UNIVERSITATEA DE MEDICINA SI FARMACIE, Iasi

Facultatea de Medicina
Anestezie-Terapie Intensiva

OCUL
Generalit
Generalitii

MEDICINA
An IV
l. Romana
Suport LP

Defini
Definiiiii
Sindrom
Sindrom clinic!
clinic!
Tulb
hemodinamic
Determinat de diverse
cauze
Caracterizat prin:
perfuzie tisular
inadecvat
Aport inadecvat de MODS
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

Defini
Definiiiii

Multiple
Multiple ii variate
variate cauze
cauze

Hemoragie masiv
IMA
Politraumatism
Peritonit
Reacie alergic
Embolie pulmonar,
etc

ACELAI TABLOU CLINIC

Fiziopatologia
Fiziopatologia general
general aa strilor
strilor
de
de oc
oc

SUPPLY
SUPPLY << DEMAND
DEMAND

Aerobic
Aerobic Metabolism
Metabolism
6 CO2
6 O2
METABOLISM
GLUCOSE

6 H2O
36 ATP

HEAT (417 kcal)

Anaerobic
Anaerobic Metabolism
Metabolism
2 LACTIC ACID

GLUCOSE

METABOLISM

2 ATP

HEAT (32 kcal)

Anaerobic?
Anaerobic? So
So What?
What?
Inadequate
Inadequate
Cellular
Cellular
Oxygenation
Oxygenation

Inadequate
Inadequate
Energy
Energy
Production
Production

Anaerobic
Anaerobic
Metabolism
Metabolism

Lactic
LacticAcid
Acid
Production
Production

Metabolic
Metabolic
Failure
Failure

Cell
CellDeath!
Death!

Metabolic
Metabolic
Acidosis
Acidosis

Presarcina
(volemia)

Postsarcina
(RVP)
DC = VB

FC

Debit
cardiac
Contractilitate
e

Frecvena
cardiac

Mechanisms
Mechanismsof
ofblood
bloodpressure
pressureregulation
regulation

Mechanisms
Mechanismsof
ofblood
bloodpressure
pressureregulation:
regulation:
Blood
Bloodpressure
pressureisisproportionate
proportionateto
tocardiac
cardiacoutput
outputand
andperipheral
peripheral
vascular
vascularresistance
resistance

Changes
Changes in
in Afterload
Afterload and
and Preload
Preload

Peripheral
Peripheral
vasoconstriction
vasoconstriction

peripheral
peripheral vascular
vascular
resistance
resistance

afterload
afterload

blood
blood pressure.
pressure.

Changes
Changes in
in Afterload
Afterload and
and Preload
Preload

Peripheral
Peripheral
vasodilation
vasodilation

peripheral
peripheral vascular
vascular
resistance
resistance

afterload
afterload

blood
blood pressure.
pressure.

Changes
Changes in
in Afterload
Afterload and
and Preload
Preload

fluid
fluid volume
volume

preload
preload

contractility
contractility
(Starlings
(Starlings Law)
Law)

blood
blood pressure.
pressure.

cardiac
cardiac output.
output.

Changes
Changes in
in Afterload
Afterload and
and Preload
Preload

fluid
fluid volume
volume

preload
preload

contractility
contractility

(Starlings
(Starlings Law)
Law)

blood
blood pressure.
pressure.

cardiac
cardiac output.
output.

Renin-Angiotensin-Aldosterone
Renin-Angiotensin-Aldosterone
Plasma
Plasma
volume
volume
&/Or
[Na+]
[Na+]

Detected by

Kidney
Kidney
(juxtaglomerular
(juxtaglomerular
apparatus)
apparatus)

Via ACE
(Angiotensin
Converting
Enzyme)

Releases
Renin
Renin
Converts

Angiotensin
AngiotensinII
II
Angiotensin
AngiotensinI
I

Angiotensinogen

Renin-Angiotensin-Aldosterone
Renin-Angiotensin-Aldosterone
vasoconstriction
vasoconstriction

Angiotensin
AngiotensinII
II

PVR
PVR

thirst
thirst
ADH
ADH
(anti-diuretic
(anti-diuretic
hormone)
hormone)

Adrenal
Adrenal
cortex
cortex

Releases

Fluid
Fluid
volume
volume

Aldosterone
Aldosterone

BP!
BP!

Na+
Na+
reabsorption
reabsorption

Cellular
Cellular Response
Response to
to Shock
Shock
OO2
O
O
2
use
use
Anaerobic
Anaerobic
metabolism
metabolism

ATP
ATP
synthesis
synthesis
+
Na
Na+Pump
Pump
Function
Function

Tissue
Tissue
perfusion
perfusion

Stimulation
Stimulationof
of
clotting
clottingcascade
cascade&&
inflammatory
inflammatory
response
response

+
Intracellular
IntracellularNa
Na+
&&water
water

Impaired
Impairedcellular
cellular
metabolism
metabolism

Impaired
Impaired
glucose
glucose
usage
usage

Cellular
Cellularedema
edema
Vascular
Vascularvolume
volume

EVALUAREA
EVALUAREAHEMODINAMIC
HEMODINAMIC
AAPACIENTULUI
PACIENTULUICU
CUSTARE
STAREDE
DEOC
OC

TA
TA

Frecvena
Frecvena cardiac
cardiac

ECG
ECG

Pulsoximetrie
Pulsoximetrie

Presiunea
Presiunea venoas
venoas central
central

Debitul
Debitul cardiac
cardiac i
i presiunea
presiunea n
n
capilarul
capilarul pulmonar
pulmonar blocat
blocat

Saturaia
Saturaia n
n oxigen
oxigen aa sngelui
sngelui venos
venos
amestecat
amestecat

Ecocardiografia
Ecocardiografia transesofagian
transesofagian i
i
transtoracic
transtoracic

Hemodynamic
Hemodynamic Assessment
Assessment of
of Shock
Shock

Basic Hemodynamic
Monitoring

BHM 21

TA
TA

Manual,palpator
Manual,palpator

Automat/neautomat
Automat/neautomat

Continuu/intermitent
Continuu/intermitent

Invaziv/neinvaziv
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
PRESIUNEAVENOAS
VENOAS
CENTRAL
CENTRAL

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

Metoda
Metodacoloanei
coloaneide
de
ap
ap

Metoda
Metodaautomat
automat
(cu
(cutransductor)
transductor)

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

Cateterul n
artera
pulmonar

Permite
Permite msurarea
msurarea
i
i calcularea
calcularea unor
unor
parametri
parametri
hemodinamici
hemodinamici
diagnosticul
diagnosticul
ocului
ocului

Permite
Permite
monitorizarea
monitorizarea
rspunsului
rspunsului la
la
tratament
tratament

Cateterul
Cateterul n
n artera
artera pulmonar
pulmonar

Indications
Indications for
for Pulmonary
Pulmonary Artery
Artery
Catheters
Catheters (PACs)
(PACs)
Evaluarea
Evaluareastarii
stariide
desoc
soc
Evaluarea
Evaluareaedemului
edemuluipulmonar
pulmonar(cardiogen
(cardiogenvs
vs
ARDS)
ARDS)
Ghidarea
Ghidarea tratamentului
tratamentului cand
candse
se combina
combinaoliguria
oliguria
sau
sauhipotensiunea
hipotensiuneasi
siedemul
edemulpulmonar
pulmonar
Optimizarea
Optimizareaindexului
indexuluicardiac
cardiacin
insocul
soculcardiogen
cardiogen
Evaluarea
Evaluareasi
si titrarea
titrareaterapiei
terapieiin
inhipertensiunea
hipertensiunea
pulmonara
pulmonara
Diagnosticul
Diagnosticulsi
sievaluarea
evaluareasuntului
suntuluiintracardiac
intracardiac
stinga-dreapta
stinga-dreapta

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

Complications
Complications of
of PACs
PACs
Complicatii
Complicatiiale
aleinseriei
inserieicateterului:
cateterului:
Pneumotorax
Pneumotorax
Puncie
Punciearterial
arterial
Embolus
Embolusaerian
aerian

Aritmii
Aritmiiatriale
atrialeori
oriventriculare
ventriculare
Infarct
Infarctpulmonar
pulmonar
Ruptura
Rupturade
deartera
artera pulmonar
pulmonar(0.2%
(0.2% incidena,
incidena,
uitarea
uitareabalonului
balonuluiumflat)
umflat)
Infecii
Infeciide
detorent
torent sanguin
sanguindeterminate
determinatede
decateter
cateter
Endocardita
Endocarditainfecioas
infecioas
Tromb
Trombmural
mural
Rsucirea
Rsucireacateterului
cateterului

Cateterul
Cateterul n
n artera
artera pulmonar
pulmonar

Parametri
Parametrimsurai:
msurai:

presiunea
presiuneavenoas
venoascentral/
central/presiunea
presiunean
natriul
atriul
drept
drept(presarcina
(presarcinaventriculului
ventricululuidrept)
drept)
presiunile
presiunilen
nartera
arterapulmonar
pulmonar(sistolica,
(sistolica,
diastolica
diastolicai
imedia)
media)
presiunea
presiunean
ncapilarul
capilarulpulmonar
pulmonarblocat
blocat
(presarcina
ventriculului
stng)
(presarcina ventriculului stng)
debitul
debitulcardiac
cardiac(metoda
(metodatermodiluiei)
termodiluiei)
saturaia
saturaian
noxigen
oxigenaasngelui
sngeluivenos
venosamestecat
amestecat

Parametri
Parametricalculai:
calculai:

indexul
indexulcardiac,
cardiac,debitul-btaie
debitul-btaie
rezistena
rezistenan
ncirculaia
circulaiapulmonar
pulmonar(postsarcina
(postsarcina
ventriculului
drept)
ventriculului drept)
rezistena
rezistenan
ncirculaia
circulaiasistemic
sistemic(postsarcina
(postsarcina
ventriculului
stng),
ventriculului stng),
transportul
transportulde
deoxigen,
oxigen,consumul
consumulde
deoxigen,
oxigen,
extracia
oxigenului,
.a.
extracia oxigenului, .a.

Monitorizarea
Monitorizarea pacientului
pacientului cu
cu oc
oc
Respiratorie
Respiratorie clinic
clinic
-- numrul
numrulde
derespiraii/min
respiraii/min

--pulsoximetrie
pulsoximetrie
--gaze
gazesanguine
sanguine
--Rx-T
Rx-T

Cardiovascular
CardiovascularTA
TAinvaziv
invaziv
--FC
FC
--ECG
ECG
--Pulsoximetrie
Pulsoximetrie
--PVC
PVC
--Debit
Debitcardiac
cardiac
--Ecocardiografie
Ecocardiografie
--ScVO2
ScVO2

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

-- PIA

PIA

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

Sond
transesofagian

Mixed Venous Oxygen Saturation

SvO2 is the oxygen saturation returning
to the right heart
Determinants of SvO2
Oxygen delivery
Oxygen extraction

High values indicate (70%):

Adequate tissue perfusion

Poor tissue extraction of oxygen

Desired values in shock

SvO2 70%

Tratamentul
Tratamentul initial
initial in
in soc:
soc:

Eliberarea
Eliberarea caii
caii aeriene
aeriene si
si ventilatia:
ventilatia:
-- O2-terapie
O2-terapie
-- IOT
IOT si
si VM
VM coma
coma ,, obnubilare
obnubilare
-- oboseala
oboseala m.
m. respiratori
respiratori
-- hipoxemie
hipoxemie severe/cianoza
severe/cianoza

Circulatia
Circulatia ::
-normalizarea
-normalizarea TA
TA
--normalizarea
-normalizarea perfuziei
perfuziei tisulare
tisulare

Principii
Principii de
de tratament
tratament in
in soc:
soc:

Obiective:
Obiective: -restabilirea
-restabilirea perfuziei
perfuziei tisulare
tisulare
-- corectarea
corectarea MODS
MODS

Optimizarea
Optimizarea -- presarcinii(volumului
presarcinii(volumului circulant)
circulant)
-- debitului
debitului cardiac(VB
cardiac(VB ,, FC
FC ))
-- rezistentei
rezistentei vasculare
vasculare
periferice(vasoconstrictoare
periferice(vasoconstrictoare ,, dilatatoare)
dilatatoare)
-- capacitatii
capacitatii de
de transport
transport aa
oxigenului
oxigenului (corectarea
(corectarea
hipoxemiei
hipoxemiei si
si optimizarea
optimizarea Hb)
Hb)

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

Oxygen Express

O2O2O2O2O2O

x 0.003

O2O2O2O2O2O2

Ca02

Arterial
Arterial Oxygen
Oxygen Content
Content
100 mm Hg

Hgb 15 gm/100
mL
Hemoglobin

SaO2 97%
Oxygen
Saturation

O2 bound to
Hgb

PaO2 100 mmHg

Partial Pressure

+ O2 in
plasma

Management
Management of
of Shock
Shock States
States

43

OCUL
OCUL HIPOVOLEMIC
HIPOVOLEMIC

Scderea
Scderea volumului
volumului
sanguin
sanguin circulant
circulant
efectiv
efectiv
((presarcin
presarcin sczut
sczut))

CLINIC
CLINIC
Semne
Semne comune
comune strilor
strilor de
de oc
oc
tahicardie,
tahicardie,tahipnee,
tahipnee, hTA,nelini
hTA,nelinite,agita
te,agitaie,
ie,
confuzie
confuziesau
saucom,
com,oligurie/anurie
oligurie/anurie

Semne
Semne de
de DC
DC sczut
sczut
extremit
extremitiireci,transpira
reci,transpiraiiii profuze,
profuze, pat
pat venos
venos
periferic
perifericcolabat,und
colabat,undde
depuls
pulscu
cuamplitudine
amplitudine
sczut,
sczut,timp
timpumplere
umplerecapilar
capilarprelungit
prelungit

Semne
Semne ii simptome
simptome clinice
clinice de
de hipovolemie
hipovolemie
sete
setevie
vie++ anamnez
anamnez pozitiv
pozitiv pt
pt pierderi!
pierderi!

Hemorrhagic
Hemorrhagic Shock
Shock

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

Parametri
Parametri hemodinamici
hemodinamici
caracteristici
caracteristici
FC
FC ((90/min)
90/min)
TA
TAsistolic
sistolicN/
N/ cu
cupensarea
pensareadiferen
diferenialei
ialei
Index
Indexcardiac
cardiac2,2l/min.m
2,2l/min.m
PVC
PVC8-12
8-12mmHg
mmHg
PCPB
PCPB8-12mm
8-12mmHg
Hg
RVS
RVS ((1500
1500dyne
dynesec/cm5)
sec/cm5)
DO2
DO2 ((500
500ml/minut/m)
ml/minut/m)
Vo2
Vo2 ((110
110ml/minut/m)
ml/minut/m)
O2ER
O2ER ((0,3
0,3))
ScVO2
ScVO260%
60%

DIAGNOSTIC
DIAGNOSTIC

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

DIAGNOSTIC
DIAGNOSTIC DIFERENIAL
DIFERENIAL
FC

TA

DC

PVC

ocul
hipovolemic

ocul
cardiogen

ocul
septic

N N

PCPB RVP

Da-vO2

SvO2

PRINCIPII
PRINCIPII DE
DE TRATAMENT
TRATAMENT
Tratament
Tratament cauzal
cauzal oprirea
oprirea pierderilor
pierderilor
Reple
Repleia
ia volemic:
volemic:

ci
ci adm,
adm, solu
soluiiiide
dereple
repleie,
ie,
ritmul
ritmuladministrrii,
administrrii, end-points
end-points

Tratament
Tratament de
de suport
suport ((ventilator,
ventilator,inotrop,
inotrop,

vasomotor,transport
vasomotor,transportde
deoxigen
oxigenla
la esuturi,
esuturi, func
funcie
ie
renal,
renal,coagulare,
coagulare, nutri
nutriional)
ional)

OC
OC CARDIOGEN
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
ETIOLOGIE

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

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

Cardiogenic
Cardiogenic Shock
Shock
R.A.S.
R.A.S.
Activation
Activation

Volume/
Volume/
Preload
Preload

Catecholamine
Catecholamine
Release
Release

CO
CO

Myocardial
Myocardial
OO22demand
demand

Impaired
Impaired
myocardial
myocardialfunction
function

SVR
SVR
OO22
supply
supply

Dyspnea
Dyspnea

Peripheral
Peripheral
&
&pulmonary
pulmonary
edema
edema

Hochman JS Circulation 2003, 107: 2998-3002

CLINIC
CLINIC
Hipotensiune
Hipotensiune
arterial
arterial
Semne
Semne de
de
hipoperfuzie
hipoperfuzie tisular
tisular
Semne
Semne de
de
congestie
congestie
pulmonar
pulmonar

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


Clinic:
Clinic:status
statusmental,
mental, temperatura
temperaturaiiculoarea
culoarea tegumentelor
tegumentelor

SpO
SpO22

TA
TAinvaziv
invaziv

ECG
ECG

PVC
PVC

Parametri
Parametrihemodinamici:
hemodinamici: presiuni
presiunin
n artera
artera pulmonar,
pulmonar, PCPB,
PCPB,
RVS,
RVS, RVP,
RVP,DC,
DC,SvO
SvO22

Ecocardiografia
Ecocardiografia

Debitul
Debitulurinar
urinar

pH
pH++ statusul
statusulgazelor
gazelor sanguine
sanguine

Funcia
Funciasistemelor
sistemelor iiorganelor:
organelor: probe
probe renale,
renale, hepatice,
hepatice,
glicemie,
glicemie,teste
testede
decoagulare,
coagulare,ionogram,
ionogram,hemoleucogram
hemoleucogram

Vasopressors
Beta=action
Alpha
Beta

Dopamine

Isoproterenol

Dobutamine

High dose

Pure Beta

Epinephrine

Norepinephrine

Phenylephrine

Pure Alpha

Low dose
58

ocul
ocul septic
septic

Definitions
Definitions

The
TheACCP/SCCM
ACCP/SCCMconsensus
consensusconference
conferencecommittee.
committee. Definitions
Definitionsfor
forsepsis
sepsisand
andorgan
organfailure
failureand
and
guidelines
for
the
use
of
innovative
therapies
in
sepsis.
Chest
1992.
guidelines for the use of innovative therapies in sepsis. Chest 1992.

SIRS
SIRS

Widespread
Widespreadinflammatory
inflammatoryresponse
response

Two
Twoor
ormore
moreof
ofthe
thefollowing
following
Temp>38
Temp>38C<36
C<36CC
Heart
HeartRate
Rate>90
>90bpm
bpm
Tachypnea
TachypneaRR>20
RR>20or
orhyperventilation
hyperventilationPaCO2
PaCO2<32
<32mmHg
mmHg
WBC
WBC>12,000<4000
>12,000<4000or
orpresence
presenceofof>10%
>10%immature
immature
neutrophils.
neutrophils.

Sepsis:
Sepsis: SIRS
SIRS++definitive
definitivesource
sourceof
of infection
infection

Severe
SevereSepsis:
Sepsis:Sepsis
Sepsis++organ
organ dysfunction,
dysfunction,
hypoperfusion,
hypoperfusion,or
or hypotension
hypotension

Definitions
Definitions

The
TheACCP/SCCM
ACCP/SCCMconsensus
consensusconference
conferencecommittee.
committee. Definitions
Definitionsfor
forsepsis
sepsisand
andorgan
organfailure
failureand
and
guidelines
for
the
use
of
innovative
therapies
in
sepsis.
Chest
1992.
guidelines for the use of innovative therapies in sepsis. Chest 1992.

Septic
SepticShock:
Shock:

Sepsis
Sepsis++hypotension
hypotensiondespite
despitefluids
fluids

Perfusion
Perfusionabnormalities
abnormalities
Lactic
Lacticacidosis
acidosis
Oliguria
Oliguria
Acute
AcuteAMS
AMS

Multiple
MultipleOrgan
OrganSystem
System Failure:
Failure:Abnormal
Abnormalfunction
functionof
of
two
twoor
ormore
moreorgans
organssuch
suchthat
thathomeostasis
homeostasiscannot
cannotbe
be
achieved
achievedwithout
withoutintervention.
intervention.

Management
Management of
of Sepsis
Sepsis

Resuscitate:
Resuscitate:ABCs
ABCs

Restore
Restore tissue
tissue perfusion
perfusion

Identify
Identify and
and eradicate
eradicate source
source of
of infection
infection

Assure
Assure adequate
adequate tissue
tissue oxygenation
oxygenation

Activated
Activated Protein
Protein CC

Steroids
Steroids

Glucose
Glucose Control
Control

Nutrition
Nutrition

Resuscitarea
Resuscitarea initiala
initiala
in
in primele
primele 66 ore
ore

Monitorizare
Monitorizare CVC/CAP
CVC/CAPsisi cateter
cateter arterial
arterial

PVC=8-12
PVC=8-12 cm
cm H2o
H2o

TA
TAmedie>65
medie>65 mm
mm Hg
Hg

Debit
Debit urinar>0,5
urinar>0,5 ml/kg/h
ml/kg/h

ScvO2>70%
ScvO2>70%

Terapie
Terapie volemica
volemica

Solutii
Solutii cristaloide
cristaloide sau
sau coloide
coloide

Volum
Volum 500
500 ml
ml coloide
coloide sau
sau 1000
1000 ml
ml
cristalode
cristalode in
in 30
30 min
min

Monitorizarea
Monitorizarea repletiei
repletiei volemice
volemice PVC
PVC

Vasopresoare
Vasopresoare ::

Daca
Daca dupa
dupa resuscitare
resuscitare volemica
volemica Tam
Tam << 65
65
mmHg
mmHg

De
De electie
electie :: Noradrenalina
Noradrenalina 2-20g/min
2-20g/min

Dopamina
Dopamina 5-20
5-20 g/kg/min
g/kg/min

Fenilefrina
Fenilefrina 40-200
40-200 g/min
g/min

Vasopresina
Vasopresina 0,01-0,04
0,01-0,04 U/min
U/min

Adrenalina
Adrenalina 1-10
1-10 g/min
g/min

Protocol
Protocolfor
forEarly
EarlyGoal-Directed
Goal-DirectedTherapy
Therapy

Suportul
Suportul ventilator:
ventilator:

Soc
Soc septic
septic risc
risc de
de I.I. resp
resp
-- IOT
IOT si
si VM
VM

Profilaxia
Profilaxia si
si tratamentul
tratamentul ARDS
ARDS
-- Vt
Vt == 66 ml/kg
ml/kg
-- Pplatou
Pplatou << 30
30 cmH2O
cmH2O
-- PEEP=
PEEP= 5-15
5-15 cm
cm H2O
H2O
-- FiO2
FiO2 minim
minim pt
pt aa asigura
asigura oxigenarea
oxigenarea cu
cu
PEEP
PEEP optim
optim

Controlul
Controlul sursei
sursei si
si tratamentul
tratamentul
ATB:
ATB:

Tratamentul
Tratamentul chirurgical
chirurgical :: abces
abces intraabdominal
intraabdominal ,,
peritonita
peritonita ,, angiocolita
angiocolita ,, perforatie
perforatie intestinala
intestinala

Cateter
Cateter intravascular
intravascular infectat
infectat :: indepartat
indepartat

Antibiotice:
Antibiotice: -- administrate
administrate precoce
precoce (in
(in prima
prima ora),
ora), iv.
iv.
,, doze
doze mari
mari
-- dupa
dupa recoltarea
recoltarea probelor
probelor pt.
pt. microbiologie
microbiologie
-- dezescaladare
dezescaladare

Corticosteroizi:
Corticosteroizi:

In
In socul
socul septic
septic la
la pacientii
pacientii ce
ce necesita
necesita
vasopresor
vasopresor dupa
dupa resuscitare
resuscitare volemica
volemica

Doza
Doza HHC
HHC 50
50 mg/6h
mg/6h

Durata
Durata aproximativ
aproximativ 77 zile
zile

Scaderea
Scaderea treptata
treptata si
si intrerupere
intrerupere dupa
dupa ce
ce am
am
reusit
reusit oprirea
oprirea vasopresorului
vasopresorului

Proteina
Proteina C
C activata
activata recombinata:
recombinata:

Antiinflamator
Antiinflamator ,, antitrombotic
antitrombotic si
si profibrinolitic
profibrinolitic

Moduleaza
Moduleaza activarea
activarea coagularii/inflamatia
coagularii/inflamatia
din
din sepsis
sepsis

La
La pacientii
pacientii cu
cu risc
risc mare
mare de
de deces
deces ::
APACHE>25
APACHE>25
>2
>2 disfunctii
disfunctii de
de organ
organ
CI
CI :: sangerare
sangerare activa
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