Choque séptico 2013

SepseChoque séptico

Antonio [email protected]

Médico coordenadorUnidade de Medicina Intensiva PediátricaUnidade de Medicina Intensiva Neonatal

Hospital Padre Albino

Professor de Pediatria nível II Faculdades Integradas Padre Albino

Catanduva / SP

Dr. Antonio Souto [email protected] 2013

UTI Pediátrica & Neonatal Hospital Padre Albino

http://www.scielo.br/pdf/jped/v78n6/7806449.pdf



Shock is the major cause of death in children regardless of disease category

Joseph A. Carcillo, M.D



Shock was commonly not recognized

Fewer patients were referred for shock than had shock(335 vs 1803)

0500

100015002000250030003500400045005000

referredfor

shock

shock

referred for shocknot referred for shockshockno shock

7%

37%



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



SepsisSepsisSepsisSIRS Severe SepsisSevere SepsisSevere Sepsis Septic ShockSeptic ShockSeptic Shock



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



SepsisSepsisSepsisSIRSSIRSSIRS Severe SepsisSevere SepsisSevere Sepsis Septic Shock

Severe Sepsis and Hypotension• Hypotension that does NOT

respond to fluid (30 cc/kg bolus)



Sepsis is a complex syndrome that develops when the initia l, appropriate host response to an infection becomes amplif ied, 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.



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



What is Shock?

• A physiologic state characterized by– Decrease in tissue perfusion

– Inadequate oxygen delivery

• Delivery isn’t keeping up with demand



Septic Shock

• Combination– Distributive

– Cardiogenic

– Hypovolemic

• Most common form of Shock

• On a continuum from SIRS to Septic Shock



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 tissue ssue perfusionperfusion

•• Extreme hypotension is a late and Extreme hypotension is a late and premorbidpremorbid signsign



“…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



Carcillo et al. defined septic shock in pediatric pa tients

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*



Carcillo JA, Davis AL, ZaritskyA. Role of early fluid

resuscitation in pediatric septic shock. JAMA.1991; 266 :1242 –

1245



20 ml/Kg a cada 5’60 ml/Kg em 15’



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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



Gustav Klimt(Baumgarten, Viena, 14 de julho de 1862— Viena, 6 de fevereiro de 1918) foi um pintor simbolista austríaco

Choque séptico 2013

Health & Medicine

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