 ????? 2017[/b] [b]"????? 2017" ??????? ????? ????? 2017. ???????? ????? ????? 2017 ??? ????. 07/06/2017 ????? 2017[/b] ????? ?????????? ???? ? ???????. ??????? 2017 ????. ??????? ?????? ??????. ??? ???????: 8 ???? 2017 ??????: ??? ????: ??????? ????????: ????? ???????? ??????: ??? ????, ????? ??????? ? ?????? ??????. ?????????????????. ????? ????? 2017 ???????? ?????? ?????? ????? ? ??????? ???????? hd 720 ? ?????????? ???????? ? ????????. ? ???? ?? ???? ???????? ?????????????? ?????? ???????????? ??? ??????? ????? ?????????? ???????, ????????????? ????? ???????????. ? ?????? ??????? ??? ?? ?????? ???? ???, ??????? ???????? ?????? ???????????????? ????? ? ???????????, ? ??????. ???????? (?????) ?????? ????? (2017): ????? ?????? ??????? ? ?????????? ?????, ?????????? ??????????????, ?????????????? ?????. ??????????? ????? ??????????? ????? ???? ??????? ???? ?? ????? ?? ????? ??? ??????? ? ??????????? ???? ? ???????? ??????? ???? ?????? ???????, ??????? ??? ???? ????? ??????? ????????. ?????? ??????????? ????? ????? ?????? ?????? ?? ???????????? ????????, ??????? ??????? ????????? ????????? ? ??????, ????? ???????? ???????????? ????????? ??????? ??????. ??? ? ???? ??????, ??? ?????????, ???????, ???????? ????????????? ?????????? ??????????, ????????. ?????? ?? ??????? ?????? ?????? "?????", ??????? ???????????? ??????? ???????, ?????????? ?? ????? ??????, ?, ?????????? ????????????, ??????? ??????? ??????????? ?????, ??? ????? ????????? ?? ??? ??? ? ?????. ????????????? ????? ?????? ????????? ???? ?????? ????? ?? ??????? ????? ???????, ?????? ??? ???????? ?????????, ??????????? ?????? ??????????? ??? ? ??????? ?? ???, ???? ?? ?????? ???????? ???? ??? ? ?????? ????? ???????? ?????. ??????????? ???????????, ???????? ?? ????, ????????? ??????? ???????? ?????? ?? ??????? ???????????? ??????????? ???????????????? ????? ????. ???????? ?????? ????? ? ??? ???????? ????????? ? ?????????? ?? ?????????? ????? ???????????? ??????, ????? ???????? ????? ???????? ?????????? ???????? ? ??? ??????????? ????????? ???????? ??????, ??????? ?????????????? ????????? ???????? ??????? ???????? ???? ??????. ????? ???????, ??? ??????????? ???? ? ?????? "?????" ?????? ?????????? ???????????? ????? ??? ????. ??????: "?????? ????? ?????? ???? ? ???????". ???????, ????? ???????? ????? ??????! ????? ????? ???????? ????? (?????? ??????) ?????? ?????, ?????????? ?????????. ??????? ???????. ??????? ?????? ??????. ????????: ????? ???????? ? ?????: ????? ???????, ????????? ??????, ??? ????, ?????? ????, ????? ???????, ?????? ?. ????, ?????? ?????, ????? ???????????, ????? ??? ????????, ?????? ???????. ??????: ??? ????, ?????? ????, ????????? ??????, ????? ???????, ????? ???????, ?????? ?. ????, ?????? ???????, ?????? ???????, ?????? ???????, ?????? ?????. ?? ???????? ? ?????? ??????? ???? ?? ????????? ??????? ????? ??? ????????? (360 / 480 / HD 720 / HD 1080) ??? ????? ???????? ?????? ????? ????? (2017) ????????? ?????? ????? ? ??????? ???????? 720 ?? ????????, ????????, ?????, ????? ? ??????? (iPad, iPhone Android) ? ?????? ???????????, ??? ??, ??? ?? ????????, ?????????, ?????????, ???????, ?????????, ????????, ????????? ? ?????? ??????. ??? ?? ??? ??????? ?? ?????? ??????? ????? ??????? ? ???? ?? ????????? ? ???????????? ??????????. [b]"????? 2017" ??????? ????? ????? 2017 ????? ???????. ????? 2017 ???? ??????. 07/06/2017 ????? 2017[/b] ????? ???????? (2017. ???????? ????? ??????. ???????????? ?? ??????? ?????: ????? (2017. ??????????? ??????? ????????? ???? ??????, ???????? ??????? ????? ?? ?????? ?????? ?????????? ? ?????????? ???????????, ?? ???????????? ?????? ??????? ? ???? ?????. ?????? ???????, ?????? ???????? ??????????? ????? ??????, ??? ??????? ????????, ?????? ??????-?????? ????????? ???? ????????? ? ?????? ?????????????? ??????. ?? ????????? ?????, ??? ??? ????????? ?????????? ? ??? ???????? ? ??? ?? ??? ??? ??????. ???, ????? ??? ?? ???????? ? ????. ???????? ?????? ????? ?????. ????-????????? (2017. ????????: HD Trailer. ??????? ???????. ????????: HD Trailer. ????????? ? ???????? (2017. ????? 2017 ???????? ??????.

Toair lRok

01 Juni 2017, 07:07

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Toair lRok

01 Juni 2017, 05:50

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Epson Helpline Number

29 Mei 2017, 16:58

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Lexmark Helpline Number

25 Mei 2017, 19:24

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Epson Support Number

25 Mei 2017, 16:49

We are providing best and free technical support services for Epson printer in UK.Call now at our UK toll-free number 0800-046-5041 and visit at our official website.Our Technician have the ability to solve your any problem related to Epson printer.

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10 Mei 2017, 14:26

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