sepsis

Terapia sepsisului sever i a ocului septicDr. Tulcan Sebastian

http://www.greycoatpublishing.co.uk/international-journal-of-intensive-care/index.htmlhttp://www.survivingsepsis.org

Cteva definiii (1)SIRS (Systemic Inflammatory Response Syndrome) = un rspuns inflamator sistemic la o injurie (infecioas sau non infecioas).SEPSIS = SIRS de origine infecioas sau presupus infecioas, cu minim dou criterii de SIRSSEPSIS SEVER = SEPSIS disfuncie de organHipoperfuzie sau anomalii de perfuzie (lactat 4mmol/L, oligurie, alterarea strii de contien) hipotensiune: TAS < 90 mmHg sau TA Medie < 70 mmHgOC SEPTIC = form de sepsis sever cu hipotensiune sau anomalii de perfuzie (lactat 4mmol/L) refractar la resuscitare cu fluide.

Managementul pacientului septic

Cteva definiii (2)


(Re)Definind SIRS 1/3 PARAMETRI GENERALITC < 36C sau > 38.3CFC > 90/minFR > 20/min sau PaCO2 < 4.3 kPa (32.2 mmHg)Status mental alteratBalan fluidic +Hiperglicemie (> 140 mg/dL) n absena diabetului


(Re)Definind SIRS 2/3 MARKERI INFLAMAORILeucocitoz >12.000/uL sau Leucopenie 2 SD PCT >2 SDHTA: TAS

(Re)Definind SIRS 3/3 DISF. DE ORGAN/ HIPOPERFUZIE TISULARPaO2/FiO2 < 300Oligurie acut (1.5 sau aPTT >60 s Trombocitopenie 4 mg/L (70umol/L)Lactat >1 mmol/Lt reumplerii capilare sau marmorare


Standard terapeuticmnunchiuri (bundles) la 3 si 6h

Ghideaz intervenia terapeutic precoce spre: controlul infeciei (3h) ameliorarea hipoperfuziei tisulare (3h) utilizarea terapiei vasopresoare (6h)


Tratamentul Antimicrobian Cu fiecare or fr tratament antibiotic empiric mortalitatea1,2Majoritatea ocurilor septice au ca origine anatomic:PlmniiAbdomenulTractul urinar

1) Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiationof effective antimicrobial therapy is the critical determinant of survival in humanseptic shock. Crit Care Med 2006; 34: 15891596.2) Barie PS, Hydo LJ, Shou J, Larone DH, Eachempati SR. Influence of antibiotictherapy on mortality of critical surgical illness caused or complicated by infection.Surg Infect (Larchmt) 2005; 6: 4154.


Spectrul Microbian! 1/3 din pac cu sepsis sever au culturi (+)3,4,5

Staphylococcus aureus (20.5%)Pseudomonas (19.9%)Enterobacterii E. Coli (16%)Fungi (19%)3) Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence 2013;5: 411.4) Rangel-Frausto MS. The epidemiology of bacterial sepsis. Infect Dis Clin NorthAm 1999; 13: 299312, vii.5) Esper AM, Moss M, Lewis CA, et al. The role of infection and comorbidity:Factors that influence disparities in sepsis. Crit Care Med 2006; 34:25762582.


Fungi? DA, dac..Colonizare cu Candida n ant. din cel putin 2 locuri>14 Z ATBPac. imunocompromii (trat. cu steroizi sau imunosupresoare, neutropenici)Pac. Hemodializai


FUNGI Tratament empiric


ATB Istoricul pacientuluiIntolerane/AlergiiATB pe ultimele 3 luniBolile subiacenteClinicSusceptibilitatea localTrat. Empiric


Trat. Empiric 1/5PNEUMONIE COMUNITARPneumococcusLegionella pneumophilaHemophilus influenzaeEnterococi G-Staphylococcus AureusMycoplasma Pneumoniae-Lactam + Macrolid / FQN


Trat. Empiric 2/5Pneumonie nosocomial precoce (

Trat. Empiric 3/5PNEUMONIE NOSOCOMIAL TARDIVPseudomonas aeruginosaKlebsiella spp.Acinetobacter spp.MRSAC antipseudomonas* sauCarbapeneme

Piperacilin/Tazobactam

Linezolid/Vancomicin (MRSA)*CEFOPERAZONA, CEFTAZIDIMA


Cefalosporinele sunt LAMEListeriaAtipice (inclusiv Mycoplasma, Chlamydia)MRSAEnterococi

Fr activitate pe aceste bacterii.


*CEFTAROLINE FOSAMILPneumonia comunitar dobnditInfecii complicate cutanate i ale . moiActivitate pe MRSA

http://www.astrazeneca.com/Media/Press-releases/Article/28082012--european-commission-approves-zinforohttp://ec.europa.eu/health/documents/community-register/2012/20120823123835/anx_123835_ro.pdf


Trat. Empiric 4/5INFECII INTRA-ABDOMINALEG- entericiAnaerobiCG3 + Metronidazol

Piperacilin/Tazobactam

Carbapeneme


Trat. Empiric 5/5INFECII URINAREG- Enterococcus-Lactami cu spectru lrgitCarbapeneme+/- AminoglicozidVancomicin (Enterococcus)


Suportul HEMODINAMICCRISTALOIDE 30ml/kgHES cost , beneficiu 0ALBUMINA dac sunt necesare volume de cristaloideLACTAT marker pentru hipoperfuzie tisular (4 mmol/L)


Early-Goal-Directed-Therapy (EGDT)Rivers et al. - EGDT scade mortalitatea cu 15%.Sunt necesare noi studii care s confirme aceste date ScvO2 70%SvO2 65%PVC 8-12 mmHgMAP 65 mmHgDebit U 0.5 ml/kgc/h


ScvO2/SvO2


VO2 = 110-160 ml/min/m^2Deficitul de VO2 cumulat n timp = Datoria O2R pt. MSOF


PVCLimitri cunoscute i susinute de studiiALTERNATIVE Posibile: FLUID CHALLENGE FLUID RESPONSIVENESShttp://www.pulsion.com/international-english/critical-care/picco-technology/


Suportul VasopresorSEPSIS SEVER include insuficiena cardiac i depresia miocardicMAP 65 mmHgNA De prim intenieVasoconstrictor puternicDOBUTAMINAdisfuncie miocardic ADRENALINADac primele sunt insuficienteEfect (-) circulaia splanhnic VASOPRESINANiciun beneficiu comparativ cu NARecomandat n ocul septic refractar la NA si DOBUTA sau pentru sevrajul lor


Alte DroguriCORTICOSTEROIZIBeneficii disputateR hiperglicemie, infeciiPROTEINA C ACTIVATR sngerareAbsena beneficiilor


Tratamente adiionale 1/2Prevenia ARDS VT 2-6 ml/kgc PBW1Pplat 30 cmH2OPEEPdecubit ventral de 3x pe zi2! fluidesevraj precoce ventilaie mecanic i sedare


PBW (kg) = 50 + 0.91 (centimeters of height 152.4) PBW (kg) = 45.5 + 0.91 (centimeters of height 152.4)1. http://www.nejm.org/doi/pdf/10.1056/NEJM2000050434218012. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1214103http://www.ardsnet.org


Tratamente adiionale 2/2Glicemia 150-180 mg/dLProfilaxia trombozei venoaseProfilaxia ulcerelor de stresAlimentaie oral/enteralHb 7-9 g/dL (! CIC, asociere cu hemoragie activ, ScvO2 70%)


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