Choque séptico
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Transcript of Choque séptico
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Decisões clínicas difíceisAntonio Souto
[email protected] de Medicina Intensiva Pediátrica
Faculdades Integradas Padre AlbinoHospital Padre Albino – Catanduva / SP
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Escolha do caso• Caso difícil ?
• Doença de base pouco freqüente
(relatos de casos e pequenas séries)• Falta de consenso com relação a conduta
• Complicação importante dentro da medicina intensiva
• Discussão da aplicação de guidelinesestabelecidos
• Importância clínica
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Coleta de dadosInformantes (Subjetivos)• Mãe• Equipe médica
• Revisão do prontuário (Objetivo)
• Aspectos mais importantes
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Paciente• Masculino• Branco
• Nasc: 22/01/1998 – 12 a • 35 Kg
• Vacinação adequada• Sem AP importantes
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HMA D1• 14h: Ferida perfuro-cortante, 10 cm, em 1/3 médio
anterior de perna esquerda quando nadava em açude (potencialmente contaminada)
• 16h: Posto de saúde:• “Relatou ferimento no portão de casa”
• CD: Sutura + curativo• Antiinflamatório
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HMA D2• Consulta m édica (manhã)• Criança abatida, afebril• Ferida inflamada com sangramento
• Pressão baixa sic• Hiperglicemia
• Antiinflamatório
•Alta
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HMA D2• Consulta m édica (noite)
• PA 70/60
• S Fisiológico 0,9%, 500 ml
•Alta
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HMA D3• Consulta m édica (manhã)
• Ferida c/ inflamação até o joelho• Sangramento e mal cheiro• Febre
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HMA D3• Consulta m édica (manhã)
• Cefalexina, 500 mg, VO, 6/6 h, por 7 dias
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HMA D3• Consulta m édica (tarde)• Avaliação cirurgia vascular
• Internação hospitalar
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HMA D3Interna ção hospitalar (enfermaria)
• HD: Ferida PC infectada + Celulite de MIE
• Internação 19h• Ceftriaxona + Clindamicina 22 h• Ranitidina
• Sem diurese durante a noite• PA 80/30 21:15h
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HMA D3
Pl 98000
Sat 91%Mn 8%
CO2t 15Lf 10%
Bic 16E 1%
BE – 9S 79%
PaO2 68B 2%
PaCO2 31TTPA 40sM/Mt 0/0
PH 7,34N 81% (2430)
Ar ambienteINR 2,24L 3000
Gaso arterTP 18,9sHb 9,6 / Ht 28,2
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HMA D4• Avaliação pelo cirurgião geral• Drenagem de material purulento
(Necrótico)
• Ceftriaxona + Clindamicina• Ranitidina• Clexane (enoxaparina )20 mg SC
• Sem Diurese durante a noite• PA 80/30 21:15h
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HMA D1/4UTI Pediátrica 11 h• Ferida aberta em MIE com drenagem de
material purulento• Edema de MIE e sinais flogísticos até a coxa
• Hematomas em perna esquerda
• MEG, torporoso, AA, febril, taquidispneico• Glasgow = 8
• MV + S S/RA• Abdome Fl, RHA+, Indolor à palpação
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HMA D1/4UTI Pediátrica 11 h
• Palidez• Taquicardia• Extremidades frias• Pulso fino• Enchimento capilar > 2 s• Hipotenso (NI)
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HMA D1/4UTI Pediátrica 11 h
• HD:
–Ferida infectada–Celulite–Choque Séptico
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UTI Pediátrica D1/4• Acesso venoso periférico
• Cetamina
• Entubação orotraqueal (Rebaixamento consc)• Ventilação pulmonar mecânica
• SIMV (FR 20, Ti 1, PIP 20, PEEP 5, FiO2 0,5)
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UTI Ped D1/4
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UTI Ped D1/4• Suporte hemodinâmico
• Via • Solução• Volume
• Drogas
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UTI Ped D1/4• Suporte hemodinâmico
• Veia periférica
• S Fisiológico 0,9%
–500 ml 11:15h–500 ml 12:15h–500 ml 12:45h ----- Lactato 4,5–500 ml 13:15h
• 2000 ml (60 ml/Kg) em 2 h
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UTI ped D1/4
Sat 88%Sat 97%
CO2t 12CO2t 11
Bic 12,3Lactato 4,5 12:30Bic 12
BE – 16,2FC 95 – 110BE – 16
PaO2 73,2PAni 60/40PaO2 114
PaCO2 34,1S/ DiuresePaCO2 28
PH 7,23PH 7,23
VPM1500 ml SF 0,9%O2 inalatório
Gaso arter 12:5913:00Gaso arter 11:00
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UTI Ped D1/4• Antibioticoterapia:
–Clindamicina–Ceftriaxona
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UTI Ped D1/4• Antibioticoterapia:
• Suspenso Clindamicina
–Oxacilina–Ceftriaxona
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UTI Ped D1/4• S Glicofisiológico 5% 60 ml/h (1440 ml/24h)• Omeprazol
• Sedação• Fentanil• Midazolam
Suspenso clexane
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UTI ped D1/4
Coagulo normalPCR 384
Sat 97%AST/ALT normais
Pl 122000
CO2t 11Glicemia 79Mn 6%
Bic 12Lf 5%
BE – 16Ur 69/ Cr 1,1S 53%
PaO2 114B 31%
PaCO2 28TTPA 46,7 sM/Mt 2/3
PH 7,23N 89%
O2 inalatórioINR 1,88L 8900
Gaso arterTP 17,1 sHb 10 / Ht 29,7
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UTI ped D1/4• Suporte hemodinâmico
• Veia periférica
• S Fisiológico 0,9%• 500 ml 11:15h• 500 ml 12:15h• 500 ml 12:45h ----- Lactato 4,5
–500 ml 13:15h• 2000 ml (60 ml/Kg) em 2 h
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UTI ped D1/4• Suporte hemodinâmico
–500 ml 13:15h2000 ml (60 ml/Kg) em 2 h
–500 ml 16h•Diurese 800 ml•FC 110 bpm•PAni 90/50
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UTI ped D1/4• 17:00
• 11-17 h• 2500 ml SF0,9%
Sat = 99,5%
CO2T = 11,9
Bic = 13
BE = - 14,9
PO2 = 215,2
PCO2 = 33,9
PH = 7,20
Gaso arterial
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UTI ped D1/4• 17:00
• Bicarbonato de s ódio
• NaHCO3 8,4% 40 ml• S Fisiol 0,9% 500 ml(1,5% 115 mEq Na)• EV em 1 h Sat = 99,5%
CO2T = 11,9
Bic = 13
BE = - 14,9
PO2 = 215,2
PCO2 = 33,9
PH = 7,20
Gaso arterial
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UTI ped D1/4• 17:00
• Importante edema em MIE• Diminuição dos pulsos periféricos• Síndrome compartimental
• Indicada Fasciotomia
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UTI ped D1/4
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UTI ped D1/4
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UTI ped D1/4
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UTI ped D1/4• Cirurgia
• Debridamento• Fasciíte necrosante• Fasciotomia• 19:20 = FC 100 – 110, PAni 70/40
• Instabilidade hemodinâmica• Bradicardia• Noradrenalina• CVC DL SCD
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UTI ped D1/4• 20:00 h POi• Suporte hemodinâmico
• Norepinefrina
• FC 135, PA ni 80/50• Instável hemodinamicamente
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UTI ped D1/4• 20:00 h POi• Suporte hemodinâmico
• Suspenso Norepinefrina• Dopamina 5 mcg /Kg/min
• FC 135, PA ni 80/50
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UTI ped D1/4• 21:56
• Dopamina 5 mcg /Kg/min
Hb 11,6/Ht 34,9
Sat = 95,9%
CO2T = 13,8
Bic = 14,4
BE = - 14
PO2 = 109,3
PCO2 = 40
PH = 7,20
Gaso arterial
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UTI ped D1/4• 21:56
• Bicarbonato de sódio
• NaHCO3 8,4% 60 ml• S Fisiol 0,9% 500 ml(1,7% 135 mEq Na)• EV em 2 h X 2
Hb 11,6/Ht 34,9
Sat = 95,9%
CO2T = 13,8
Bic = 14,4
BE = - 14
PO2 = 109,3
PCO2 = 40
PH = 7,20
Gaso arterial
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UTI ped D1/4• 00:30
• Bicarbonato de sódio
• NaHCO3 8,4% 60 ml• S Fisiol 0,9% 500 ml(1,7% 135 mEq Na)• EV em 2 h X 2
• Na 141,1 mEq/l
Hb 10,5/Ht 31,6
Sat = 99,4%
CO2T = 14,9
Bic = 15,9
BE = - 9,9
PO2 = 178,3
PCO2 = 30
PH = 7,33
Gaso arterial
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UTI ped D1/4 mapa
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UTI ped D2/5
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UTI ped D2/5• Fasciíte necrosante MIE• Choque Séptico
• SGF 40 ml/h (1000 ml/24h)• Fentanil/Midazolan• Ventilação pulmonar mecânica• (Respiratório estável)• Oxacilina/Ceftriaxona• Omeprazol
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UTI ped D2/5• Fasciíte necrosante MIE• Choque Séptico
• Instável hemodinamicamente• Dopamina 5 mcg/Kg/min
• T 38,9 PVC +20• FC 125 Sat 96%
• PAni 90/20 Gluco 91
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UTI ped D2/5• Instável hemodinamicamente
• T 38,9 PVC +20• FC 125 Sat 96%• PAni 90/20 Gluco 91
• 10:00h• Lactato 3,9
• Dopamina 10 mcg /Kg/min
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UTI ped D2/5• Instável hemodinamicamente
• 12:00h• Dopamina 10 mcg/Kg/min
• Diurese 200 ml (1 ml/Kg/h)• T 38,2 PVC +21
• FC 126 Sat 96%• PAni 80/30 Hb 12,5/Ht 37,6
Sat = 72,3%
CO2T = 16,7
Bic = 17,8
BE = - 9,7
PO2 = 47,2
PCO2 = 43,3
PH = 7,23
Gaso venosa C
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UTI ped D2/5• Instável hemodinamicamente
• 16:00h• Dopamina 10 mcg/Kg/min
• T 37 PVC +18
• FC 107 Sat 97%• PAni 90/30 Hb 10,4/Ht 31,1
Sat = 95%
CO2T = 17,6
Bic = 18,6
BE = - 8
PO2 = 87,7
PCO2 = 40
PH = 7,23
Gaso arterial
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UTI ped D2/5• Instável hemodinamicamente
• 16:00h• Dopamina 12,5 mcg /Kg/min• Hidrocortisona 120 mg (3,5 mg/Kg)
• Hidrocortisona 30 mg 6/6
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UTI ped D2/5• Estável hemodinamicamente
• 20:00h• Dopamina 12,5 mcg/Kg/min
• Hidrocortisona 120 mg
• T 36,2 PVC +18• FC 89 Sat 96%• PAni 100/50
• Diurese 500 ml (2,5 ml/kg/h)Hb 8/Ht 24Sat = 86,6%
CO2T = 17,2
Bic = 17,8
BE = - 8,4
PO2 = 58,5
PCO2 = 35,5
PH = 7,31
Gaso venosa C
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UTI ped D2/5• Estável hemodinamicamente
• 20:00h• Dopamina 12,5 mcg/Kg/min
• Hidrocortisona 30 mg 6/6
• Oxacilina/Ceftriaxona
• Metronidazol
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UTI ped D2/5• Estável hemodinamicamente
• 6:00h• Dopamina 12,5 mcg/Kg/min
• Hidrocortisona 30 mg 6/6
• T 36,2 C PVC +19• FC 88 Sat 98%• PAni 100/50 Gluco 91/90/142• Diurese 600/300 (2 ml/Kg/h)
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UTI ped D2/5• Conduta cir úrgica
• Troca de curativos
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UTI ped D2/5 mapa
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UTI ped D2/5
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UTI ped D3/6• Fasciíte necrosante MIE• Choque Séptico
• SF 60 ml/h (1500 ml/24h)• Fentanil/Midazolan• Ventilação pulmonar mecânica(Respiratório estável)• Oxacilina/Ceftriaxona/Metronidazol• Omeprazol
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UTI ped D3/6• Fasciíte necrosante MIE• Choque Séptico
• Estável hemodinamicamente• Dopamina 12,5 mcg/Kg/min• Hidrocortisona 30 mg 6/6h (3,5 mg/Kg/d)
• T 35,8 PVC +21
• FC 92 Sat 98%
• PAni 110/50 Gluco 170 Lactato 2
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UTI ped D3/6
Hb 10,5/Ht 31,5
Sat = 83,6%
CO2T = 18,9
Bic = 19,7
BE = - 8
PO2 = 59,9
PCO2 = 48,9
PH = 7,22
Gaso VC 9h
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UTI ped D3/6• s/ dopamina (troca de medica ção)
• Instável hemodinamicamente• (CHOQUE)
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UTI ped D3/6• Instável hemodinamicamente• (CHOQUE)
• 9:00h Epinefrina 0,1 mcg /Kg/min
• 11:00h Epinefrina 0,2 mcg /Kg/min
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UTI ped D3/6• 11:00h Epinefrina 0,2 mcg /Kg/min
• 12:00h• T 36,4 PVC +24• FC 122 Sat 99%
• PAni 90/50 Gluco 157
• Diurese 200 ml/6h (0,9 ml/Kg/h)
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UTI ped D3/6
Hb/Ht
Sat = 78,5%
CO2T = 17,1
Bic = 19,5
BE = - 5,5
PO2 = 44,1
PCO2 = 33,4
PH = 7,38
Gaso VC 19h
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UTI ped D3/6 mapa
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UTI ped D3/6• Conduta cir úrgica
• Troca de curativos
• Novo debridamento de acordo com a evolu ção (melhora clínica)
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UTI ped D4/7
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UTI ped D4/7• Fasciíte necrosante MIE• Choque Séptico
• SF 40 ml/h • Fentanil/Midazolan• Ventilação pulmonar mecânica(Respiratório estável)• Oxacilina/Ceftriaxona/Metronidazol• Omeprazol
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UTI ped D4/7• Fasciíte necrosante MIE• Choque Séptico
• Estável hemodinamicamente• Epinefrina 0,2 mcg/Kg/min• Hidrocortisona 30 mg 6/6h (3,5 mg/Kg/d)• FEBRE• T 37,3 C PVC +15
• FC 87 Sat 97%• PAni 100/50 Gluco 125
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UTI ped D4/7
Coagulo normalPCR 192
AST/ALT normais
Pl 154000
Glicemia 80Mn 6%
Lf 4%
Ur 62/ Cr 0,6S 74%
B 16%
A/G 0,85M/Mt 0/0
Glob 2,1N 90%
Alb 1,8L 30400
Prot T 3,9Hb 9,4/ Ht 30
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UTI ped D4/7• Culturas
• HMC negativa
• Secreção/material perna• Escherichia Coli• Enterobacter sp• Ceftriaxona S
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UTI ped D4/7• Estável hemodinamicamente• Epinefrina 0,2 a 0,15 mcg/Kg/min
• PAni 100/50 a 130/80• FC 100 (82 a 126)• PVC +15 a + 18• SatVC 78,4% a 84,5%
• FEBRE
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UTI ped D4/7
Sat = 78,4%
Bic = 18,3
BE = -8,1
PO2 = 49
PH = 7,29
Gaso VC 12h
Hb 11,5/HT 34,5
Sat = 80,6%
Bic = 22,1
BE = -2,7
PO2 = 45,1
PH = 7,4
Gaso VC 17h
Sat = 84,5%
Bic = 23,4
BE = -1,3
PO2 = 49,2
PH = 7,4
Gaso VC 23h
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UTI ped D4/7• Edema importante• “Pouca diurese”• S Fisiológico 0,9% 500 ml• Furosemida 1mg/Kg = diurese de 1800 ml
• Albumina 1,8 g/dl• Albumina 1 g/kg
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UTI ped D4/7
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UTI ped 4/7• Conduta cir úrgica
• Troca de curativos
• Novo debridamento de acordo com a evolu ção (melhora clínica)
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UTI ped D5/8
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UTI ped D5/8• Fasciíte necrosante MIE• Choque Séptico
• SGF/K 70 ml/h • Fentanil/Midazolan• Ventilação pulmonar mecânica(Respiratório estável)• Oxacilina/Ceftriaxona/Metronidazol• Omeprazol• Albumina
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UTI ped D5/8• Fasciíte necrosante MIE• Choque Séptico
• Estável hemodinamicamente• Epinefrina 0,15 mcg/Kg/min• Hidrocortisona 30 mg 6/6h (3,5 mg/Kg/d)• FEBRE• T 37,4 C PVC
• FC 106 Sat 97%• PAni 110/60 Gluco 115
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UTI ped D5/8• Infec ção
• Falha terapêutica
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UTI ped D5/8• Conduta cir úrgica pediátrica
• Debridamento extenso de todo MIE com retirada de grande quantidade de material necró tico, grande quantidade de secre ção purulenta, grande perda de tecido
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UTI ped D5/8• Conduta cir úrgica pediátrica
• Debridamento extenso de todo MIE com retirada de grande quantidade de material necró tico, grande quantidade de secre ção purulenta, grande perda de tecido
• AMPUTAÇÃO ?
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UTI ped D5/8
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UTI ped D5/8
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UTI ped D5/8• Antibioticoterapia
• Suspenso Oxacilina/Ceftriaxona/Metronidazol
• Piperacilina-tazobactam + Amicacina
• Vancomicina
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UTI ped D5/8
• Importante melhora clínica ao longo do dia
• Mantendo febre
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UTI ped D5/8
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UTI ped D6/9• Fasciíte necrosante MIE
• SGF/K 40 ml/h + Nutrição parenteral• Fentanil/Midazolan• Ventilação pulmonar mecânica(Respiratório estável)• Piperacilina-tazobactam/Vancomicina• Omeprazol• Albumina
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UTI ped D6/9• Fasciíte necrosante MIE
• Estável hemodinamicamente• Suspenso Epinefrina• Suspenso Hidrocortisona
• FEBRE
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UTI ped D6/9
Hb/Ht
Sat = 77,8%
CO2T = 25,5
Bic = 29,2
BE = 4,9
PO2 = 40,3
PCO2 = 45,1
PH = 7,43
Gaso VC 12h
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UTI ped resumo• Fasciíte necrosante MIE
• Complica ções• Lesão aguda pulmonar• Aumento do suporte ventilatório
– PEEP 12/15
• VPM por 6 dias após estabilidade hemodinâmica, totalizando 11 dias
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UTI ped resumo• Fasciíte necrosante MIE
• 23 dias de internação• 5 dias c/ drogas cardiovasculares• 11 dias em VPM/sedação• 2 esquemas antibióticos• Jejum por 7 dias- NP/NE
• Alta da UTI neuro normal, RE em ar ambiente, suplementação c/ dieta enteral, antibióticos por 6 semanas (osteomielite), cirurgia pediátrica
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UTI ped resumo• Conduta cirurgica pediátrica
• Curativos diários• Novos Debridamentos• Sutura elástica• Enxerto
• Alta hospitalar no 39 º dia de interna ção
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UTI ped resumo
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UTI ped• Questionamentos restrospectivos
– Abordagem inicial na cidade de origem– Indicação da internação– Diagnóstico de choque/encaminhamento para UTI– Terapêutica hemodinâmica (volume/drogas)– Profilaxia de TVP– Esquema antibiótico inicial– Uso de corticosteróide no choque– Uso de bicarbonato de sódio– Transfusão de hemoderivados– Monitorização hemodinâmica (PAinvasiva)– Abordagem cirúrgica/debridamento/amputação
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PEDIATRICS Vol. 112 No. 4 October 2003, pp. 793-799
Early Reversal of Pediatric-Neonatal Septic Shock b y Community Physicians Is Associated With Improved Outcome
Early resuscitation with fluid and inotropic therapies improves survival in a time-dependent manner (American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) Guidelines )
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Early reversal of hemodynamic abnormalities reduced mortality (OR 0.44 95% CI [0.29-0.68])
0,00%
5,00%
10,00%
15,00%
20,00%
25,00%
30,00%
35,00%
HR BP CR>2 BP/CR>2
PersistentResolved
2.7%4.5%
7.7%
2.9%
7.6%
12.4%
33.6%
15.8%
(6/298)
(40/890)
(16/206)(4/139)
(5/66)
(36/290)
(80/238)
(3/19)
* *
*
*
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Fluid challenge revisitedJean-Louis Vincent, MD, PhD, FCCM; Max Harry Weil, MD, PhD, ScD (Hon), FCCM
Crit Care Med 2006; 34:1333–1337
The fluid challenge is reserved for hemodynamically unstablepatients and offers three major advantages:
1.Quantitation of the cardiovascular responseduring volume infusion.
2. Prompt correction of fluid deficits.
3. Minimizing the risk of fluid overload and its potentially adverse effects, especially on thelungs.
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What’s going on inside your body?
• Vasoconstriction and thrombosis ����
• edema � hypoxia � necrosis of the fascia, skin, soft tissue, and muscles.
• Additional necrosis involving the subcutaneous nerves.
Justina Du, Thao Nguyen, Camille Thorsen
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Description of NF• Clinical features
– Fulminant destruction of tissue– Systemic signs of toxicity– High rate of mortality
• Pathological features– Extensive tissue destruction
– Thrombosis of blood vessels
– Abundant bacteria spreading along fascial planes– Unimpressive infiltration of acute inflammatory cells
David Hough MSIII Penn State College of Medicine
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Biology and Pathogenesis of Thrombosis andProcoagulant Activity in Invasive Infections Caused byGroup A Streptococci and Clostridium perfringensAmy E. Bryant*
CLINICAL MICROBIOLOGY REVIEWS, July 2003, p. 451–462
Occlusive microvascular thrombosis participatesin the rapid destruction of viable tissue in gram -positive necrotizing infections
CONCLUSIONS
The severe pain and rapid tissue destruction probably result fromhypercoagulation and vascular occlusion mediated byunique interactions of the organisms and their toxins with the humancoagulation system
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Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysisDjillali Annane, Eric Bellissant, Pierre Edouard Bollaert, Josef Briegel, Didier Keh, Yizhak Kupfer
BMJ, doi:10.1136/bmj.38181.482222.55 (published 2 August 2004)
ConclusionsFor all trials, regardless of duration of treatment and dose, use ofcorticosteroids did not significantly affect mortality.
With long courses of low doses of corticosteroids, however, mortality at 28 days and hospital morality was reduced.
CORTICÓIDE PARA TODOS NA SEPSE?Suzana M. A. Lobo
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Is there a role for sodium bicarbonate in treating lacticacidosis from shock?John H. Boyd and Keith R. WalleyCurrent Opinion in Critical Care 2008, 14:379–383
Recent findings
The most recent 2008 Surviving Sepsis guidelines strongly recommend
against the use of bicarbonate in patients with pH at least 7.15 , while deferring judgment in more severe acidemia.
There is little rationale or evidence for the use of bicarbonate therapy for lactic acidosis due to shock.
Effective therapy of lactic acidosis due to shock is to reverse the cause.
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Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis Garnacho-Montero, Jose MD, PhD; Garcia-Garmendia, Jose Luis MD, PhD; Barrero-Almodovar, Ana MD; Jimenez-Jimenez, Francisco J. MD, PhD; Perez-Paredes, Carmen MD; Ortiz-Leyba, Carlos MD, PhD
Volume 31(12), December 2003, pp 2742-2751
In patients admitted to the ICU for sepsis, the ade quacy of initial empirical antimicrobial treatment is crucia l in terms of outcome
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Volume 32(11) Supplement November 2004 pp S513-S526
Source control in the management of severe sepsis and septic shock: An evidence-based review[Scientific Reviews]Marshall, John C. MD; Maier, Ronald V. MD, FACS; Jimenez, Maria MD; Dellinger, E Patchen MD
Conclusion:Source control represents a key component of succes s in therapy of sepsis.
It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function.
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Necrotizing Fasciitis Report of 39 Pediatric Cases
Antonio Fustes-Morales, MD; Pedro Gutierrez-Castrellon, MD; Carola Duran-Mckinster, MD; Luz Orozco-Covarrubias, MD; Lourdes Tamayo-Sanchez, MD; Ramon Ruiz-Maldonado, MD
Arch Dermatol. 2002;138:893-899
Conclusions: Necrotizing fasciitis in children is frequently misdiagnosed, and severalfeatures differ from those of NF in adults..
Early surgical debridement andantibiotics were the most importanttherapeutic measures .
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Biology and Pathogenesis of Thrombosis andProcoagulant Activity in Invasive Infections Caused byGroup A Streptococci and Clostridium perfringensAmy E. Bryant*CLINICAL MICROBIOLOGY REVIEWS, July 2003, p. 451–462
Tissue destruction progresses rapidly to involve an entire extremity andsuch patients require emergent amputation or extensivesurgical debridement and prolonged hospitalization .
In fact, a recent article in the American Journal of Surgeryrecommended radical debridement to maximize limb salvageand survival in cases of severe soft tissue infection
radical amputation remains the single bestlife -saving treatment .
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Treatment of NF- Surgery
• Surgery
– Early and aggressive surgical exploration and debridement
– This should be done in the first 24 hours of sympto ms
– Repeat debridement should be repeated daily until a ll necrotic tissue has been removed (typically 2-4 tim es)
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Necrotizing Soft Tissue Infections
• Extensive tissue destruction• High mortality rate• Mixed aerobic and anaerobic– gram -negative and gram -positive bacteria
• Recognize early and treat promptly– Surgical Rx: debride all necrotic tissue– May require amputationReturn to OR daily until wound is under control
– Worry about reconstruction later• Hyperbaric O2 controversial
Michael A. West, MD, PhDDepartment of Surgery
University California San FranciscoSan Francisco, CA, USA
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COMMON ANTIBIOTIC CHOICES FOR NECROTIZING SOFT TISSUE INFECTION
There are several alternativesReview antibiotics after 48 hours
Mixed infection (80%)Carbapenem or Piperacillin/tazobactam + Aminoglycoside
Monomicrobial (20%)High dose clindamycin or High-dose penicillin
Michael A. West, MD, PhDDepartment of Surgery
University California San FranciscoSan Francisco, CA, USA
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Hospital Padre Albino
Hospital Emílio carlos
Escola de medicina
Antonio [email protected] de Medicina Intensiva PediátricaFaculdades Integradas Padre AlbinoHospital Padre Albino – Catanduva / SP
Obrigado !