vi curso nacional de vm 27 de março de 2014 carmen silvia valente barbas professora livre docente...
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VI CURSO NACIONAL DE VM27 de março de 2014
Carmen Silvia Valente BarbasProfessora Livre Docente da Disciplina de
Pneumologia da FMUSPMédica Intensivista e Pneumologista do Hospital
Albert Einstein
Posição prona e ECMO na SDRA
ACUTE RESPIRATORY DISTRESS SYNDROME• Less than 1 week bilateral infiltrate • Not explained by CHF or hypervolemia • Presence of risk factor
• PaO2/FIO2 <300- mild• PaO2/FIO2 <200-moderate• PaO2/FIO2<100- severe
JAMA 2012; 307(23): 2526-2533
GRAVITY
GRAVITY
RECRUITMENT: PRONE POSITION
PaO2 (50-75%)
The New England Journal of Medicine The New England Journal of Medicine Vol.345, n 8, August 23, 2001Vol.345, n 8, August 23, 2001
________________________________________________________________________________________________ EFFECT OF PRONE POSITIONING ON THE SURVIVAL EFFECT OF PRONE POSITIONING ON THE SURVIVAL OF PATIENTS WITH ACUTE RESPIRATORY FAILUREOF PATIENTS WITH ACUTE RESPIRATORY FAILURE
Luciano Gattinoni,MD; Gianni Tognoni,MD...............................Roberto Latini ,MDLuciano Gattinoni,MD; Gianni Tognoni,MD...............................Roberto Latini ,MD for the Prone-Supine Study Groupfor the Prone-Supine Study Group
Italian + Switzerland Multicenter Randomized TrialItalian + Switzerland Multicenter Randomized Trial
152 patients supine 152 patients prone152 patients supine 152 patients prone
Mean increase of PaO2 to FIO2 44.6Mean increase of PaO2 to FIO2 44.6±68.2 ±68.2 63 63±66.8 p=0.02±66.8 p=0.02 10 Days mortality 25 % 21.1% 10 Days mortality 25 % 21.1% ICU discharge Mortality 50.7% 48%ICU discharge Mortality 50.7% 48%6 months mortality 62.5% 58.6% 6 months mortality 62.5% 58.6% Pos Hoc analysis Pos Hoc analysis 10 day mortality -PaO2/FIO2<88 47.2% 23.1% p<0.0510 day mortality -PaO2/FIO2<88 47.2% 23.1% p<0.05
SEVERE ARDSSEVERE ARDSOR DIFFICULTOR DIFFICULTTO RECRUITTO RECRUITARDSARDS
GRAVITY
ALVEOLAR RECRUITMENT AND PRONE POSITION
-PULMONARY PULMONARY HYPERTENSIONHYPERTENSIONAND OR RIGHT AND OR RIGHT VENTRICULAR VENTRICULAR DYSFUNCTIONDYSFUNCTION
FEATURE ARTICLESDecrease in PaCO2 with prone position is predictive of improved outcome in acute respiratory distress syndromeGattinoni L,Vagginelli F; Carlesso E; Taccone P; Conte V; Chiumello D; Valenza F; Caironi P; Pesenti A Crit Care Med - 01-DEC-2003; 31(12): 2727-33
CESAR TRIAL : EXTRACORPOREAL MEMBRANE OXYGENATION IMPROVES SURVIVAL IN PATIENTS WITH SEVERE RESPIRATORY FAILURE. Peek GJ et al Lancet , 2009.
Glenfield (Leicester-Julho 2001-Agosto 2006)• Insuficiencia respiratória grave , mas potencialmente reversivel • Escore de Murray 3 ou maior• pH < 7,2 Exclusões : altas pressões em vias aéreas ou FIO2 > 80% mais de 7 dias e ou contraindicações para tratamento
CESAR TRIAL : EXTRACORPOREAL MEMBRANE OXYGENATION IMPROVES SURVIVAL IN PATIENTS WITH SEVERE RESPIRATORY FAILURE. Peek GJ et al Lancet , 2009.
180 pacientes 90 ECMO 90 CMV sobrevida em 6 meses 57/90 (63%) versus 41/90 (47%) – RR= 0.69(0.05-0.97-p=0.03)
1 Sobrevivente extra para cada 6 pacientes tratados 2 ECMO aumenta a sobrevida após 6 meses e é custo efetiva
comparada com CMV