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Dopamina: medicação de escolha em choque
séptico refratário a volume?
Apresentador "Pro”

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

UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA

Antonio Souto acasouto@bol.com.br 2011


Because of the paucity of outcome-directed, randomized
controlled trials, the recommendations for hemodynamic
support of term newborns and children in this document
are primarily expert opinion rather than irrefutable
vidence.
Crit Care Med 2002; 30:1365 -1378



58% CI↓ + SVRI↑

20% CI↑ + SVRI↓

22% CI↑ + SVRI↑

nCI=3,3L/min/m2;
nSVRI= 800 dyne/sec/cm5



58% CI↓ + SVRI↑

20% CI↑ + SVRI↓

22% CI↑ + SVRI↑

Pediatrics 1998;102(2)



Unlike adults, children with fluid-refractory
shock are frequently hypodynamic and
respond to inotrope and vasodilator therapy.



Because hemodynamic states are heterogeneous
and change with time,

an incorrect cardiovascular therapeutic
regimen should be suspected in any child
with persistent shock.



...fluid-refractory shock are frequently hypodynamic and respond
to inotrope and vasodilator therapy

Dopamina (5-15 mg/kg/min)

•Ação predominantemente beta-1 cardíaco
•Efeito inotrópico positivo
•Moderada vasodilatação periférica (efeito beta-2 na circulação muscular
esquelética e a seu efeito delta nas circulações esplâncnica e renal)

Promove um aumento do DC e da PAM pelo aumento da FC,
contratilidade, como pela redução moderada na pós-carga apesar do
mínimo efeito na resistência vascular sitêmica.
Crit Care Med 2004; 32:1928–1948



Many studies have tested the observations and
recommendations of the 2002 guidelines.
Crit Care Med 2009; 37:666–688



... the guidelines were
useful and effective without
any evidence of harm.

Crit Care Med 2009; 37:666–688



•Wills BA, Nguyen MD, Ha TL, et al: Comparison of the three fluid solutions for resuscitation in dengue shock. N
Engl J Med 2005; 353:877–889

•Maitland K, Pamba A, English M, et al: Randomized trial of volume expansion with albumin or saline in children
with severe malaria: Preliminary evidence of albumin benefit. Clin Infect Dis 2005; 40:538–545

•Han YY, Carcillo JA, Dragotta MA, et al: Early reversal of pediatric-neonatal septic shock by community
physicians is associated with improved outcome. Pediatrics 2003; 112:793–799

•Ninis N, Phillips C, Bailey L, et al: The role of healthcare delivery on outcome of meningococcal disease in
children: Casecontrol study of fatal and non-fatal cases.BMJ 2005; 330:1475

•de Oliveira CF, de Oliveira DS, Gottschald AF, et al: ACCM/PALS haemodynamic support guidelines for
paediatric septic shock: An outcomes comparison with and without monitoring central venous oxygen saturation.
Intensive Care Med 2008; 34:1065–1075

•Karapinar B, Lin JC, Carcillo JA: ACCM guidelines use, correct antibiotic therapy,and immune suppressant
withdrawal are associated with improved survival in pediatric sepsis, severe sepsis, and septic shock. Crit Care
Med 2004; 32(12 Suppl 3):A161

•Maat M, Buysse CM, Emonts M, et al: Improved survival in children with sepsis and purpura: Effects of age,
gender, and era. Crit Care 2007; 11:172

•Odetola FO, Gebremariam A, Freed GL: Patient and hospital correlates of clinical outcomes and resource
utilization in severe pediatric sepsis. Pediatrics 2007; 119:487–494

Crit Care Med 2009; 37:666–688



Taken together, these studies indirectly
and directly

support the utility and efficacy

of implementation of the time sensitive,
goal-directed recommendations of the
2002 guidelines... Crit Care Med 2009; 37:666–688



Crit Care Med 2009; 37:666–688



O uso de drogas vasopressoras permanece controverso.
A escolha de uma droga permanece aberta.

... questão sem solidas e robustas respostas...



Sepsis is a complex, highly variable, multiple system,
clinical process ...
Pediatr Crit Care Med 2005; 6[Suppl.]:S55–S60

...complex interactions between the infecting microorganism
and the host immune, inflammatory and coagulation
responses...



... these terms do not allow for precise characterization
and staging of patients with this condition.

Crit Care Med 2003 Vol. 31, No. 4



TNM (Pierre Denoix, 1946)

will stratify patients on the basis of their Predisposing
conditions, the nature and extent of the insult (in the
case of sepsis, Infection), the nature and magnitude of
the host Response, and the degree of concomitant
Organ dysfunction
Crit Care Med 2003;31:1250–6



http://www.infectio-lille.com/diaporamas/2011/KIPNIS_DUACAI2011.pdf



WHAT CLINICAL SIGNS AND HEMODYNAMIC VARIABLES CAN BE
USED TO DIRECT TREATMENT OF NEWBORN AND PEDIATRIC
SHOCK?

...to define septic shock by clinical,
hemodynamic, and oxygen use variables
only.

...to restoring normal mental status and
peripheral perfusion.



...hemodynamic states are heterogeneous and
change with time...



Podem então ser traçadas “diretrizes” uniformes para
aplicação em crianças tão diferentes?

...o trabalho desenvolvido por Dr. Carcillo e a força-tarefa
procuram pôr alguma ordem e sistematização nas condutas
das diferentes apresentações clínicas...



Clinical criteria generally used to
definite septic shock do not allow for
early identification of patients with good
or bad prognosis.



Our hypothesis is that “dopamine-
sensitive” patients have a better
prognosis than those with a “dopamine-
resistant” profile.



Mortality rate was
16% (seven of 44
patients) for the
Dopa-S group
compared
with 79% (52 of 66
patients) for the
Dopa- R group (p
.0006)



… the use of dopamine is controversial
since it could delay the use of
norepinephrine, hence leading to
persistent circulatory failure.



The present results clearly demonstrate that the
rapid administration of incremental doses of
dopamine followed by a switch to epinephrine or
norepinephrine

does not increase mortality rate when
compared with other septic shock
studies.



We have demonstrated that the use of
dopamine responsiveness is a reliable
and independent predictive factor for
mortality.



The use of dopamine allows discrimination between
two very differing groups with regard to mortality
outcomes,

thereby enabling the inclusion of
homogeneous groups, in terms of
severity, in multiple-center studies.



Dopamina: medicação de escolha em choque
séptico refratário a volume?
Apresentador "Pro”



Vasopressors/ inotropes should
only be used after appropriate
volume resuscitation in septic
shock...
Parker et al. CCM 2004;32 (suppl): s591



... to define septic shock by clinical, hemodynamic, and oxygen use .

Crit Care Med 2002; 30:1365 -1378



Obrigado !
Hospital Emílio Carlos
Escola de medicina

Hospital Padre Albino


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