Choque séptico 2013

1. Sepse Choque séptico Antonio Souto acasouto@bol.com.br Médico coordenador Unidade de Medicina Intensiva Pediátrica Unidade de Medicina Intensiva Neonatal Hospital Padre Albino Professor de Pediatria nível II Faculdades Integradas Padre Albino Catanduva / SP

2. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino http://www.scielo.br/pdf/jped/v78n6/7806449.pdf

3. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino

4. Dr. Antonio Souto acasouto@terra.com.br 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

5. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino Shock was commonly not recognized Fewer patients were referred for shock than had shock (335 vs 1803) 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 referred for shock shock referred for shock not referred for shock shock no shock 7 % 37%

8. Dr. Antonio Souto acasouto@terra.com.br 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

9. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino SepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere Sepsis Septic ShockSeptic ShockSeptic Shock

10. Dr. Antonio Souto acasouto@terra.com.br 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

11. Dr. Antonio Souto acasouto@terra.com.br 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)

16. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino Sepsis is a complex syndrome that develops when the initial, appropriate host response to an infection becomes amplified, and is then dysregulated. Genetic variations •disrupt innate immune sensing of infectious organisms and the ability of the immune 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.

24. Dr. Antonio Souto acasouto@terra.com.br 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

25. Dr. Antonio Souto acasouto@terra.com.br 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

26. Dr. Antonio Souto acasouto@terra.com.br 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

32. Dr. Antonio Souto acasouto@terra.com.br 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 tissuessue perfusionperfusion •• Extreme hypotension is a late andExtreme hypotension is a late and premorbidpremorbid signsign

33. Dr. Antonio Souto acasouto@terra.com.br 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

34. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino Carcillo et al. defined septic shock in pediatric patients 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*

39. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA.1991; 266 :1242 – 1245

42. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino 20 ml/Kg a cada 5’ 60 ml/Kg em 15’

46. Dr. Antonio Souto acasouto@terra.com.br 2013 UTI Pediátrica & Neonatal Hospital Padre Albino DopaminaDopamina DopaminaDopamina DobutaminaDobutamina AdrenalinaAdrenalina Choque frioChoque frio Choque quenteChoque quente NorNor--adrenalinaadrenalina ChoqueChoque refratrefratáário ario a volumevolume ChoqueChoque refratrefratáário ario a volumevolume dopaminodopamino resistenteresistente

52. Dr. Antonio Souto acasouto@terra.com.br 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

57. Dr. Antonio Souto acasouto@terra.com.br 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

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