UNIVERSITATEA DE MEDICINA SI FARMACIE, Iasi Facultatea de Medicina Anestezie-Terapie Intensiva

MEDICINA An IV l. Romana Suport LP

OCUL
Generaliti

Definiii
Sindrom clinic!
Tulb hemodinamic
Determinat de diverse cauze Caracterizat prin: perfuzie tisular inadecvat MODS Aport inadecvat de O2 la celule

Tulb metabolic generalizat

Caracterizat de : Tulburarea generalizat a balanei ntre aportul i consumul de O2 al esuturilor

Apariia metabolismului anaerob i MODS

Definiii
n Multiple i variate cauze
Hemoragie masiv IMA Politraumatism Peritonit Reacie alergic Embolie pulmonar, etc

ACELAI TABLOU CLINIC

Fiziopatologia general a strilor de oc

SUPPLY < DEMAND

Aerobic Metabolism
6 CO2 6 O2

METABOLISM
GLUCOSE

6 H2O 36 ATP

HEAT (417 kcal)

Anaerobic Metabolism
2 LACTIC ACID

GLUCOSE

METABOLISM

2 ATP

HEAT (32 kcal)

Anaerobic? So What?
Inadequate Cellular Oxygenation

Inadequate Energy Production

Anaerobic Metabolism

Lactic Acid Production

Metabolic Failure

Cell Death!

Metabolic Acidosis

Presarcina (volemia)
DC = VB FC

Postsarcina (RVP)

Debit cardiac
Contractilitate e Frecvena cardiac

Mechanisms of blood pressure regulation

Mechanisms of blood pressure regulation: Blood pressure is proportionate to cardiac output and peripheral vascular resistance

Changes in Afterload and Preload

n Peripheral vasoconstriction peripheral vascular resistance

afterload
blood pressure.

Changes in Afterload and Preload

Peripheral vasodilation

peripheral vascular
resistance

afterload
blood pressure.

Changes in Afterload and Preload

fluid volume
preload

contractility (Starlings Law) blood pressure. cardiac output.

Changes in Afterload and Preload

fluid volume preload contractility
(Starlings Law)

blood pressure.

cardiac output.

Renin-Angiotensin-Aldosterone
Plasma volume
&/Or [Na+] Detected by Kidney (juxtaglomerular apparatus) Releases Renin Converts Angiotensin II Angiotensin I Angiotensinogen

Via ACE (Angiotensin Converting Enzyme)

Renin-Angiotensin-Aldosterone
vasoconstriction
Angiotensin II thirst

PVR

ADH (anti-diuretic hormone)

Fluid volume

BP!

Adrenal cortex

Releases Aldosterone

Na+ reabsorption

Cellular Response to Shock

O2 use Tissue perfusion Impaired cellular metabolism

Anaerobic metabolism

Stimulation of clotting cascade & inflammatory response

Impaired glucose usage

ATP synthesis Intracellular Na+ & water

Na+ Pump Function

Cellular edema Vascular volume

EVALUAREA HEMODINAMIC A PACIENTULUI CU STARE DE OC

TA Frecvena cardiac ECG Pulsoximetrie Presiunea venoas central Debitul cardiac i presiunea n capilarul pulmonar blocat Saturaia n oxigen a sngelui venos amestecat Ecocardiografia transesofagian i transtoracic

Hemodynamic Assessment of Shock

Basic Hemodynamic Monitoring

BHM 21

TA
Manual,palpator
Automat/neautomat Continuu/intermitent Invaziv/neinvaziv

PULSOXIMETRIA Permite determinarea saturaiei n oxigen a sngelui arterial periferic Principiul determinrii: absorbia luminii roii este diferit n funcie de gradul ncrcrii cu oxigen a hemoglobinei Dispozitiv cu surs de lumin roie i sensor Se plaseaz pe esuturi periferice subiri, ce permit transiluminare: Degetele de la mn, picior Lobulul urechii Aripa nasului

PRESIUNEA VENOAS CENTRAL

Cateter venos central (vrful cateterului n vena cav sup.) Cateter introdus prin vena jugular intern, extern, subclavicular, axilar, brahial Metode de msurare: Metoda coloanei de ap Metoda automat (cu transductor)

Cateterul n artera pulmonar

Cateter lung de aprox. 1m introdus prin abord venos central - vrful cateterului ntr-un ram al arterei pulmonare Cateter introdus prin vena jugular intern sau subclavicular parcurge vena cav superioar, atriul drept, ventriculul drept, art. pulm. comun, un ram principal al art. pulm., ramificaii ale art. pulm.

Cateterul n artera pulmonar

Permite msurarea i calcularea unor parametri hemodinamici diagnosticul ocului

Permite monitorizarea rspunsului la tratament

Cateterul n artera pulmonar

Indications for Pulmonary Artery Catheters (PACs)

Evaluarea starii de soc Evaluarea edemului pulmonar (cardiogen vs ARDS) Ghidarea tratamentului cand se combina oliguria sau hipotensiunea si edemul pulmonar Optimizarea indexului cardiac in socul cardiogen Evaluarea si titrarea terapiei in hipertensiunea pulmonara Diagnosticul si evaluarea suntului intracardiac stinga-dreapta

Relative Contraindications of PACs

Coagulopatie severa sau trombocitopenia (PLT < 50000) Proteze valve cardiace cord stng Pacemaker endocardial/ defibrilator Precauii la cei cu BRS (5% risc de bloc complet) Endocardita cord drept Aritmii atriale sau ventriculare necontrolate Tromb mural ventricular drept

Complications of PACs
Complicatii ale inseriei cateterului:
Pneumotorax Puncie arterial Embolus aerian

Aritmii atriale ori ventriculare Infarct pulmonar Ruptura de artera pulmonar (0.2% incidena, uitarea balonului umflat) Infecii de torent sanguin determinate de cateter Endocardita infecioas Tromb mural Rsucirea cateterului

Cateterul n artera pulmonar

Parametri msurai:
presiunea venoas central/ presiunea n atriul drept (presarcina ventriculului drept) presiunile n artera pulmonar (sistolica, diastolica i media) presiunea n capilarul pulmonar blocat (presarcina ventriculului stng) debitul cardiac (metoda termodiluiei) saturaia n oxigen a sngelui venos amestecat

Parametri calculai:
indexul cardiac, debitul-btaie rezistena n circulaia pulmonar (postsarcina ventriculului drept) rezistena n circulaia sistemic (postsarcina ventriculului stng), transportul de oxigen, consumul de oxigen, extracia oxigenului, .a.

Monitorizarea pacientului cu oc
Respiratorie clinic
- numrul de respiraii/min
- pulsoximetrie - gaze sanguine - Rx-T

Cardiovascular TA invaziv
- FC - ECG - Pulsoximetrie - PVC - Debit cardiac - Ecocardiografie - ScVO2

Monitorizarea pacientului cu oc
Neurologica starea de constienta
Diureza Temperatura centrala / periferica Alte PIC n - PIA

Monitorizarea pacientului cu oc
Paraclinic acido-bazic - electrolitic - coagulare - glicemie - functie renala , hepatica - hematologie Bacteriologic culturi din sange , secretii bronice , urin , secreii plag , lcr

Sond transesofagian

Mixed Venous Oxygen Saturation

SvO2 is the oxygen saturation returning to the right heart Determinants of SvO2 High values indicate (70%):
Oxygen delivery Oxygen extraction

Desired values in shock SvO2 70%

Adequate tissue perfusion Poor tissue extraction of oxygen

Tratamentul initial in soc:

n Eliberarea caii aeriene si ventilatia: - O2-terapie - IOT si VM coma , obnubilare - oboseala m. respiratori - hipoxemie severe/cianoza n Circulatia : -normalizarea TA -normalizarea perfuziei tisulare

Principii de tratament in soc:

n Obiective: -restabilirea perfuziei tisulare
- corectarea MODS

Optimizarea - presarcinii(volumului circulant)

- debitului cardiac(VB , FC ) - rezistentei vasculare periferice(vasoconstrictoare , dilatatoare) - capacitatii de transport a oxigenului (corectarea hipoxemiei si optimizarea Hb)

Oxygen Delivery
DO2=Cardiac Output x 1.34 (Hgb x SaO ) + Pa0
2 2

x 0.003

Oxygen Express

O2O2O2O2O2 O2

O2O2O2O2O2O2

Ca02

Arterial Oxygen Content

100 mm Hg

Hgb 15 gm/100 mL

SaO2 97% Oxygen Saturation

Hemoglobin

PaO2 100 mmHg

Partial Pressure

O2 bound to Hgb

+ O2 in plasma

Management of Shock States

43

OCUL HIPOVOLEMIC

n Scderea volumului sanguin circulant efectiv (presarcin sczut)

CLINIC
Semne comune strilor de oc
tahicardie, tahipnee, hTA,nelinite,agitaie, confuzie sau com, oligurie/anurie

Semne de DC sczut
extremiti reci,transpiraii profuze, pat venos periferic colabat,und de puls cu amplitudine sczut, timp umplere capilar prelungit

Semne i simptome clinice de hipovolemie

sete vie + anamnez pozitiv pt pierderi!

Hemorrhagic Shock
Parameter Blood loss (ml) Blood loss (%) I <750 <15% <100 Normal 1420 >30 Normal II 7501500 1530% >100 Decreased 2030 2030 Anxious III 15002000 3040% >120 Decreased 3040 515 Confused IV >2000 >40% >140 Decreased >35 Negligible Lethargic

Pulse rate (beats/min)

Blood pressure Respiratory rate (bpm)

Urine output (ml/hour)

CNS symptoms

Crit Care. 2004; 8(5): 373381.

Parametri hemodinamici caracteristici

FC ( 90/min) TA sistolic N/ cu pensarea diferenialei Index cardiac 2,2l/min.m PVC 8-12 mmHg PCPB 8-12mm Hg RVS ( 1500 dyne sec/cm5) DO2 ( 500 ml/minut/m) Vo2 ( 110 ml/minut/m) O2ER ( 0,3 ) ScVO2 60%

DIAGNOSTIC

Clinic al ocului hipovolemic Parametrii hemodinamici i dg formei de oc Dg etiologic sursa caracter

DIAGNOSTIC DIFERENIAL
FC TA DC PVC PCPB RVP Da-vO2 SvO2

ocul hipovolemic ocul cardiogen ocul septic

N N

PRINCIPII DE TRATAMENT
Tratament cauzal oprirea pierderilor
Repleia volemic:
ci adm, soluii de repleie, ritmul administrrii, end-points

Tratament de suport (ventilator, inotrop,

vasomotor,transport de oxigen la esuturi, funcie renal, coagulare, nutriional)

OC CARDIOGEN

Insuficiena primar a funciei de pomp a inimii

=TA

sistemic < 90mmHg sau TA medie < cu 30mmHg fa de valorile bazale

IC < 2,2l/min m2
PCPB > 15mmHg

ETIOLOGIE

Deficit de contractilitate
IMA,miocardite, cardiomiopatii,droguri cu efect inotrop negativ

Defecte mecanice cardiace

alterri flux sg n interiorul cordului, tulburri severe de ritm cardiac

Cardiogenic Shock
R.A.S. Activation
CO

Catecholamine Release

Volume/ Preload

Myocardial O2 demand

SVR
O2 supply Peripheral & pulmonary edema

Impaired myocardial function

Dyspnea

Hochman JS Circulation 2003, 107: 2998-3002

CLINIC
Hipotensiune arterial Semne de hipoperfuzie tisular Semne de congestie pulmonar

DIAGNOSTIC
Dg strii de oc Dg pozitiv de oc cardiogen parametri hemodinamici Dg etiologic

n n n n n n n n n n

Clinic: status mental, temperatura i culoarea tegumentelor SpO2 TA invaziv ECG PVC Parametri hemodinamici: presiuni n artera pulmonar, PCPB, RVS, RVP, DC, SvO2 Ecocardiografia Debitul urinar pH + statusul gazelor sanguine Funcia sistemelor i organelor: probe renale, hepatice, glicemie, teste de coagulare, ionogram, hemoleucogram

Vasopressors
Pure Alpha Beta=action Alpha Beta Pure Beta

High dose Dopamine Low dose

58

ocul septic

Definitions
The ACCP/SCCM consensus conference committee. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992.

n SIRS
Widespread inflammatory response Two or more of the following
Temp>38 C<36 C Heart Rate >90 bpm Tachypnea RR>20 or hyperventilation PaCO2 <32 mmHg WBC >12,000<4000 or presence of >10% immature neutrophils.

n Sepsis: SIRS + definitive source of infection n Severe Sepsis: Sepsis + organ dysfunction, hypoperfusion, or hypotension

Definitions
The ACCP/SCCM consensus conference committee. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992.

n Septic Shock:
Sepsis + hypotension despite fluids Perfusion abnormalities
Lactic acidosis Oliguria Acute AMS

n Multiple Organ System Failure: Abnormal function of two or more organs such that homeostasis cannot be achieved without intervention.

Management of Sepsis
n n n n n n n n Resuscitate: ABCs Restore tissue perfusion Identify and eradicate source of infection Assure adequate tissue oxygenation Activated Protein C Steroids Glucose Control Nutrition

Resuscitarea initiala in primele 6 ore

n Monitorizare CVC/CAP si cateter arterial
n PVC=8-12 cm H2o

n TA medie>65 mm Hg
n Debit urinar>0,5 ml/kg/h

n ScvO2>70%

Terapie volemica
n Solutii cristaloide sau coloide n Volum 500 ml coloide sau 1000 ml cristalode in 30 min n Monitorizarea repletiei volemice PVC

Vasopresoare :
n Daca dupa resuscitare volemica Tam < 65 mmHg n De electie : Noradrenalina 2-20g/min n Dopamina 5-20 g/kg/min n Fenilefrina 40-200 g/min n Vasopresina 0,01-0,04 U/min n Adrenalina 1-10 g/min

Protocol for Early Goal-Directed Therapy

Suportul ventilator:
n Soc septic risc de I. resp - IOT si VM n Profilaxia si tratamentul ARDS - Vt = 6 ml/kg - Pplatou < 30 cmH2O - PEEP= 5-15 cm H2O - FiO2 minim pt a asigura oxigenarea cu PEEP optim

Controlul sursei si tratamentul ATB:

n Tratamentul chirurgical : abces intraabdominal , peritonita , angiocolita , perforatie intestinala
n Cateter intravascular infectat : indepartat n Antibiotice: - administrate precoce (in prima ora), iv. , doze mari - dupa recoltarea probelor pt. microbiologie - dezescaladare

Corticosteroizi:
n In socul septic la pacientii ce necesita vasopresor dupa resuscitare volemica
n Doza HHC 50 mg/6h n Durata aproximativ 7 zile n Scaderea treptata si intrerupere dupa ce am reusit oprirea vasopresorului

Proteina C activata recombinata:

n Antiinflamator , antitrombotic si profibrinolitic n Moduleaza activarea coagularii/inflamatia din sepsis n La pacientii cu risc mare de deces : APACHE>25 >2 disfunctii de organ CI : sangerare activa

Proposed Actions of Activated Protein C in Modulating the Systemic Inflammatory, Procoagulant, and Fibrinolytic Host Responses to Infection

Bernard G et al. N Engl J Med 2001;344:699-709

 Controlul glicemic < 150 mg/dl Profilaxia TVP : heparina , mijloace mecanice Profilaxia ulcerului de stress: antiH2, inhibitori ai pompei de protoni Tratament cu bicarbonat : la pH < 7,15 Epurare extrarenala