Novidades na Sépsis com Implicações na Prática Clínica
DOI:
https://doi.org/10.24950/rspmi.786Palavras-chave:
Sépsis, Síndrome de Resposta Inflamatória Sistémica, Unidades de Cuidados IntensivosResumo
A sépsis é a resposta do organismo à infeção. Na sépsis grave há três
intervenções que comprovadamente salvam vidas: 1. Reconhecimento
precoce com estratificação de gravidade; 2. Prevenção e suporte de
órgãos em disfunção otimizando o fornecimento de O2 (DO2); 3.
Controlo do foco com antibioterapia adequada e cirurgia / drenagem
(quando indicado). Depois da publicação das recomendações SSC
2012 surgiram na literatura novidades que impõem atualização da prática
clínica. As manifestações inicias dependem do estado imunológico
e da presença de comorbilidades. O número de manifestações de
SIRS correlaciona-se com o prognóstico e exigem a pesquisa de critérios
de gravidade que quando presentes impõem intervenção urgente.
As manifestações de disóxia (hiperlactacidemia) de hipotensão que
não responde ao preenchimento adequado e/ou se associa a disfunção
de órgãos de novo, são as mais graves. Na prescrição de fluidos
na sépsis proscreveram-se amidos e gelatinas, reconheceu-se que
a albumina não tem efeitos nefastos nem lugar na reposição volémica,
que os cristaloides equilibrados são preferíveis e que a perfusão
excessiva de NaCl 0,9% implica risco de acidemia hiperclorémica A
ecografia, ao lado do doente, tem papel relevante no diagnóstico
diferencial e estratificação de gravidade, na avaliação da resposta ao
tratamento e na identificação da causa da sépsis. A estratificação de
gravidade e a monitorização do tratamento devem seguir a estratégia
“2O+2C”, resumida em 4 perguntas: Como está a oxigenação?
Como está a circulação? Como estão os órgãos nobres? Como está a
célula? A sépsis grave é uma urgência que exige tratamento imediato.
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Referências
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013; 39: 165-228.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. International Sepsis Definitions C. 2001 SCCM/ESICM/ACCP/ATS/
SIS International Sepsis Definitions Conference. Intensive Care Med. 2003; 29: 530-38.
Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA. 1995; 273: 117-23.
Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015; 372: 1629-38.
Ait-Oufella H, Lemoinne S, Boelle PY, Galbois A, Baudel JL, Lemant J, et al. Mottling score predicts survival in septic shock. Intensive Care Med. 2011; 37: 801-7.
Coudroy R, Jamet A, Frat J-P, Veinstein A, Chatellier D, Goudet V, Cabasson S, Thille AW, Robert R. Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients. Intensive Care Med.2015; 41:452–59.
Ait-Oufella H, Bige N, Boelle PY, Pichereau C, Alves M, Bertinchamp R, et al. Capillary refill time exploration during septic shock. Intensive Care Med. 2014; 40: 958-64.
Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/
Society of Critical Care Medicine. Chest. 1992; 101: 1644-55.
Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al. Consensus on circulatory shock and hemodynamic monitoring.
Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014; 40: 1795-15.
Puskarich MA, Trzeciak S, Shapiro NI, Heffner AC, Kline JA, Jones AE, et al. Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. Resuscitation. 2011; 82: 1289-93.
Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Machado FR, Noritomi DT, et al. Reclassifying the spectrum of septic patients using lactate: severe sepsis, cryptic shock, vasoplegic shock and dysoxic shock. Rev Bras Terap Intensiva. 2013; 25: 270-8.
Dellinger RP. The Surviving Sepsis Campaign: Where have we been and where are we going? Cleve Clin J Med. 2015; 82: 237-44.
Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med. 2010; 36: 222-31.
Vincent JL, Weil MH. Fluid challenge revisited. Crit Care Med. 2006;34:1333-7.
Hoste EA, Maitland K, Brudney CS, Mehta R, Vincent JL, Yates D, et al. Four phases of intravenous fluid therapy: a conceptual model. Br J Anaesth. 2014; 113: 740-47.
Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011; 39: 259-65.
Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013; 369: 1243-51.
Woodcock TE, Woodcock TM. Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Br J Anaesth. 2012; 108: 384-94.
Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R, Investigators SS. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004; 350: 2247-56.
SAFE Study Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group; Australian Red Cross Blood Service; George Institute for International Health, Myburgh J, et al.. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007; 357: 874-84.
Investigators SS, Finfer S, McEvoy S, Bellomo R, McArthur C, Myburgh J, et al. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med. 2011; 37: 86-96.
Das UN. Albumin infusion for the critically ill--is it beneficial and, if so, why and how? Crit Care. 2015; 19: 156.
Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014; 370: 1412-21.
Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008; 358: 125-39.
Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Aneman A, Madsen KR, et al. Hydroxyethyl starch 130/0.42 versus Ringer´s acetate in severe sepsis. N Engl J Med. 2012; 367: 124-34.
Reinhart K, Perner A, Sprung CL, Jaeschke R, Schortgen F, Johan Groeneveld AB, et al. European Society of Intensive Care M.
Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients. Intensive Care Med. 2012; 38: 368-83.
Raghunathan K, Murray PT, Beattie WS, Lobo DN, Myburgh J, Sladen R, et al. Choice of fluid in acute illness: what should be given? An international consensus. Br J Anaesth. 2014; 113: 772-83.
Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012; 308: 1566-72.
Shaw AD, Raghunathan K, Peyerl FW, Munson SH, Paluszkiewicz SM, Schermer CR. Association between intravenous chloride load
during resuscitation and in-hospital mortality among patients with SIRS. Intensive Care Med. 2014; 40: 1897-905.
Raghunathan K, Shaw A, Nathanson B, Sturmer T, Brookhart A, Stefan MS, et al. Association between the choice of IV crystalloid and
in-hospital mortality among critically ill adults with sepsis.Crit Care Med. 2014; 42: 1585-91.
Shaw AD, Schermer CR, Lobo DN, Munson SH, Khangulov V, Hayashida DK, et al. Kellum Impact of intravenous fluid composition
on outcomes in patients with systemic inflammatory response syndrome. Crit Care.2015; 19:334
Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999; 340: 409-17.
Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014; 371: 1381-91.
Pinsky MR. Understanding preload reserve using functional hemodynamic monitoring. Intensive Care Med 2015; 41: 1480-2.
Vieillard-Baron A. Septic cardiomyopathy. Ann Intensive Care. 2011; 1: 6.
Boulain T, Garot D, Vignon P, Lascarrou JB, Desachy A, Botoc V, et al. Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients: a prospective multicentre study. Crit Care. 2014; 18: 609.
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA, Emergency Medicine Shock Research Network I. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010; 303: 739-46.
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008; 134: 172-78.
Investigators A, Group ACT, Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014; 371: 1496-506.
Pro CI, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014; 370: 1683-93.
Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of early, goal-directed resuscitation for septic
shock. N Engl J Med. 2015; 372: 1301-11.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and
septic shock. N Engl J Med. 2001; 345: 1368-77.
Asfar P, Meziani F, Hamel JF, Grelon F, Megarbane B, Anguel N, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014; 370: 1583-93.
Beck V, Chateau D, Bryson GL, Pisipati A, Zanotti S, Parrillo JE, et al. Timing of vasopressor initiation and mortality in septic shock: a cohort study. Crit Care. 2014; 18: R97.
Funk D, Doucette S, Pisipati A, Dodek P, Marshall JC, Kumar A. Cooperative Antimicrobial Therapy of Septic Shock Database
Research G. Low-dose corticosteroid treatment in septic shock: a propensity-matching study. Crit Care Med. 2014; 42: 2333-41.
Povoa P, Salluh JI, Martinez ML, Guillamat-Prats R, Gallup D, Al-Khalidi HR, et al. Clinical impact of stress dose steroids in patients with septic shock: insights from the PROWESS-Shock trial. Crit Care. 2015; 19: 193.
Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006; 34: 1589-96.
Ferrer R, Martin-Loeches I, Phillips G, Osborn TM, Townsend S, Dellinger RP. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014;
: 1749-55.
Kumar A. An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy. Virulence. 2014; 5: 80-97.
Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med. 2015; 43: 3-12.
Marik P. “Less Is More”: The New Paradigm in Critical Care. In: Marik P, editor. Evidence-Based Critical Care. 3rd ed. Berlin: Springer; 2015. p. 7-12.
Carneiro AH, Neutel E. Manual do Curso de Evidência na Emergência - MCEE 2011. Porto; MCEE; 2011.
Shankar-Hari M, Deutschman CS, Singer M. Do we need a new definition of sepsis? Intensive Care Med. 2015; 41: 909-11.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International ConsensusDefinitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315801-10.
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Direitos de Autor (c) 2023 Medicina Interna
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