Post on 10-Apr-2018
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
1/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
16 de Dezembro de 2003
Hospital So Lucas da PUCRSHospital So Lucas da PUCRS -- UTI GeralUTI Geral
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
2/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Base TericaDefinies
ACCP/SCCM Consensus Conference Definitions
InfectionA host response to the presence of micro-organisms or tissue invasion by
microorganisms.
BacteremiaThe presence of viable bacteria in circulating blood
Systemic Inflammatory Response Syndrome (SIRS)The systemic inflammatory response to a wide variety of severe clinical insults,
manifested by two or more of the following conditions:
Temperature > 38C or < 36C
Heart rate > 90 beats/min
Respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg
WBC count > 12,000/mm3 , < 4000/mm3 , or > 10% immature (band) forms.
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
3/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Base TericaDefinies
SepsisThe systemic inflammatory response to infection. In association with infection,
manifestations of sepsis are the same as those previously defined for SIRS. It
should be determined whether they are a direct systemic response to the presence
of an infectious process and represent an acute alteration from baseline in the
absence of other known causes for such abnormalities. The clinical manifestations
would include two or more of the following conditions as a result of a documented
infection.
Severe Sepsis/SIRS.Sepsis (SIRS) associated with organ dysfunction, hypoperfusion, or hypotension.
Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic
acidosis, oliguria, or an acute alteration in mental status.
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
4/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Base TericaDefinies
Refractory (Septic) Shock/SIRS Shock.A subset of severe sepsis (SIRS) and defined as sepsis (SIRS) induced
hypotension despite adequate fluid resuscitation along with the presence of
perfusion abnormalities that may include, but are not limited to, lactic acidosis,
oliguria, or an acute alteration in mental status. Patients receiving inotropic or
vasopressor agents may no longer be hypotensive by the time they manifest
hypoperfusion abnormalities or organ dysfunction, yet they would still be
considered to have septic (SIRS) shock.
Multiple Organ Dysfunction Syndrome (MODS).Presence of altered organ function in an acutely ill patient such that homeostasis
cannot be maintained without intervention.
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
5/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Base TericaEndpoints
Evidncias na literatura de que a otimizao das variveis de transportede oxignio podem melhorar desfechos de pacientes (Shoemaker et al 1967,1973, 1982, 1988; Bland et al 1985)
Valores supra-normais
CI 4,5 l/min/m2
DO2 600-650 ml/min/m2
VO2 160-170 ml/min/m2
SvO2 70%
Manuteno de PAM 60-70 mmHg
Manuteno de um fluxo sangneo tecidual adequado
Resultados mistos (Yu et al 1993; Hayes et al 1994)
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
6/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Elevation of Systemic Oxygen Delivery in the Treatment of Critically Ill PatientsMichelle A. Hayes, Andrew C. Timmins, Ernest Yau, Mark Palazzo, Charles J. Hinds, and David Watson
New England Journal of Medicine - Volume 330:1717-1722 June 16, 1994 Number 24
Objetivo: Determinar atravs de um ECR se a otimizao da oferta de oxignio
atravs da infuso de dobutamina poderia melhorar o desfechos de um grupo diversode pacientes
Seleo de casos: Pacientes consecutivos admitidos em 2 UTIs por um perodo de2 anos. Para pacientes cirrgicos, os critrios de alto risco foram adaptados deShoemaker et al. Pacientes no-cirrgicos apresentavam condies com risco de vida(IRpA, choque sptico). Eram excludos pacientes < 16 anos, gestantes, submetidos a
neurocirurgia, doena cardaca prvia ou neoplasia hematolgica Passos iniciais:
Cateter de Swan-Ganz e Linha arterial
Dopamina p/ todos a 2 g/kg/min / SatO2 > 90%
Uso de colides e cristalides / Hb > 10 g/dl
Reposio volmica (curva ITSVE vs PoAP - metap Plateau)
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
7/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Elevation of Systemic Oxygen Delivery in the Treatment of Critically Ill PatientsMichelle A. Hayes, Andrew C. Timmins, Ernest Yau, Mark Palazzo, Charles J. Hinds, and David Watson
New England Journal of Medicine - Volume 330:1717-1722 June 16, 1994 Number 24
Treatment group: Dobutamine (5 to 200 g per kilogram per minute) was administered to
increase the cardiac index and oxygen delivery until all three goals had been achievedsimultaneously, unless there was sinus tachycardia at a rate over 130 beats per minute,tachyarrhythmia, or electrocardiographic evidence of myocardial ischemia, in which case thedose of dobutamine was immediately decreased or discontinued and then titrated to achievethe highest possible values for the cardiac index and oxygen delivery and consumption.
Control group: Dobutamine was administered only if the cardiac index was less than 2.8liters per minute per square meter.
In both groups: Norepinephrine (0.05 to 20 g per kilogram per minute) was administered,if required, to maintain the mean arterial pressure at 80 mm Hg while avoiding excessiveperipheral vasoconstriction (systemic-vascular-resistance index above 1500 dyn sec cm-5per square meter).
In both groups: Treatment was initiated in the intensive care unit, the aim being to achievetarget values as soon as possible after enrollment, and was continued until death or apparent
resolution of the acute illness.
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
8/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
9/34
p
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
10/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
11/34
P=0,12
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
12/34
P=0,04
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
13/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
14/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Elevation of Systemic Oxygen Delivery in the Treatment of Critically Ill PatientsMichelle A. Hayes, Andrew C. Timmins, Ernest Yau, Mark Palazzo, Charles J. Hinds, and David Watson
New England Journal of Medicine - Volume 330:1717-1722 June 16, 1994 Number 24
Conclusions:
When volume replacement was adequate and perfusion pressure wellmaintained, the overall outcome in high-risk patients was not improved byusing dobutamine at the time of admission to the intensive care unit in anattempt to achieve target values for oxygen delivery and consumption.
Not only was it often impossible to increase oxygen consumption, but ourresults also suggest that in some cases aggressive efforts to boost oxygen
consumption may have been detrimental.
It remains to be seen whether there are advantages to targeting oxygendelivery rather than oxygen consumption and whether other inotropic agentsmay have a more favorable effect on oxygen consumption.
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
15/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Elevation of Systemic Oxygen Delivery in the Treatment of Critically Ill PatientsMichelle A. Hayes, Andrew C. Timmins, Ernest Yau, Mark Palazzo, Charles J. Hinds, and David Watson
New England Journal of Medicine - Volume 330:1717-1722 June 16, 1994 Number 24
Problemas:
Nmero pequeno de paientes com choque sptico
Doses atualmente consideradas intolerveis de drogas vasoativas
Pacientes transfundidos com freqncia (Hb > 10)
Nveis de lactato relativamente baixos (2,1-2,2 mmol/l)
Reposio volmica adequada?
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
16/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
A trial of goal-oriented hemodynamic therapy in critically ill patientsLuciano gattinoni, Luca brazzi, Paolo pelosi, Roberto latini, Gianni tognoni, Antonio pesenti, Roberto fumagalli
New England Journal of Medicine - Volume 333:1025-1033 October 19, 1995 Number 16
Objetivo: Determinar atravs de um ECR se a otimizao hemodinmica a nveis
supranormais de ndice cardaco ou a nveis normais de SvO2
poderia melhorar amorbi-mortalidade de pacientes criticamente doentes
Seleo de casos: Pacientes consecutivos admitidos em 56 UTIs no perodo de
07/1991 a 08/1993. Pacientes arrolados apresentavam: cirurgia de alto risco, choque
hemorgico, sepse e choque sptico, IRpA por DPOC ou politrauma
Trs Grupos:
IC normal (2,5-3,5 l/min/m2
) IC supra-fisiolgico (>4,5 l/min/m2
SvO2 70%
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
17/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
A trial of goal-oriented hemodynamic therapy in critically ill patientsLuciano gattinoni, Luca brazzi, Paolo pelosi, Roberto latini, Gianni tognoni, Antonio pesenti, Roberto fumagalli
New England Journal of Medicine - Volume 333:1025-1033 October 19, 1995 Number 16
Manejo:
PAM 60 mmHg
PoAP at 18 mmHg
PVC entre 8 e 12 mmHg
Dbito urinrio de pelo menos 0,5 ml/kg/h
pH entre 7,3 e 7,5
Cristalides, colides e hemoderivados
Noradrenalina, adrenalina, dopamina, dobutamina
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
18/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
19/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
20/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
21/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
22/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
23/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
24/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
25/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
A trial of goal-oriented hemodynamic therapy in critically ill patientsLuciano gattinoni, Luca brazzi, Paolo pelosi, Roberto latini, Gianni tognoni, Antonio pesenti, Roberto fumagalli
New England Journal of Medicine - Volume 333:1025-1033 October 19, 1995 Number 16
Concluso:
A otimizao do ndice cardaco e da SvO2 de pacientes
criticamente enfermos no demonstrou benefcios em
termos de morbi-mortalidade, no grupo de pacientes
estudados.
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
26/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Early goal-directed therapy in the treatment of severe sepsis
and septic shockEmanuel rivers, ryant nguyen, Suzanne Havstad, Julie Ressler, Alexandria Muzzin, Bernhard Knoblich, Edward Peterson, and
Michael Tomlanovich
New England Journal of Medicine - Volume 345:1368-1377 November 8, 2001 Number 19
Objetivo: Determinar se o uso precoce de uma terapia guiada por metas (early goal-directed therapy) em pacientes com sepse e choque sptico antes que os mesmos sejam
admitidos na UTI capaz de diminuir a disfuno orgnica e a mortalidade.
Seleo de casos: Ensaio clnico randomizado, arrolando pacientes consecutivosadmitidos na emergncia de um hospital tercirio no perodo de 03/1997 a 03/2000, que
preenchessem os critrios de sepse e/ou choque sptico da ACCP/SCCM.
Passos iniciais:Cateter venoso central com capacidade de monitorizao da ScvO2 e linha arterial
Bolus de cristalideat atingir uma PVC de 8-12 mmHg
Vasopressor se PAM < 65 mmHg
Se ScvO2 < 70%, transfuso at atingir Ht = 30%
Se ScvO2 < 70% aps medidas prvias: Dobutamina (2,5-20 g/kg/min)
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
27/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
28/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
29/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
30/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
31/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
32/34
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
33/34
Temas em Terapia Intensiva
Otimizao Hemodinmica na Sepse
Early goal-directed therapy in the treatment of severe sepsis
and septic shockEmanuel rivers, ryant nguyen, Suzanne Havstad, Julie Ressler, Alexandria Muzzin, Bernhard Knoblich, Edward Peterson, and
Michael Tomlanovich
New England Journal of Medicine - Volume 345:1368-1377 November 8, 2001 Number 19
Concluso:
Aearly goal-directed therapy oferecida a pacientes com sepse/choque
sptico, mesmo que por poucas horas, mas no incio das manifestaes
traz um benefcios concretos aos pacientes em termos de morbi-
mortalidade
8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse
34/34