XII copati

1. Dopamina: medicação de escolha em choque
séptico refratário a volume?
Apresentador "Pro”
Antonio Souto
[email protected]
Médico coordenador
Unidade de Medicina Intensiva Pediátrica
Unidade de Medicina Intensiva Neonatal
Hospital Padre Albino
Professor de Pediatria nível II
Faculdades Integradas Padre Albino
Catanduva / SP

2. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

3. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Becauseof thepaucityofoutcome-directed, randomized
controlled trials, the recommendations for hemodynamic
support of termnewborns and children in this document
are primarily expert opinion rather than irrefutable
vidence.
Crit Care Med 2002; 30:1365 -1378

4. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
nCI=3,3L/min/m
2
;
nSVRI= 800 dyne/sec/cm 5
58% CI↓+ SVRI↑
20% CI↑+ SVRI↓
22% CI↑+ SVRI↑

5. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Pediatrics 1998;102(2)
58% CI↓+ SVRI↑
20% CI↑+ SVRI↓
22% CI↑+ SVRI↑

6. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

7. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Unlikeadults, childrenwithfluid-refractory
shock are frequently hypodynamic and
respondto inotropeandvasodilatortherapy.

8. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Because hemodynamic states are heterogeneous
andchangewithtime, anincorrect cardiovascular therapeutic
regimenshouldbesuspectedin any child
withpersistentshock.

9. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
...fluid-refractory shock are frequently hypodynamic and respond
to inotrope and vasodilator therapy Dopamina (5-15 mg/kg/min) •Ação predominantemente beta-1 cardíaco
•Efeito inotrópico positivo
•Moderada vasodilatação periférica (efeito beta-2 na circulação muscular
esquelética e a seu efeito delta nas circulações es plâncnica e renal)
Promove um aumento do DC e da PAM pelo aumento da FC,
contratilidade, como pela redução moderada na pós-carga apesar do
mínimo efeito na resistência vascular sitêmica.
Crit Care Med 2004; 32:1928–1948
Pediatrics 1998;102(2)

10. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Crit Care Med 2009; 37:666–688
Many studies have tested the observations and
recommendationsofthe2002 guidelines.

11. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Crit Care Med 2009; 37:666–688
... theguidelineswere
usefulandeffectivewithout
anyevidenceofharm.

12. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Crit Care Med 2009; 37:666–688
•Wills BA, Nguyen MD, Ha TL, et al: Comparison of the three fluid solutions for resuscitation in dengue shock. N
Engl J Med2005; 353:877–889
•Maitland K, Pamba A, English M, et al: Randomized trialof volume expansion with albumin or saline in children
with severe malaria: Preliminary evidence of albumin bene fit. Clin Infect Dis2005; 40:538–545
•Han YY, Carcillo JA, Dragotta MA, et al: Early reversalof pediatric-neonatal septic shock by community
physicians is associated with improved outcome. Pediatrics2003; 112:793–799
•Ninis N, Phillips C, Bailey L, et al: The role of healt hcare delivery on outcome of meningococcal disease in
children: Casecontrol study of fatal and non-fatal cases .BMJ 2005; 330:1475
•de Oliveira CF, de Oliveira DS, Gottschald AF, et al : ACCM/PALS haemodynamic support guidelines for
paediatric septic shock: An outcomes comparison with and w ithout monitoring central venous oxygen saturation.
Intensive Care Med2008; 34:1065–1075
•Karapinar B, Lin JC, Carcillo JA: ACCM guidelines use, correct antibiotic therapy,and immune suppressant
withdrawal are associated with improved survival in pedi atric sepsis, severe sepsis, and septic shock. Crit Care
Med2004; 32(12 Suppl 3):A161
•Maat M, Buysse CM, Emonts M, et al: Improved survival in children with sepsis and purpura: Effects of age,
gender, and era. Crit Care2007; 11:172
•Odetola FO, Gebremariam A, Freed GL: Patient and hospital correlates of clinical outcomes and resource
utilization in severe pediatric sepsis. Pediatrics2007; 119:487–494

13. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

14. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

15. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Takentogether, thesestudiesindirectly
anddirectly
supporttheutilityandefficacy
ofimplementationofthetime sensitive,
goal-directedrecommendationsofthe
2002 guidelines...
Crit Care Med 2009; 37:666–688

16. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Crit Care Med 2009; 37:666–688

17. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

18. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
O uso de drogas vasopressoras permanece controverso.
A escolha de uma droga permanece aberta. ... questão sem solidas e robustas respostas...

19. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Sepsis is a complex, highly variable, multiple system,
clinicalprocess...
Pediatr Crit Care Med 2005; 6[Suppl.]:S55–S60
...complexinteractionsbetweentheinfectingmicroorganism
andthehost immune, inflammatoryandcoagulation
responses...

20. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

21. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
... theseterms do not allowfor precise characterization
andstagingofpatientswiththiscondition.
Crit Care Med 2003 Vol. 31, No. 4

22. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
TNM (Pierre Denoix, 1946) will stratify patients on the basis of their
P
redisposing
conditions, the nature and extent of the insult (in the
case of sepsis,
I
nfection), the nature and magnitude of
the host
R
esponse, and the degree of concomitant
O
rgandysfunction
Crit Care Med 2003;31:1250–6

23. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

24. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
http://www.infectio-lille.com/diaporamas/2011/KIPNIS_DUACAI2011.pdf

25. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
WHAT CLINICAL SIGNS AND HEMODYNAMIC VARIABLES CAN BE
USED TO DIRECT TREATMENT OF NEWBORN AND PEDIATRIC
SHOCK? ...
to define septic shock by clinical,
hemodynamic, and oxygen use variables
only .
...
to restoring normal mental status and
peripheralperfusion
.

26. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
...hemodynamic states are heterogeneous and
changewithtime...
Pediatrics 1998;102(2)

27. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

28. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

29. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

30. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

31. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

32. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Podem então ser traçadas “diretrizes”uniformes para
aplicação em crianças tão diferentes?
...o trabalho desenvolvido por Dr. Carcilloe a forç a-tarefa
procuram pôr alguma ordem e sistematização nas condutas
das diferentes apresentações clínicas...

33. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

34. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Clinical criteria generally used to
definite septic shock do not allow for
early identification of patients with good
or bad prognosis.

35. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Our hypothesisis that “dopamine-
sensitive” patientshave a better
prognosis than those with a “dopamine-
resistant”profile.

36. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Mortality rate was
16% (seven of 44
patients) for the
Dopa-S group
compared
with 79% (52 of 66
patients) for the
Dopa- R group (p
.0006)

37. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
…the use of dopamine is controversial
since it could delay the use of
norepinephrine, hence leading to
persistent circulatory failure.

38. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
The present results clearly demonstrate that the
rapid administration of incremental doses of
dopamine followed by a switch to epinephrine or
norepinephrine does not increase mortality rate when
compared with other septic shock
studies.

39. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
We have demonstrated that the use of
dopamine responsiveness is a reliable
and independent predictive factor for
mortality.

40. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
The use of dopamine allows discrimination between
two very differing groups with regard to mortality
outcomes, thereby enabling the inclusion of
homogeneous groups, in terms of
severity, in multiple-centerstudies.

41. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

42. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Dopamina: medicação de escolha em choque
séptico refratário a volume?
Apresentador "Pro”

43. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

44. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

45. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

46. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Vasopressors/ inotropesshould
onlybeusedafter appropriate
volume resuscitationin septic
shock... Parker et al. CCM 2004;32 (suppl): s591

47. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011

48. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
... to define septic shock by clinical, hemodynamic, a nd oxygen use .
Crit Care Med 2002; 30:1365 -1378

49. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
... to define septic shock by clinical, hemodynamic, a nd oxygen use .
Crit Care Med 2002; 30:1365 -1378

50. UTI Pediátrica & Neonatal / Hospital Padre Albino                          FIPA
Antonio Souto                       
[email protected]
2011
Hospital Padre Albino
Hospital Emílio Carlos
Escola de medicina
Obrigado !