Hipoperfusao oculta
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Hipoperfusao oculta

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Hipoperfusao oculta Hipoperfusao oculta Presentation Transcript

  • HIPOPERFUSÃO OCULTAPRATICANDO PARÂMETROS SERGIO KIFFER MACEDO
  • Microvascular Blood Flow Is Altered in Patients with Sepsis Am J Respir Crit Care Med 2002;166:98–104
  • Persistent microcirculatory alterationsare associated with organ failure and death in patients with septic shock Sakr Y, et al Crit Care Med 2004; 32:1825–1831
  • PARÂMETROS ABORDADOS:
  • PARÂMETROS ABORDADOS:• LACTATO
  • PARÂMETROS ABORDADOS:• LACTATO
  • PARÂMETROS ABORDADOS:• LACTATO• ScvO2
  • PARÂMETROS ABORDADOS:• LACTATO• ScvO2
  • PARÂMETROS ABORDADOS:• LACTATO• ScvO2• ∆ CO2
  • PARÂMETROS ABORDADOS:• LACTATO• ScvO2• ∆ CO2
  • PARÂMETROS ABORDADOS:• LACTATO• ScvO2• ∆ CO2• ∆ CO2/C(a-v)O2
  • LactatoVN: < 2 mmol/ L
  • Citoplasma Mitocôndria Ciclo de Krebs
  • •LACTATO / PIRUVATO = 10:1 Citoplasma •AERÓBICO = 673KCal ADR Glicose Mitocôndria O2Gliceraldeido-3-fosfato ALCALOSE Acetil-CoA NAD+ CO2 NADH + H+ NAD+ ALCALOSE SEPSE Piruvato Ciclo de Krebs ENDOTOXEMIA 1,3-difosfoglicerato TIAMINA ATP PDH NA Piruvato DH + H+ CO2 NA LD H2O D+ H Lactato
  • metabolismo celular = MRO 2 36 ATP VO2 < MRO 2 2 ATP repercussões sobre a SvO 2 extração ∫ débito ...... ∫ SvO2débito ∫ Hgb ...... ∫ SvO2Hgb ∫ SaO2 ...... ∫ SvO2 DO2 ácido lático ∫ extração ...... SvO2SaO 2 ...... metabolismo SvO2 alterado arterial venoso CHOQUE QUANDO VO 2 < MRO 2
  • metabolismo celular = MRO 2 36 ATP VO2 < MRO 2 2 ATP repercussões sobre a SvO 2 extração ∫ débito ...... ∫ SvO2débito ∫ Hgb ...... ∫ SvO2 ∫ SaO2 ...... ∫ SvO2Hgb DO2 Lactato ácido lático ∫ extração ...... SvO2SaO 2 ...... metabolismo SvO2 alterado arterial venoso CHOQUE QUANDO VO 2 < MRO 2
  • Interpretation ofDe Baker D Intensive Care Med (2003) 29:699–702
  • Prolonged lactate clearance is associated withincreased mortality in the surgical intensive care unit 100 100 80 60 42, 5 40 20 13, 3 3, 9 0 <24 h 24- 48 h 48- 96 Abnormal unt il 96 h McNellis J, et al. Am J Surg. 2001 Nov;182(5):481-5
  • Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Bakker J, et al. Am J Surg 1996 Feb;171(2):221-6
  • CLEARENCE DE LACTATO(Lactato basal – Lactato após 6 h) x 100 Lactato basal
  • ScvO2VN: > 70%
  • Time course of continuously measured SvO2 and ScvO2 Reinhart K, et al.Intensive Care Med (2004) 30:1572–1578
  • Limits of mixed venous oxygen saturation Bloos F and Reinhart K. Intensive Care Med (2005) 31:911–913
  • Variables that affect mixedvenous oxygen saturation Rivers EP, et al Curr Opin Crit Care 2001, 7:204–211
  • Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Occult Tissue Hypoxia• Phase 1 – Triage• Phase 2 – After VS stabilization, 31 of 36 patients had – ScvO2 < 65% – Lactate > 2 mM/L• Phase 3 – Relief of occult tissue hypoxia Rady and Rivers, Am J Emerg Med. 1996 Mar;14(2):218-25
  • ∆CO2VN: 4-6mmHg
  • Citoplasma ADR Glicose Mitocôndria O2Gliceraldeido-3-fosfato ALCALOSE Acetil-CoA NAD+ CO2 NADH + H+ NAD+ ALCALOSE SEPSE Piruvato Ciclo de Krebs ENDOTOXEMIA 1,3-difosfoglicerato TIAMINA ATP PDH NA Piruvato DH + H+ CO2 NA LD H2O D+ H Lactato
  • Citoplasma ↑CO2 ADR Glicose Mitocôndria O2 Gliceraldeido-3-fosfato ALCALOSE Acetil-CoA NAD+ CO2 NADH + H+ NAD+ ALCALOSE SEPSE Piruvato Ciclo de Krebs ENDOTOXEMIA 1,3-difosfoglicerato TIAMINA ATP PDH NA Piruvato DH + H+ CO2 NA LD H2O D+ H LactatoO2
  • Veno-Arterial CO2 Gradient
  • Veno-Arterial CO2 Gradient ΔPCO2 = PvCO2 - PaCO2 NORMAL = 4-6mmHg CO2 production (VCO2)= CO x (CvCO2 - CaCO2) ΔPCO2 = k x VCO2 COΔPCO2 IS INVERSELY RELATED TO CARDIAC OUTPUT
  • ∆CO2 / C(a- v)O2VN: até 1,4 mmHg
  • ∆CO2 / C(a-v)O2CaO2 = (1.34 x SaO2 x Hb) + (0.003 x PaO2)
  • ∆CO2 / C(a-v)O2 CaO2 = (1.34 x SaO2 x Hb) + (0.003 x PaO2)CvO2 = (1.34 x SvO2 x Hb) + (0.003 x PvO2)
  • Respiratory Quotient Could Be a Better Perfusion Variable to Predict Mortality in Septic Shock 0.76 (cut-off value 1.0 (sensitivity 63% Rezende E et al Submitted to SCCM