XII copati

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XII copati

  1. 1. 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
  2. 2. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  3. 3. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPABecause of the paucity of outcome-directed, randomizedcontrolled trials, the recommendations for hemodynamicsupport of term newborns and children in this documentare primarily expert opinion rather than irrefutablevidence. Crit Care Med 2002; 30:1365 -1378Antonio Souto acasouto@bol.com.br 2011
  4. 4. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA 58% CI↓ + SVRI↑ 20% CI↑ + SVRI↓ 22% CI↑ + SVRI↑ nCI=3,3L/min/m2; nSVRI= 800 dyne/sec/cm5Antonio Souto acasouto@bol.com.br 2011
  5. 5. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA 58% CI↓ + SVRI↑ 20% CI↑ + SVRI↓ 22% CI↑ + SVRI↑ Pediatrics 1998;102(2)Antonio Souto acasouto@bol.com.br 2011
  6. 6. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  7. 7. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAUnlike adults, children with fluid-refractoryshock are frequently hypodynamic andrespond to inotrope and vasodilator therapy.Antonio Souto acasouto@bol.com.br 2011
  8. 8. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPABecause hemodynamic states are heterogeneousand change with time,an incorrect cardiovascular therapeuticregimen should be suspected in any childwith persistent shock.Antonio Souto acasouto@bol.com.br 2011
  9. 9. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA...fluid-refractory shock are frequently hypodynamic and respondto inotrope and vasodilator therapy Pediatrics 1998;102(2)Dopamina (5-15 mg/kg/min)•Ação predominantemente beta-1 cardíaco•Efeito inotrópico positivo•Moderada vasodilatação periférica (efeito beta-2 na circulação muscularesquelética 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 domínimo efeito na resistência vascular sitêmica. Crit Care Med 2004; 32:1928–1948Antonio Souto acasouto@bol.com.br 2011
  10. 10. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAMany studies have tested the observations andrecommendations of the 2002 guidelines. Crit Care Med 2009; 37:666–688Antonio Souto acasouto@bol.com.br 2011
  11. 11. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA... the guidelines wereuseful and effective withoutany evidence of harm. Crit Care Med 2009; 37:666–688Antonio Souto acasouto@bol.com.br 2011
  12. 12. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA•Wills BA, Nguyen MD, Ha TL, et al: Comparison of the three fluid solutions for resuscitation in dengue shock. NEngl J Med 2005; 353:877–889•Maitland K, Pamba A, English M, et al: Randomized trial of volume expansion with albumin or saline in childrenwith 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 communityphysicians 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 inchildren: 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 forpaediatric 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 suppressantwithdrawal are associated with improved survival in pediatric sepsis, severe sepsis, and septic shock. Crit CareMed 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 resourceutilization in severe pediatric sepsis. Pediatrics 2007; 119:487–494 Crit Care Med 2009; 37:666–688Antonio Souto acasouto@bol.com.br 2011
  13. 13. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  14. 14. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  15. 15. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPATaken together, these studies indirectlyand directlysupport the utility and efficacyof implementation of the time sensitive,goal-directed recommendations of the2002 guidelines... Crit Care Med 2009; 37:666–688Antonio Souto acasouto@bol.com.br 2011
  16. 16. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA Crit Care Med 2009; 37:666–688Antonio Souto acasouto@bol.com.br 2011
  17. 17. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  18. 18. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAO uso de drogas vasopressoras permanece controverso.A escolha de uma droga permanece aberta.... questão sem solidas e robustas respostas... Antonio Souto acasouto@bol.com.br 2011
  19. 19. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPASepsis 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... Antonio Souto acasouto@bol.com.br 2011
  20. 20. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  21. 21. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA ... these terms do not allow for precise characterization and staging of patients with this condition. Crit Care Med 2003 Vol. 31, No. 4Antonio Souto acasouto@bol.com.br 2011
  22. 22. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA 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;31:1250–6Antonio Souto acasouto@bol.com.br 2011
  23. 23. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  24. 24. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA http://www.infectio-lille.com/diaporamas/2011/KIPNIS_DUACAI2011.pdfAntonio Souto acasouto@bol.com.br 2011
  25. 25. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA 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.Antonio Souto acasouto@bol.com.br 2011
  26. 26. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA...hemodynamic states are heterogeneous andchange with time... Pediatrics 1998;102(2)Antonio Souto acasouto@bol.com.br 2011
  27. 27. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  28. 28. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  29. 29. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  30. 30. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  31. 31. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  32. 32. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA Podem então ser traçadas “diretrizes” uniformes para aplicação em crianças tão diferentes? ...o trabalho desenvolvido por Dr. Carcillo e a força-tarefaprocuram pôr alguma ordem e sistematização nas condutas das diferentes apresentações clínicas... Antonio Souto acasouto@bol.com.br 2011
  33. 33. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  34. 34. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAClinical criteria generally used todefinite septic shock do not allow forearly identification of patients with goodor bad prognosis. Antonio Souto acasouto@bol.com.br 2011
  35. 35. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAOur hypothesis is that “dopamine-sensitive” patients have a betterprognosis than those with a “dopamine-resistant” profile. Antonio Souto acasouto@bol.com.br 2011
  36. 36. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA 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)Antonio Souto acasouto@bol.com.br 2011
  37. 37. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA… the use of dopamine is controversialsince it could delay the use ofnorepinephrine, hence leading topersistent circulatory failure. Antonio Souto acasouto@bol.com.br 2011
  38. 38. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAThe present results clearly demonstrate that therapid administration of incremental doses ofdopamine followed by a switch to epinephrine ornorepinephrinedoes not increase mortality rate whencompared with other septic shockstudies. Antonio Souto acasouto@bol.com.br 2011
  39. 39. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAWe have demonstrated that the use ofdopamine responsiveness is a reliableand independent predictive factor formortality.Antonio Souto acasouto@bol.com.br 2011
  40. 40. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAThe use of dopamine allows discrimination betweentwo very differing groups with regard to mortalityoutcomes,thereby enabling the inclusion ofhomogeneous groups, in terms ofseverity, in multiple-center studies. Antonio Souto acasouto@bol.com.br 2011
  41. 41. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  42. 42. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPADopamina: medicação de escolha em choqueséptico refratário a volume?Apresentador "Pro”Antonio Souto acasouto@bol.com.br 2011
  43. 43. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  44. 44. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  45. 45. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  46. 46. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAVasopressors/ inotropes shouldonly be used after appropriatevolume resuscitation in septicshock...Parker et al. CCM 2004;32 (suppl): s591 Antonio Souto acasouto@bol.com.br 2011
  47. 47. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPAAntonio Souto acasouto@bol.com.br 2011
  48. 48. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA... to define septic shock by clinical, hemodynamic, and oxygen use . Crit Care Med 2002; 30:1365 -1378Antonio Souto acasouto@bol.com.br 2011
  49. 49. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA... to define septic shock by clinical, hemodynamic, and oxygen use . Crit Care Med 2002; 30:1365 -1378Antonio Souto acasouto@bol.com.br 2011
  50. 50. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA Obrigado ! Hospital Emílio Carlos Escola de medicinaHospital Padre AlbinoAntonio Souto acasouto@bol.com.br 2011

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