Temas em Terapia Intensiva - Otimização hemodinâmica na sepse

8/8/2019 Temas em Terapia Intensiva - Otimizao hemodinmica na sepse

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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


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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.


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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.


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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.


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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)


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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)


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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.


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p


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P=0,12


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P=0,04


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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.


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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?


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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%


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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


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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.


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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)


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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


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Temas em Terapia Intensiva - Otimização hemodinâmica na sepse

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