Choque séptico 2013

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Choque séptico 2013

  1. 1. SepseChoque sépticoAntonio Soutoacasouto@bol.com.brMédico coordenadorUnidade de Medicina Intensiva PediátricaUnidade de Medicina Intensiva NeonatalHospital Padre AlbinoProfessor de Pediatria nível IIFaculdades Integradas Padre AlbinoCatanduva / SP
  2. 2. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albinohttp://www.scielo.br/pdf/jped/v78n6/7806449.pdf
  3. 3. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  4. 4. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoShock is the major cause of death in childrenregardless of disease categoryJoseph A. Carcillo, M.D
  5. 5. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoShock was commonly not recognizedFewer patients were referred for shock than had shock(335 vs 1803)0500100015002000250030003500400045005000referredforshockshockreferred for shocknot referred for shockshockno shock7%37%
  6. 6. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  7. 7. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  8. 8. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoBone et al. Chest 1992;101:1644SepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere SepsisSystemic Inflammatory Response SyndromeSIRS 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. 9. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoSepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere Sepsis Septic ShockSeptic ShockSeptic Shock
  10. 10. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoSepsisSepsisSepsisSIRSSIRSSIRS Severe Sepsis Septic ShockSeptic ShockSeptic ShockSepsis plus Organ Dysfunction• Elevated Creatinine• Elevated INR• Altered Mental Status• Elevated Lactate• Hypotension that responds to fluid
  11. 11. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoSepsisSepsisSepsisSIRSSIRSSIRS Severe SepsisSevere SepsisSevere Sepsis Septic ShockSevere Sepsis and Hypotension• Hypotension that does NOTrespond to fluid (30 cc/kg bolus)
  12. 12. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  13. 13. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  14. 14. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  15. 15. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  16. 16. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoSepsis 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 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.
  17. 17. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  18. 18. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  19. 19. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  20. 20. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  21. 21. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  22. 22. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  23. 23. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  24. 24. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoFigure 1. FACTORS AFFECTING OXYGEN DELIVERYDO2CaO2COSVHROxygenationHgbA-a gradientDPGAcid-Base BalanceBlockersCompetitorsTemperatureDrugsConduction SystemVentricularComplianceEDVESV ContractilityCVPVenous VolumeVenous ToneAfterload BlockersTemperature CompetitorsDrugs Autonomic ToneMetabolic MilieuIonsAcid BaseTemperatureDrugsToxinsInfluenced ByInfluenced ByInfluenced ByInfluenced By
  25. 25. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoWhat is Shock?• A physiologic state characterized by– Decrease in tissue perfusion– Inadequate oxygen delivery• Delivery isn’t keeping up withdemand
  26. 26. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoSeptic Shock• Combination– Distributive– Cardiogenic– Hypovolemic• Most common form of Shock• On a continuum from SIRS to Septic Shock
  27. 27. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  28. 28. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  29. 29. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  30. 30. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  31. 31. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  32. 32. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoClinical 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 tissuessueperfusionperfusion•• Extreme hypotension is a late andExtreme hypotension is a late and premorbidpremorbid signsign
  33. 33. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino“…with a high index of suspicion…septicshock can be recognized early (beforehypotension) by a triad of signs…” Carcilloet.al, 2002•Hypo/hyperthermia•Altered mental status•Peripheral vasodilation/constriction
  34. 34. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoCarcillo et al. defined septic shock in pediatric patientsTachycardia (which may be absent in thehypothermic patient) with signs of decreasedperfusion including decreased peripheralpulses compared with central pulses, alteredalertness, flash capillary refill or capillary refill>2 secs, mottled or cool extremities, ordecreased urine outputInternational pediatric sepsis consensus conference: Definitions for sepsis and organdysfunction in pediatrics*
  35. 35. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  36. 36. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  37. 37. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  38. 38. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  39. 39. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoCarcillo JA, Davis AL, ZaritskyA. Role of early fluidresuscitation in pediatric septicshock. JAMA.1991; 266 :1242 –1245
  40. 40. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  41. 41. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  42. 42. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino20 ml/Kg a cada 5’60 ml/Kg em 15’
  43. 43. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  44. 44. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  45. 45. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  46. 46. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoDopaminaDopaminaDopaminaDopaminaDobutaminaDobutaminaAdrenalinaAdrenalinaChoque frioChoque frio Choque quenteChoque quenteNorNor--adrenalinaadrenalinaChoqueChoquerefratrefratáário ario avolumevolumeChoqueChoquerefratrefratáário ario avolumevolumedopaminodopaminoresistenteresistente
  47. 47. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  48. 48. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  49. 49. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  50. 50. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  51. 51. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  52. 52. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoVolume 115(2), February 1999, pp 462-474Inadequate Antimicrobial Treatment ofInfections: A Risk Factor for HospitalMortality Among Critically III PatientsKollef, Marin H. MD, FCCP; Sherman, Glenda RN; Ward, Suzanne RN; Fraser,Victoria J. MD
  53. 53. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  54. 54. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  55. 55. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  56. 56. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre Albino
  57. 57. Dr. Antonio Souto acasouto@terra.com.br 2013UTI Pediátrica & Neonatal Hospital Padre AlbinoGustav Klimt(Baumgarten, Viena,14 de julho de 1862— Viena, 6 de fevereiro de 1918)foi um pintor simbolista austríaco

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