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Choque séptico 2013
1. Sepse
Choque séptico
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. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
http://www.scielo.br/pdf/jped/v78n6/7806449.pdf
3. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
4. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Shock is the major cause of death in children
regardless of disease category
Joseph A. Carcillo, M.D
5. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Shock was commonly not recognized
Fewer patients were referred for shock than had shock
(335 vs 1803)
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
referred
for
shock
shock
referred for shock
not referred for shock
shock
no shock
7
%
37%
6. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
7. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
8. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Bone et al. Chest 1992;101:1644
SepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere Sepsis
Systemic Inflammatory Response Syndrome
SIRS 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. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
SepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere Sepsis Septic ShockSeptic ShockSeptic Shock
10. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
SepsisSepsisSepsisSIRSSIRSSIRS Severe Sepsis Septic ShockSeptic ShockSeptic Shock
Sepsis plus Organ Dysfunction
• Elevated Creatinine
• Elevated INR
• Altered Mental Status
• Elevated Lactate
• Hypotension that responds to fluid
11. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
SepsisSepsisSepsisSIRSSIRSSIRS Severe SepsisSevere SepsisSevere Sepsis Septic Shock
Severe Sepsis and Hypotension
• Hypotension that does NOT
respond to fluid (30 cc/kg bolus)
12. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
13. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
14. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
15. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
16. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Sepsis 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 the
immune 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. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
18. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
19. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
20. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
21. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
22. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
23. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
24. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Figure 1. FACTORS AFFECTING OXYGEN DELIVERY
DO2
CaO2
CO
SV
HR
Oxygenation
Hgb
A-a gradient
DPG
Acid-Base Balance
Blockers
Competitors
Temperature
Drugs
Conduction System
Ventricular
Compliance
EDV
ESV Contractility
CVP
Venous Volume
Venous Tone
Afterload Blockers
Temperature Competitors
Drugs Autonomic Tone
Metabolic Milieu
Ions
Acid Base
Temperature
Drugs
Toxins
Influenced By
Influenced By
Influenced By
Influenced By
25. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
What is Shock?
• A physiologic state characterized by
– Decrease in tissue perfusion
– Inadequate oxygen delivery
• Delivery isn’t keeping up with
demand
26. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Septic Shock
• Combination
– Distributive
– Cardiogenic
– Hypovolemic
• Most common form of Shock
• On a continuum from SIRS to Septic Shock
27. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
28. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
29. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
30. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
31. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
32. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Clinical 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 tissuessue
perfusionperfusion
•• Extreme hypotension is a late andExtreme hypotension is a late and premorbidpremorbid signsign
33. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
“…with a high index of suspicion…septic
shock can be recognized early (before
hypotension) by a triad of signs…” Carcillo
et.al, 2002
•Hypo/hyperthermia
•Altered mental status
•Peripheral vasodilation/constriction
34. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Carcillo et al. defined septic shock in pediatric patients
Tachycardia (which may be absent in the
hypothermic patient) with signs of decreased
perfusion including decreased peripheral
pulses compared with central pulses, altered
alertness, flash capillary refill or capillary refill
>2 secs, mottled or cool extremities, or
decreased urine output
International pediatric sepsis consensus conference: Definitions for sepsis and organ
dysfunction in pediatrics*
35. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
36. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
37. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
38. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
39. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Carcillo JA, Davis AL, Zaritsky
A. Role of early fluid
resuscitation in pediatric septic
shock. JAMA.1991; 266 :1242 –
1245
40. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
41. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
42. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
20 ml/Kg a cada 5’
60 ml/Kg em 15’
43. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
44. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
45. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
46. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
DopaminaDopamina
DopaminaDopamina
DobutaminaDobutamina
AdrenalinaAdrenalina
Choque frioChoque frio Choque quenteChoque quente
NorNor--adrenalinaadrenalina
ChoqueChoque
refratrefratáário ario a
volumevolume
ChoqueChoque
refratrefratáário ario a
volumevolume
dopaminodopamino
resistenteresistente
47. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
48. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
49. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
50. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
51. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
52. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Volume 115(2), February 1999, pp 462-474
Inadequate Antimicrobial Treatment of
Infections: A Risk Factor for Hospital
Mortality Among Critically III Patients
Kollef, Marin H. MD, FCCP; Sherman, Glenda RN; Ward, Suzanne RN; Fraser,
Victoria J. MD
53. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
54. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
55. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
56. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
57. Dr. Antonio Souto acasouto@terra.com.br 2013
UTI Pediátrica & Neonatal Hospital Padre Albino
Gustav Klimt
(Baumgarten, Viena,
14 de julho de 1862
— Viena, 6 de fevereiro de 1918)
foi um pintor simbolista austríaco