choque séptico 2013
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Up to date 2013TRANSCRIPT
SepseChoque séptico
Antonio [email protected]
Médico coordenadorUnidade de Medicina Intensiva PediátricaUnidade de Medicina Intensiva Neonatal
Hospital Padre Albino
Professor de Pediatria nível II Faculdades Integradas Padre Albino
Catanduva / SP
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
http://www.scielo.br/pdf/jped/v78n6/7806449.pdf
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Shock is the major cause of death in children regardless of disease category
Joseph A. Carcillo, M.D
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Shock was commonly not recognized
Fewer patients were referred for shock than had shock(335 vs 1803)
0500
100015002000250030003500400045005000
referredfor
shock
shock
referred for shocknot referred for shockshockno shock
7%
37%
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Bone et al. Chest 1992;101:1644
SepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere Sepsis
Systemic Inflammatory Response Syndrome SIRS criteria
• Temp < 96.8° or > 100.4° F• HR > 90• RR > 20 or PCO2 < 32• WBC < 4 or > 12 or bands > 10%
Septic ShockSeptic ShockSeptic Shock
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
SepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere Sepsis Septic ShockSeptic ShockSeptic Shock
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
SepsisSepsisSepsisSIRSSIRSSIRS Severe Sepsis Septic ShockSeptic ShockSeptic Shock
Sepsis plus Organ Dysfunction• Elevated Creatinine• Elevated INR• Altered Mental Status• Elevated Lactate• Hypotension that responds to fluid
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
SepsisSepsisSepsisSIRSSIRSSIRS Severe SepsisSevere SepsisSevere Sepsis Septic Shock
Severe Sepsis and Hypotension• Hypotension that does NOT
respond to fluid (30 cc/kg bolus)
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Sepsis is a complex syndrome that develops when the initia l, appropriate host response to an infection becomes amplif ied, and is then dysregulated.
Genetic variations•disrupt innate immune sensing of infectious organisms and the ability of theimmune system to respond to infection•diversity of the clinical presentation of sepsis•the response to current medical treatment•the genetic predisposition to infection in each individual patient.
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Figure 1. FACTORS AFFECTING OXYGEN DELIVERY
DO2
CaO2
CO
SV
HR
Oxygenation
Hgb
A-a gradient DPG
Acid-Base Balance Blockers
Competitors Temperature
Drugs Conduction System
Ventricular Compliance
EDV
ESV Contractility
CVP Venous Volume
Venous Tone
Afterload Blockers Temperature Competitors Drugs Autonomic Tone
Metabolic Milieu Ions
Acid Base Temperature
Drugs Toxins
Influenced By
Influenced By
Influenced By
Influenced By
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
What is Shock?
• A physiologic state characterized by– Decrease in tissue perfusion
– Inadequate oxygen delivery
• Delivery isn’t keeping up with demand
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Septic Shock
• Combination– Distributive
– Cardiogenic
– Hypovolemic
• Most common form of Shock
• On a continuum from SIRS to Septic Shock
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Clinical PresentationClinical Presentation
•• Early diagnosis requires a high index of suspicionEarly diagnosis requires a high index of suspicion
•• Diagnosis is made through the physical examination focused on tiDiagnosis is made through the physical examination focused on tissue ssue perfusionperfusion
•• Extreme hypotension is a late and Extreme hypotension is a late and premorbidpremorbid signsign
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
“…with a high index of suspicion…septic
shock can be recognized early (before
hypotension) by a triad of signs…” Carcillo
et.al, 2002
• Hypo/hyperthermia
• Altered mental status
• Peripheral vasodilation/constriction
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Carcillo et al. defined septic shock in pediatric pa tients
Tachycardia (which may be absent in the hypothermic patient) with signs of decreased
perfusion including decreased peripheral pulses compared with central pulses, altered alertness, flash capillary refill or capillary refill
>2 secs, mottled or cool extremities, or decreased urine output
International pediatric sepsis consensus conference: Definitions for sepsis and organ
dysfunction in pediatrics*
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Carcillo JA, Davis AL, ZaritskyA. Role of early fluid
resuscitation in pediatric septic shock. JAMA.1991; 266 :1242 –
1245
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
20 ml/Kg a cada 5’60 ml/Kg em 15’
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
DopaminaDopamina
DopaminaDopamina
DobutaminaDobutamina
AdrenalinaAdrenalina
Choque frioChoque frio Choque quenteChoque quente
NorNor--adrenalinaadrenalina
Choque Choque
refratrefratáário a rio a
volumevolume
Choque Choque
refratrefratáário a rio a
volume volume
dopaminodopamino
resistenteresistente
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Volume 115(2), February 1999, pp 462-474
Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically III Patients
Kollef, Marin H. MD, FCCP; Sherman, Glenda RN; Ward , Suzanne RN; Fraser, Victoria J. MD
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Dr. Antonio Souto [email protected] 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Gustav Klimt(Baumgarten, Viena, 14 de julho de 1862— Viena, 6 de fevereiro de 1918) foi um pintor simbolista austríaco