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sau
invazia
unei
caviti
BACTERIEMIE:
prezena
bacteriilor
snge
obiectivat sau
nu prin hemoculturi pozitive
SIRS sindromul de rspuns inflamator sistemic
temperatur corporal sub 36C sau peste 38C;
tahicardie (peste 90 bti/minut);
tahipnee (peste 20 respiraii/minut);
leucocitoz peste 12.000/mm sau leucopenie sub
4.000/mm3 sau
prezena neutrofilelor imature n proporie de peste 10%.
OC
SEPTIC:
SEPSIS
SEVER
cu
hipotensiune
Pancreatit
SIRS
Traume
Arsuri
Altele
Infecie
SIRS
INFECIE
Pancreatit
Bacterii
Traume
Virusuri
Arsuri
Parazii
Ali agg.
Altele
Sepsis
INFECIE
SIRS
2 criterii
SIRS ca
rezultat al infeciei
Bacteriemie
Pancreatit
SEPSIS
Bacterii
Traume
Virusuri
Arsuri
Parazii
Ali agg.
Altele
O boal continu
Infecie
Sepsis
SIRS + un proces
presupus sau confirmat a
fi infecios
Sepsis Sever
TTahicardie
Hipotensiune
CVP
PAOP
Oligurie
Anurie
Creatininei
Trombocitelor
PT/APTT
Protein C
D-dimer
STADIUL
IV
supresie
imun
exagerat
fereastr imunologic mecanism aprut n urma
necesitii
de
punere
sub
control
sistemului
proinflamator i antiinflamator
SEPSISUL SEVER
un cerc vicios al inflamaiei i tulburrilor de coagulare
SEPSIS
MOARTE
Pseudomonas aeruginosa
Staphylococcus aureus
Enterobacter spp.
Klebsiella pneumoniae
Acinetobacter spp.
40
30
20
2001
2000
1999
1998
1997
1995
1994
1993
1992
1991
1990
1996
10
1989
Resistance (%)
Pseudomonas aeruginosa
Resistant to Quinolones
Year
15
10
Year
2000
1999
1998
1997
1996
1994
1993
1992
1991
1990
1995
5
1989
Resistance (%)
ICU Patients
Non-ICU Patients
2001
2000
1999
2001
1998
1999
1997
1997
1996
1995
1995
1993
1994
1991
1993
1989
1992
1991
20
10
1990
30
100
80
60
40
20
0
1989
50
40
Resistance (%)
Resistance (%)
60
Methicillin-Resistant
Coagulase-Negative Staphylococci
Methicillin-Resistant
Staphylococcus aureus
Year
Year
Year
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
35
30
25
20
15
10
5
0
1989
ICU Patients
Non-ICU Patients
Resistance (%)
Vancomycin-Resistant Enterococci
Finlanda
Suedia
4
Iceland
1
Rusia
1
Germania
5
Polonia
1
Finland
Sweden
Norway
Marea Britanie
2
Estonia
Croatia
1
Russia
Denmark
Latvia
Irish
Republic
United
Kingdom
Belgia
8
Lithuania
Netherlands
Belarus
Belgium
Cehia
1
Poland
Germany
Czech
Republic
Ukraine
Slovakia
France
Austria
Hungary
Maldova
Slovenia
Romania
Croatia
Portugal
Monaco
San
Marino
Spain
Bosnia &
Herzegovina
Georgia
Serbia &
Montenegro
Armenia
Azerbaijan
Bulgaria
Andorra
Italy
Turcia
9
Macedonia
Spania
6
Vatican City
Gibraltar
Albania
Turkey
Greece
Cyprus
Grecia
1
Numar
de
izolate
1060
1012
939
779
685
393
436
437
433
335
205
253
147
102
S. aureus
E. coli
Enterobacter spp.
P. aeruginosa
E. faecalis
Klebsiella spp. Acinetobacter spp.
Gram-pozitive
Gram-negative
Declanatori infecioi
Cascad de citokine / mediatori ai inflamaiei
Hipotensiune i oc
MODS
Moarte
PLMNUL
ETIOLOGIE
Bacterii
Streptococcus pneumoniae
Staphylococcus aureus
H. Influenzae
b. anaerobi( pneumonie de aspiratie):
- Bacteroides spp.
- Fusobacterium spp.
- Prevotella spp.
Enterobacteriacee
E. coli
Kl. pneumoniae
Serratia spp.
Ps. aeruginosa
Legionella spp.
Acinetobacter spp.
Proteus spp.
Enterococcus spp.
Salmonella spp.
ETIOLOGIE( continuare)
Virusuri
v. gripal
v. sincitial respirator
adenovirusuri( tip 4 si 7)
Fungi
Histoplasma capsulatum
Coccidoides immitis
Aspergillus spp.
Candida spp.
TABLOU CLINIC
pneumonie pleurezie
bronhopneumonie
abces pulmonar
mediastinita purulenta
Infectie respiratorie acuta
Sindromul de detres
respiratorie acut - ARDS
Hipoxemie sever progresiv datorit alterrii raportului ventilaie
perfuzie
Caracterizat prin edem pulmonar non-cardiogenic, scderea
complianei pulmonare, hipoxemie refractar
Afectarea structural a unitii alveolar-capilare
Scderea diametrului cilor respiratorii mici, crescnd travaliul respirator
Formarea edemului n alveole, interfernd cu schimburile gazoase
ARDS
1994
Definitie de consens
NEJM 2000;342,18:1334-1349
Alveolar
Filling
Expansion of
interstitium with
macrophages and
inflammation
Hyaline
Membran
es
Faza fibroproliferativ
Hipoxemie persistent
Alveolit fibrozant
Creterea spaiului mort intraalveolar
Scderea complianei pulmonare
Hipertensiune pulmonar
NEJM 2000;342,18:1334-1349
Alveolit fibrozant
NEJM 2000;342,18:1334-1349.
FAZA DE RECUPERARE
Revenirea gradat a hipoxiei
SISTEM
CARDIO-VASCULAR
ETIOLOGIE
Agentii etiologici implicati in afectarea cardiaca/ endocardiaca:
-
BACTERII:
FUNGI:
Streptococcus pneumoniae
Staphylococcus aureus
N. meningitidis
H. influentzae
Pseudomonas
Aspergillus spp.
Candida spp.
TABLOU CLINIC
endocardita
miocardita
pericardita
pancardita
Citokine
depresante
TNFa + IL1b
iNOS,
cNOS
Betaadreno
receptori
NO
Disfuncie miocardic
Remodelare cardic
Scderea fraciei de ejecie
Creterea cantitii de colagen
Edem miocardic
Apoptoza miocitelor
Modificri ale permeabilitii endocardice
Redistribuie / malperfuzie la nivelul microcirculaiei
cardiace
Scderea rspunsului la catecolamine
SEPTIC SHOCK
- CARDIO VASCULAR -
SEPSIS
Myocardial Depression
Refractory Vasodilatation
Capillary Permeability
Hypotension
Loss
Tissue Perfusion
of intravascular volume
Cell Death
Rspuns la nivel
cardio-vascular
Vasodilataie i creterea
permeabilitii vasculare
Scderea SVR
Hipotensiune
Creterea frecvenei cardiace
La nceput, creterea debitului, apoi
scderea debitului cardiac
Creterea nevoii de oxigen periferice
i la nivelul miocardului
EDEM
EDEM PERIFERIC
Datorit creterii permeabilitii vasculare
Efectele edemului pot conduce la:
Coagularea diseminat
intravascular - CID
Include:
Trombocitopenie
Creterea timpului de protrombin
Creterea produilor de degradare a fibrinei
Creterea D-dimerilor
Conduce la obstrucia vaselor cu diametru mic prin
tromboz i tendin la hemoragie prin consumul
factorilor de coagulare
CID IN SEPSIS
Cytokine
s
Tissu
e
facto
r
surface
Non-adhesive
Adhesive surface
Endothelial
cells
Monocytes
Platelets
Leukocytes
Accelerates
coagulation
1.
SISTEM DIGESTIV
BCL-2, z-VAD
Apoptoz enterocite
Creterea permeabilitii
Translocare bacterian
Circuit de
feedback
Scderea
barierei
normale
intestinal
e
Rspuns hepatobiliar
Hipercatabolism, creterea gluconeogenezei
Scderea sintezei proteice
Scderea detoxifierii produselor de catabolism i a
toxinelor
Scderea capacitii de a converti lactatul n glucoz
TABLOU CLINIC
abces hepatic
tromboflebita v. porta
SISTEM ENDOCRIN
insulin
SISTEM NERVOS
TABLOU CLINIC
meningita
abces cerebral
NO
Afectarea
axei Hypothalamic-pituitary-adrenale
sistemului nervos simpatic
cii antiinflamatorii colinergice
Radicali liberi
limiteaz livrarea de oxigen spre creier
Citokine inflamatorii
Afecteaz funcionarea mitocondrial i
extracia O2 de ctre neuroni
Distrug bariera hemato-encefalic
Edem perimicrovascular
Distrugerea legturilor dintre astrocite
aminoacizi aromatici intr n creier i interfer cu
neurotransmiterea
RINICHIUL
TABLOU CLINIC
abces renal
Good and Bad Effects of Nitric Oxide on the Kidney during Sepsis.
Oxygen radical
scavenger
Peroxynitrite
Tubular damage
Reactive
oxygen
species
Cytokine
s
Inducible NO
synthase (iNOS)
NO
Systemic
vasodilatio
n, renal
eNOS
Glomerular
microthrombi
AVP and
Hydrocortison
e
Hypotension,
Increased
Catecholamines
and Pressor
Resistance to
Norepinephrine and
Angiotensin II
Renal
Ischemia
Early
Resuscitatio
n
Insulin
Hyperglycemia
Activated
Protein C
Disseminated
Intravascular
Coagulation
Glomerular and
WBC
Vascular
Dysfunction
Microthrombosis
and
Inflammation
Hydrocortisone
DIAGNOSTIC
Ex. nespecifice
hemoleucograma
VSH
fibrinogen
PCR
teste hepatice
teste renale
Ex. specifice
hemocultura
culturi din situsuri normal sterile( LCR, lichid pleural, pericardic, articular)
testul la procalcitonina
urocultura
cultura din colectii
cultura cateterului
Ex. complementare:
EKG
Rg. Toracica
Echocardiografie
CT
RMN
2006
2007
2008
A. RESUSCITARE INITIALA
(primele 6 ore, esentiale pentru mortalitatea
la 28 de zile)
-
B. DIAGNOSTIC
C. ANTIBIOTERAPIA
Monoterapie combinata
Study
Variables
Country
Heyland (49)
Monotherapy
Meropenem
Garnacho Montero(50)
Combination
Mero+Cipro
Monotherapy
Meropenem
Canada and US
Spain
2 8
Number of sites
Combination
Mero+Cipro
Number of patients
370
369
67
116
Prevalence of P.
aeruginosa (%)
100
100
Prevalence of
polymicrobial
VAP (%)
24.3
21.4
Appropiateness of
antibiotic (%)
85.1
93.1
56.7
90.5
Mortality (%)
18.1
19.2
50.7
37.1
Contextul clinic
- la pacientul suspect de VAP febril, stabil
hemodinamic, se pot astepta rezultatele bacteriologice 24 ore
- bacteriemia reprezinta urgenta in functie de stabilitatea
hemodinamica;
- MRSA;
- Ps aeruginosa;
- Terapia inadecvata de prima intentie determina in
VAP mortalitate 75% 58% in caz de intarziere;
- Pacientii asimptomatici cu urocultura pozitiva
Nu reprezinta urgenta.
Starting antibiotics
Suspicion of infection in patient with:
- haemodynamic instability
- neuromeningeal symptoms
- neutropenia
- splenectomy
Terapia de Dezescaladare:
Terapia Iniial Adecvat
Alvarez-Lerma,1996
Rello, 1997
Terapie iniial
inadecvat
Kollef, 1999
Kollef, 1998
Ibrahim, 2000
Luna, 1997
Mortalitate*
0%
20%
40%
60%
80%
100%
Principiile dezescaladrii
Lovete scurt cu spectru ultralarg
Identific inta n timp util
Lovete inta identificat
Ce s folosim pentru
dezescaladare ?
Carbapenemi:
Imipenem
Meropenem
Ertapenem
Ceftazidim Flouroquinolon
Aminoglicozid
Linezolid / Vancomicin
Caspofungin / Fluconazol
O boal continu
Infecie
Penicilin
Ampicilin
Amoxicilin
Oxacilin
Aminoglicozide
Flourochinolone
CGII/III
Macrolide
Sepsis
Ertapenem
Aminoglicozide
Fluorochinolone
CGIII/IV
C-antiPs.
-lactami +ihib.
lactamaze
Linezolid/Vancomicin
Macrolide
Sepsis Sever
Imipenem / Meropenem
Aminoglicozide
Fluorochinolone GIV
CGIII antiPS
CGIV (Cefepim, Cefpirom)
Linezolid / Vancomicin
Macrolide
TRATEAZA:
Pneumonia i NU aspiratul traheal
Bacteriemia i NU cateterul
Infecia de tract urinar i NU sonda
Mortailtate (%)
80
60
40
20
0
030
301h
12
23
34
45
56
69
912
1224 2436
>36
DEZIDERATUL INITIAL:
HIT HARD! HIT FAST!
BACTERICIDIE RAPIDA
ENDOTOXINEMIE MINIMA
DEZIDERATELE FAZEI
URMATOARE:
1. DEZESCALADARE LA 48- 72 DE ORE
- VAP 8 zile;
- infectii intraabdominale necomplicate 3-5 zile;
- infectii asociate cateterului 14 zile.
Site of infection
Duration of antibiotic
therapy
Lung infections
Community-acquired pneumonia due to S. pneumoniae
8 days
Ventilator-associated pneumonia
8 days
14 days
21 days
>= 28 days
Pre-determined
Intra-abdominal infections
Community peritonitis
< 8 days
Post-operative peritonitis
14 days
< 8 days
10-14 days
14 days
21 days
21 days
Brain abscess
>= 28 days
duration
of
antibiotic
< 8 days
14 days
S. aureus (complicated)
> 28 days
therapy
Predetermined
duration
Day8
NegativeBAL
Immediate
Dynamic
management
BAL:pathogen
<10.000cfu/mL
Day4
Clinicalresolution
Dailymeasurement
Clinical/biological
approach
CPIS<6
Day3
F. VASOPRESOARE
MAP >= 65 mmHg
Norepinefina sau dopamina
Vasopresina
G. TERAPIE INOTROPA
H. CORTICOTERAPIE
Haemodynamic
resuscitation
Fluid
challenges
Vassopresors if
patient remains
hypotensive
Nonrefractory
septic shock
Fluid
challenges
Refractory
septic
shock*
Low dose
steroids**
TRANSFUZIA DE SANGE
Hb > 7 g% (target : 7-9 g%)
Eritropoetina - nu este tratament specific pentru anemia din
sepsisul sever dar se poate folosi in anumite situatii (IR)
Plasma congelata nu se poate folosi pentru corectie in absenta
sangerarii
NU antitrombina in socul septic datorita riscului de sangerare
Concentrul trombocitar la valori cu risc de sangerare (5.00030.000 /mm3)
Terapia de suport
ventilatia mecanica (ARDS);
sedare, analgezie, blocaj neuromuscular;
controlul glicemiei;
suport renal;
terapia cu bicarbonat;
profilaxia tromboflebitei;
profilaxia ulcerului de stres.
Terapie de suport cat mai putin agresiva
Integrarea datelor
transfuzie
antibioterapie
3 ferestre ale perfuziei tisulare:
piele
debit urinar
status mental
DE LA INCEPUTURILE
NEGRE
LA NIRVANA
NIRVANA
No protocol care
but
intelligent care
Art of medicine
not only the science of medicine
(Ch. Sprung, Critical Care, august 2008)
ECIC Lisabon 2008