Most Beautiful Call Girl in Bangalore Contact on Whatsapp
XII copati
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. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
3. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
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
Antonio Souto acasouto@bol.com.br 2011
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/cm5
Antonio Souto acasouto@bol.com.br 2011
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. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
7. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Unlike adults, children with fluid-refractory
shock are frequently hypodynamic and
respond to inotrope and vasodilator therapy.
Antonio Souto acasouto@bol.com.br 2011
8. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Because hemodynamic states are heterogeneous
and change with time,
an incorrect cardiovascular therapeutic
regimen should be suspected in any child
with persistent shock.
Antonio Souto acasouto@bol.com.br 2011
9. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
...fluid-refractory shock are frequently hypodynamic and respond
to 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 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
Antonio Souto acasouto@bol.com.br 2011
10. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Many studies have tested the observations and
recommendations of the 2002 guidelines.
Crit Care Med 2009; 37:666–688
Antonio Souto acasouto@bol.com.br 2011
11. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
... the guidelines were
useful and effective without
any evidence of harm.
Crit Care Med 2009; 37:666–688
Antonio Souto acasouto@bol.com.br 2011
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. 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
Antonio Souto acasouto@bol.com.br 2011
13. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
14. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
15. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
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
Antonio Souto acasouto@bol.com.br 2011
16. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Crit Care Med 2009; 37:666–688
Antonio Souto acasouto@bol.com.br 2011
17. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
18. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
O 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. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
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...
Antonio Souto acasouto@bol.com.br 2011
20. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
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. 4
Antonio Souto acasouto@bol.com.br 2011
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;31:1250–6
Antonio Souto acasouto@bol.com.br 2011
23. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
24. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
http://www.infectio-lille.com/diaporamas/2011/KIPNIS_DUACAI2011.pdf
Antonio Souto acasouto@bol.com.br 2011
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. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
...hemodynamic states are heterogeneous and
change with time...
Pediatrics 1998;102(2)
Antonio Souto acasouto@bol.com.br 2011
27. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
28. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
29. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
30. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
31. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
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-tarefa
procuram pôr alguma ordem e sistematização nas condutas
das diferentes apresentações clínicas...
Antonio Souto acasouto@bol.com.br 2011
33. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
34. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Clinical criteria generally used to
definite septic shock do not allow for
early identification of patients with good
or bad prognosis.
Antonio Souto acasouto@bol.com.br 2011
35. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Our hypothesis is that “dopamine-
sensitive” patients have a better
prognosis than those with a “dopamine-
resistant” profile.
Antonio Souto acasouto@bol.com.br 2011
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. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
… the use of dopamine is controversial
since it could delay the use of
norepinephrine, hence leading to
persistent circulatory failure.
Antonio Souto acasouto@bol.com.br 2011
38. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
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.
Antonio Souto acasouto@bol.com.br 2011
39. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
We have demonstrated that the use of
dopamine responsiveness is a reliable
and independent predictive factor for
mortality.
Antonio Souto acasouto@bol.com.br 2011
40. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
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.
Antonio Souto acasouto@bol.com.br 2011
41. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
42. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Dopamina: medicação de escolha em choque
séptico refratário a volume?
Apresentador "Pro”
Antonio Souto acasouto@bol.com.br 2011
43. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
44. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
45. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
46. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Vasopressors/ inotropes should
only be used after appropriate
volume resuscitation in septic
shock...
Parker et al. CCM 2004;32 (suppl): s591
Antonio Souto acasouto@bol.com.br 2011
47. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Antonio Souto acasouto@bol.com.br 2011
48. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
... to define septic shock by clinical, hemodynamic, and oxygen use .
Crit Care Med 2002; 30:1365 -1378
Antonio Souto acasouto@bol.com.br 2011
49. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
... to define septic shock by clinical, hemodynamic, and oxygen use .
Crit Care Med 2002; 30:1365 -1378
Antonio Souto acasouto@bol.com.br 2011
50. UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA
Obrigado !
Hospital Emílio Carlos
Escola de medicina
Hospital Padre Albino
Antonio Souto acasouto@bol.com.br 2011