Sepsis y Falla Organica Multipletratamiento no antibiotico Jairo Alarcón, Pediatra Intensivista Jefe Urgencias y Emergencias Pediatricas Universidad del Valle Hospital Universitario del Valle Cali, Colombia

Sepsis y Falla Organica Multiple Objetivos de la charla: Conocer Conceptos tradicionales Consideraciones fisiopatologícas Aspecto terapéuticos básicos

Sepsis y Falla Organica Multiple Una historia de descubrimientos y Logros

Sepsis atraves del tiempo: Historia de Descubrimientos c. 100 BC “small creatures invisible to the eye, fill the atmosphere, and breathed through the nose cause dangerous diseases.” Marcus Terentius Varro, De re rustica libri III Marcus Terentius Varro, in De re rustica libri III (three books on agriculture), was the first to articulate the notion of contagion. References Lagassé P, ed. The Columbia Encyclopedia. 6th ed. New York, NY: Columbia University Press; 2000. Wilson RF. A brief introduction to sepsis: its importance and some historical notes. Heart Lung. 1976;5:393–396.

Sepsis y Falla Organica Multiple 1864 - 1879 French chemist Louis Pasteur put forth the “germ theory” of disease in a lecture before the French Academy. Louis Pasteur announced to the French Academy that Streptococcus causes puerperal sepsis. References Broad W, Wade N. Betrayers of the Truth: Fraud and Deceit in the Halls of Science. New York, NY: Simon & Schuster Inc; 1982. Classic pages in obstetrics and gynecology: Louis Pasteur. Septicémie puerpérale. Am J Obstet Gynecol. 1974;118:282.

Definiciones-Consenso ACCP/SCCM Sepsis Severa Sepsis Disfuncion de organos Shock Septico Hipotension a pesar de resuscitacion con liquidos Sindrome de Disfuncion Multiple de Organos(FDOM) Funcion alterada de organos en un paciente agudamente enfermo Homeostasis no se puede mantener sin soporte. Infeccion Respta inflamatoria a microorganismos,o Invasion de tejidos normalmente esteriles Sindrome de Respuesta inflamatoria sistemica(SIRS) Respuesta sistemica auna amplia variedad de procesos. Sepsis Infeccion mas 2 criterios de SIRS criteria The American College of Chest Physicians (ACCP) and Society of Critical Care Medicine (SCCM) held a consensus conference in August 1991 to agree on a set of definitions that could be applied to patients with sepsis and organ dysfunction. The consensus panel also recommended the use of severity scoring methods to characterize the disease and develop a comprehensive model for the syndrome. This slide provides a brief definition of the various components of the sepsis syndrome. Notably, this is a non-linear process rather than a continuum and the presence of organ dysfunction identifies a population with a significant risk of mortality. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101:1644-55. Bone RC et al. Chest. 1992;101:1644-55.

Sepsis y Falla Organica Multiple

Terapia en Sepsis Severa Sepsis Sedacion -Analgesia Adecuada Nutricion Soporte Hematologico Otras medidas de soporte Avances. Soporte Hemodinamico Control del Foco Antibioticos Ventilacion Mecanica Terapia de Reemplazo Standard care of the patient with severe sepsis consists of a number of medical (and sometimes surgical) interventions intended to normalize physiology and eliminate infection. These are divided into: Source control: This term refers to management of the source of the infection. It can consist of surgery to drain an abscess or removal of an infected catheter. Antibiotics: While the initial therapy may be broad-based and empiric, identification of the specific pathogen by microbiologic studies may result in a switch of the antibiotic to those that are the most specific and bacteriocidal. Hemodynamic support: This term refers to volume replenishment therapy followed, when necessary, by appropriate use of drugs such as norepinephrine to maintain blood pressure and organ perfusion. Mechanical ventilation: Respiratory failure is a common manifestation of pulmonary organ dysfunction in patients with severe sepsis. Mechanical ventilation is instituted to increase oxygenation and improve gas exchange. Renal replacement therapy: Impaired renal function is a sign of organ dysfunction in patients with severe sepsis. Renal replacement therapy consists of temporary hemodialysis or ultrafiltration. Sedation and analgesia: Sedation is often required to treat anxiety and agitation in patients with severe sepsis. Because these patients are at risk for pain and physical discomfort, analgesics also are commonly employed. Ensure adequate nutrition: Sepsis is a hypercatabolic state. Therefore, caloric and nitrogen requirements should be met and enteral nutrition provided in a timely fashion. Provide hematological support: Critically ill patients may require packed red blood cells, platelets, and coagulation factors. Other supportive measures: These include measures to prevent deep venous thrombosis, stress ulcer prophylaxis, etc. Wheeler AP, Bernard GR. Treating patients with severe sepsis. N Engl J Med. 1999;340:207-14. Wheeler AP, Bernard GR. N Engl J Med. 1999;340:207-14.

SEPSIS SEVERA Resucitación : Vía aérea-Ventilación-Circulación: Optimice la oxigenación. Monitorice la perfusión tisular. Frialdad distal sensorio comprometido Oliguria . Llenado capilar alterado. Hipotension. Acidosis Metabolica.

SEPSIS Restauración de la Perfusión Tisular Hipotensión : Perdida Volumen Plasmático Escape tisular. Reducción tono vascular. Depresión del miocardio. Alteración de los mecanismos compensadores.

SEPSIS SEVERA Restauración de la perfusión tisular Líquidos intravenosos Volumen entre 20-60 cc/kg/hr La necesaria para recuperar TAM Cristaloides-coloide-elementos sanguíneos Definir las necesidades-status volumen Reevalué las necesidades.

SEPSIS SEVERA Restauración de la perfusión tisular DO2 = CO x CaO2 CaO2= (Hb x 1,34 xSatO2) + (0.0033xPao2) Hb ideal… SatO2 : FiO2 necesario

SEPSIS SEVERA Restauración de la perfusión tisular DO2 = CO x CaO2 CO : FC x VL Frecuencia cardiaca: ideal…actual! VL: Precarga Postcarga Contractilidad Metabólico

SEPSIS SEVERA Restauración de la perfusión tisular DO2 = CO x CaO2 CO : FC x VL VL: Precarga : cristaloides-coloides Postcarga: Contractilidad miocardica Metabólico:

SEPSIS SEVERA Restauración de la perfusión tisular DO2 = CO x CaO2 CO : FC x VL VL: Precarga : Postcarga: vasopresores-inodilatadores Contractilidad miocardica Metabólico

SEPSIS SEVERA Restauración de la perfusión tisular DO2 = CO x CaO2 CO : FC x VL VL: Precarga : Postcarga: vasopresores-inodilatadores Contractilidad miocardica Metabólico

SEPSIS SEVERA Terapia Cardiovascular. Disfuncion Cardiovascular: a pesar de un agresivo volumen de resucitación,en la mayoría de niños con shock séptico severo esta comprometida. Soporte temprano y oportuno vaso activos Niños tienen predominantemente falla cardiaca, o falla vascular o una combinación.

SEPSIS SEVERA Contractilidad Optimización Gasto Cardiaco Postcarga: La presencia e integralidad de receptores adrenergicos. Sensibilidad vascular disminuida a diferentes catecolaminas. Contractilidad Capacidad intrínseca del corazón para ejercer sus funciones de bomba adecuadamente. Depende de : precarga postcarga. Factores: Ph, Glicemia, Ca, T,

SEPSIS SEVERA Restauración de la perfusión tisular DO2 = CO x CaO2 CO : FC x VL VL: Precarga : Postcarga: vasopresores-inodilatadores Contractilidad miocárdica Metabólico: Calcio-Glucosa-P-K

SOPORTE HEMODINAMICO EN SHCK SEPTICO EN NIñOS Y Lactantes. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock* Joseph A. Carcillo, MD; Alan I. Fields, MD Critica Care Medicine , Volume 30 • Number 6 • June 2002

SOPORTE HEMODINAMICO EN SHOCK SEPTICO EN Neonatos. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock* Joseph A. Carcillo, MD; Alan I. Fields, MD Critica Care Medicine , Volume 30 • Number 6 • June 2002

SEPSIS SEVERA Terapia Antibiotica.  Antibióticos deben ser administrados acorde a la edad y al foco de sospecha etiológica. La aparición de gérmenes resistentes obligan a adaptar los esquemas a la institución tratante. Siempre la erradicación del foco ocupa un rol fundamental sin ser desplazados por la terapia de resucitación de volumen y cardiovascular en el niño con shock séptico.

Terapia en Sepsis Severa Sepsis Soporte Hemodinamico Control del Foco Antibioticos Ventilacion Mecanica Terapia de Reemplazo Sedacion -Analgesia Adecuada Nutricion Soporte Hematologico Otras medidas de soporte Avances. Standard care of the patient with severe sepsis consists of a number of medical (and sometimes surgical) interventions intended to normalize physiology and eliminate infection. These are divided into: Source control: This term refers to management of the source of the infection. It can consist of surgery to drain an abscess or removal of an infected catheter. Antibiotics: While the initial therapy may be broad-based and empiric, identification of the specific pathogen by microbiologic studies may result in a switch of the antibiotic to those that are the most specific and bacteriocidal. Hemodynamic support: This term refers to volume replenishment therapy followed, when necessary, by appropriate use of drugs such as norepinephrine to maintain blood pressure and organ perfusion. Mechanical ventilation: Respiratory failure is a common manifestation of pulmonary organ dysfunction in patients with severe sepsis. Mechanical ventilation is instituted to increase oxygenation and improve gas exchange. Renal replacement therapy: Impaired renal function is a sign of organ dysfunction in patients with severe sepsis. Renal replacement therapy consists of temporary hemodialysis or ultrafiltration. Sedation and analgesia: Sedation is often required to treat anxiety and agitation in patients with severe sepsis. Because these patients are at risk for pain and physical discomfort, analgesics also are commonly employed. Ensure adequate nutrition: Sepsis is a hypercatabolic state. Therefore, caloric and nitrogen requirements should be met and enteral nutrition provided in a timely fashion. Provide hematological support: Critically ill patients may require packed red blood cells, platelets, and coagulation factors. Other supportive measures: These include measures to prevent deep venous thrombosis, stress ulcer prophylaxis, etc. Wheeler AP, Bernard GR. Treating patients with severe sepsis. N Engl J Med. 1999;340:207-14. Wheeler AP, Bernard GR. N Engl J Med. 1999;340:207-14.

Bacteremic sepsis in intensive care: Temporal trends in incidence, organ dysfunction, and prognosis Conclusion: The fatality rate of bacteremic sepsis remained constant over the study period, despite an increased incidence of bacteremia and associated organ dysfunction. Continued efforts need to be directed toward the prevention of bacteremic sepsis, given the magnitude and poor prognosis of this syndrome. Hugonnet: Crit Care Med, Volume 31(2).February 2003.390-394