Download - Anestesia em Urgencias e Trauma 2015
![Page 1: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/1.jpg)
Urgências e Trauma
Fabrício Tavares Mendonça TEA/TSA
![Page 2: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/2.jpg)
![Page 3: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/3.jpg)
Definição de Urgência e Risco
Procedimento de emergência: aquele que a vida ou um membro está ameaçado; há tempo limitado ou ausente para avaliação clinica suplementar; tipicamente < 6 h.
Procedimento de urgência: pode haver tempo para avaliação clinica limitada, geralmente quando a vida ou um membro está ameaçado; tipicamente > 6h e < 24 h
Fleisher LA, et al. 2014 ACC/AHA Perioperative Guideline
![Page 4: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/4.jpg)
Vane, LA e Silva ED. Reposição Volêmica, Transfusão Peroperatória e Monitorização.Atualização em Anestesiologia, volume 15, SAESP. Ed. Manole. 2013.
![Page 5: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/5.jpg)
CONDUTA ANESTESICA
![Page 6: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/6.jpg)
Avaliação Pré-Anestésica
O que vc deve pensar ?
![Page 7: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/7.jpg)
Paciente
CondiçõesPré-
Existentes
Urgência Cirúrgica
Mecanismo do
Trauma
![Page 8: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/8.jpg)
Avaliação Pré-Anestésica
O que vc deve fazer ?
Estratificar o Risco
![Page 9: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/9.jpg)
![Page 10: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/10.jpg)
![Page 11: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/11.jpg)
![Page 12: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/12.jpg)
ATLS
A
B
CE
D• Via aérea permeável• Estabilização cervical
• Exposição/busca por deformidades
• Exames Comple-mentares
• Hipotensão >> Sangramento
• Reposição Fluidos• Aquecimento
• Ventilação• Gases• Raio X de Tx
• Alterações Neuro• ECG• Pupilas• Défcit
Sensitivo/Motor
![Page 13: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/13.jpg)
Faixa Etária
?
Doenças Coexistentes
?
Estômago Cheio
?
Gestante
?
Intoxicação Exógena
?
ChoqueHipoperfusão
?
Fatores relacionados ao paciente
![Page 14: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/14.jpg)
Condições Cirúrgicas de Urgência
Complicações durante internação
Compartimentais/Isquêmicas Queimaduras
Inflamatórias/InfecciosasHemorrágicas
![Page 15: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/15.jpg)
![Page 16: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/16.jpg)
Mecanismo do Trauma
![Page 17: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/17.jpg)
![Page 18: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/18.jpg)
Mecanismo do Trauma
Trauma de tórax
• Lesões penetrantes– Aberto
• Lesões contusas desaceleração– Fratura de costelas Tórax instável– Hemo/Pneumotórax
![Page 19: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/19.jpg)
Trauma Cranioencefálico – TCE
• Fratura• Contusão• Hematoma
Mecanismo do Trauma
![Page 20: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/20.jpg)
Mecanismo do Trauma
Trauma Cardíaco
• Penetrantes rara sobrevivência
• Contuso – Ruptura pericárdica Tamponamento– Lesão de estruturas CONTUSAO CARDIACA
![Page 21: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/21.jpg)
Mecanismo do Trauma
Trauma abdominal
• Contuso Baço, fígado, rins e visceras oca• Penetrante …
Trauma de extremidades …
![Page 22: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/22.jpg)
Manejo Intraoperatório
![Page 23: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/23.jpg)
![Page 24: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/24.jpg)
Estratégias de manejo da via aérea
![Page 25: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/25.jpg)
![Page 26: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/26.jpg)
![Page 27: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/27.jpg)
![Page 28: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/28.jpg)
![Page 29: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/29.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
![Page 30: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/30.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
![Page 31: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/31.jpg)
![Page 32: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/32.jpg)
![Page 33: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/33.jpg)
![Page 34: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/34.jpg)
![Page 35: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/35.jpg)
![Page 36: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/36.jpg)
![Page 37: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/37.jpg)
![Page 38: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/38.jpg)
![Page 39: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/39.jpg)
![Page 40: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/40.jpg)
Como vc induziria anestesia ?
Um homem de 61 anos apresenta feridas perfurocortantes no abdome, hemitorax esquerdo e crânio. Os sinais vitais sao: PA 85x60 mmHg, FC 130, FR 32 irpm. Ele foi levado a S.O para laparotomia exploradora.
![Page 41: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/41.jpg)
![Page 42: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/42.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
(Tiopental)
![Page 43: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/43.jpg)
Diminui cortisol supressão adrenal
Alguns defendem reposição de 100 mg de hidrocortisona 8/8 h
![Page 44: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/44.jpg)
![Page 45: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/45.jpg)
Há também taxas significativas de InsA nos grupos de controle não tratados com etomidato.
No contexto da doença crítica e comprometimento hemodinâmico, a estabilidade cardiovascular de etomidato continua a ser o principal atrativo. No entanto, há fortes indícios de que outros agentes, tais como a cetamina, podem oferecer tal estabilidade com condições de intubação comparáveis.
Apesar de vários relatos sugerem uma associação positiva com a mortalidade, não há causalidade conclusivo em trauma ou pacientes de emergência hipotensos que receberam uma dose única de indução de etomidato.
![Page 46: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/46.jpg)
Consecutive patients were eligible if they had received an induction agent for endotracheal intubation within the first 48 hours of septic shock onset
Todos os pacientes receberam hidrocortisona
![Page 47: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/47.jpg)
Um bolus intravenoso de 50 mg de hidrocortisona foi administrado a cada 6 horas, começando dentro das primeiras 12 horas de choque séptico, durante pelo menos 5 dias, de acordo com a reversão de choque.
![Page 48: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/48.jpg)
Os pacientes foram agrupados como os que receberam etomidate para intubação (coorte etomidato) versus aqueles indivíduos que receberam outro hipnótico (coorte não etomidato).
![Page 49: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/49.jpg)
![Page 50: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/50.jpg)
Methods:• Retrospective review of all major adult trauma patients who required intubation at the
QEII HSC in Halifax since 2000Results:• A total of 315 patients were included. Patients receiving etomidate were similar to those
who did not, including ISS and preintubation blood pressure. There was no difference in ICU LOS, hospital LOS, or ventilation-free days.
• Twenty-eight-day mortality was higher in the etomidate group (20.0% v. 10.8%, p = 0.04). Conclusion:• Administration of etomidate for emergency intubation in the trauma patient may be
associated with increased mortality. Etomidate should be used with caution in trauma patients requiring intubation. The risk-benefit of etomidate use in this patient population requires further investigation
![Page 51: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/51.jpg)
![Page 52: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/52.jpg)
![Page 53: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/53.jpg)
![Page 54: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/54.jpg)
![Page 55: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/55.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
![Page 56: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/56.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
![Page 57: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/57.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
![Page 58: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/58.jpg)
Manejo Intraoperatório
![Page 59: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/59.jpg)
Como vc manteria anestesia ?
Um homem de 61 anos apresenta feridas perfurocortantes no abdome, hemitorax esquerdo e crânio. Os sinais vitais sao: PA 85x60 mmHg, FC 130, FR 32 irpm. Ele foi levado a S.O para laparotomia exploradora.
![Page 60: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/60.jpg)
Como vc manteria anestesia ?
Assim que se conseguir estabilização hemodinâmica, agentes anestésicos devem ser cuidadosamente titulados, evitando-se hipotensão:• Sedativos amnésia assim que possível• Opióides titulados• Inalatórios em baixas concentrações
![Page 61: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/61.jpg)
Manejo Intraoperatório
![Page 62: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/62.jpg)
Choque no Trauma
Definição
![Page 63: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/63.jpg)
![Page 64: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/64.jpg)
Choque no Trauma
Diagnóstico e monitorização
![Page 65: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/65.jpg)
Hipoperfusão
Hemorrágico
Obstrutivo
Neurogênico
Cardiogênico
Distributivo
Choque no Trauma Diag Etiológico
Morte Celular DMOS
![Page 66: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/66.jpg)
Revista da AMRIGS, Porto Alegre, 55 (2): 179-196, abr.-jun. 2011
Diagnóstico Manifestações
![Page 67: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/67.jpg)
Revista da AMRIGS, Porto Alegre, 55 (2): 179-196, abr.-jun. 2011
Diagnóstico Avaliação Complementar
![Page 68: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/68.jpg)
Manejo Intraoperatório
![Page 69: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/69.jpg)
Um homem de 61 anos apresenta feridas perfurocortantes no abdome, hemitorax esquerdo e crânio. Os sinais vitais sao: PA 85x60 mmHg, FC 130, FR 32 irpm. Ele foi levado a S.O para laparotomia exploradora.
Como vc monitorizaria ?
![Page 70: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/70.jpg)
![Page 71: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/71.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
![Page 72: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/72.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 73: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/73.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 74: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/74.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 75: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/75.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 76: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/76.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 77: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/77.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 78: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/78.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 79: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/79.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 80: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/80.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.
www.cambridge.org/9780521870580
![Page 81: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/81.jpg)
![Page 82: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/82.jpg)
![Page 83: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/83.jpg)
![Page 84: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/84.jpg)
Manejo Intraoperatório
![Page 85: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/85.jpg)
Reposição Volêmica
![Page 86: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/86.jpg)
REPOSIÇÃO VOLÊMICA
Como?
Qual fluido?
Quanto?
“Não convém a gente levantar escândalo de começo, só aos poucos
é que o escuro fica claro.”Grande Sertão: Veredas
![Page 87: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/87.jpg)
![Page 88: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/88.jpg)
![Page 89: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/89.jpg)
![Page 90: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/90.jpg)
![Page 91: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/91.jpg)
Charles E. SMITH ed. Trauma Anesthesia. Cambridge University Press, 2008.www.cambridge.org/9780521870580
![Page 92: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/92.jpg)
Pressão arterial e perfusão de órgãos
Manter a PS em torno de 90 mmHg ou PAM em torno de 60-65 mmHg é suficientemente útil para manter a perfusão tecidual e de órgãos vitais sem gerar o risco de aumentar hemorragias
Vane, LA e Silva ED. Reposição Volêmica, Transfusão Peroperatória e Monitorização.Atualização em Anestesiologia, volume 15, SAESP. Ed. Manole. 2013.
PAM de 60-80 mmHg, tendendo ao limite superior nos casos de TCE e/ou TRM
![Page 93: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/93.jpg)
![Page 94: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/94.jpg)
Treatment Choices for Fluid Management
Fluid Management
Crystalloid Colloid
Synthetic balancedBalancedUnbalanced Natural
Sodium Chloride0.9%
Plasma-LyteRinger’s LactateRinger’s Acetate
Hartmann’s
HESGelatin
Human Albumin
Different fluids with different modes of action, and different side effects
HESDextranGelatin
Synthetic unbalanced
![Page 95: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/95.jpg)
![Page 96: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/96.jpg)
![Page 97: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/97.jpg)
Cristalóides Isotônicos
Nesse cenário, o Ringer-Lactato continua tendo papel de destaque no tratamento do choque, principalmente em virtude da similaridade de eletrólitos com o plasma.
Vane, LA e Silva ED. Reposição Volêmica, Transfusão Peroperatória e Monitorização.Atualização em Anestesiologia, volume 15, SAESP. Ed. Manole. 2013.
![Page 98: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/98.jpg)
Cristalóides Isotônicos
Nesse cenário, o Ringer-Lactato continua tendo papel de destaque no tratamento do choque, principalmente em virtude da similaridade de eletrólitos com o plasma.
Vane, LA e Silva ED. Reposição Volêmica, Transfusão Peroperatória e Monitorização.Atualização em Anestesiologia, volume 15, SAESP. Ed. Manole. 2013.
• Reduz a viscosidade sanguínea otimizar perfusão• RL auxílio no tamponamento sistêmico dos acidóticos
![Page 99: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/99.jpg)
Cristalóides Isotônicos
Nesse cenário, o Ringer-Lactato continua tendo papel de destaque no tratamento do choque, principalmente em virtude da similaridade de eletrólitos com o plasma.
Vane, LA e Silva ED. Reposição Volêmica, Transfusão Peroperatória e Monitorização.Atualização em Anestesiologia, volume 15, SAESP. Ed. Manole. 2013.
• Reduz a viscosidade sanguínea otimizar perfusão• RL auxílio no tamponamento sistêmico dos acidóticos
Solução Fisiológica a 0,9% é uma alternativa aceitavel, principalmente se houver TCE associado; mas a
hipercloremia deve ser evitada.
![Page 100: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/100.jpg)
![Page 101: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/101.jpg)
![Page 102: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/102.jpg)
Acidose dilucional hiperclorêmica
• Alteração renal
– Vasoconstrição renal– Aumento da resistência vascular renal– Diminuição da filtração glomerular– Diminuição do excesso de base– Aumento no tempo de início da diurese
![Page 103: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/103.jpg)
• 4266 surgical patients who developed post op hyperchloremia
• Propensity matched with 4266 who did not• Groups were well matched with minimal
differences• Anesth Analg 2013;117:412–21 Anesth Analg 2013;117:412–21
![Page 104: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/104.jpg)
2–21 Anesth Analg 2013;117:41
![Page 105: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/105.jpg)
CUIDADO !!!!!
![Page 106: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/106.jpg)
Ringer Lactato
• Mais próximo ao plasma: evita distúrbio eletrolítico iatrogênico– K: cuidado hipercalemia– Ca: citrato anti-coagulantes– Lactato: hiperlactatemia risco acidose respiratória
• Hipotônico– Menor osmolaridade: inibe ADH– Melhor débito urinário– Cuidado com edema cerebral
![Page 107: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/107.jpg)
Ringer Lactato
• Mistura racêmica
– Isomero D: < adesão neutrófilos• < adesão neutrófilos• < adesão plaquatas• < expressão genes mediadores inflamação
– Isomero L• Proteção imunológica
![Page 108: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/108.jpg)
Ringer lactato X solução salina
![Page 109: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/109.jpg)
Ringer lactato X solução salina
![Page 110: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/110.jpg)
Ringer lactato X solução salina
![Page 111: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/111.jpg)
Plasma-lyteR
• Physiologically balanced, containing sodium, potassium, magnesium and chloride but no calcium• Contains the bicarbonate precursors acetate and gluconate
![Page 112: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/112.jpg)
Renal Results: Chowdhury/Lobo Study
NaCl 0.9% significantly reduced renal blood flow, renal cortical tissue perfusion, urine output, and significantly increased time to first void vs. Plasma-Lyte
1. Chowdhury et al. Annals of Surgery July 2012, 256(1): 18-24
Time to First Void (P=0.006) Total Volume (P=0.002)Plasma-Lyte 90 min. 833 mL
NaCl 0.9% 142 min 533 mL
![Page 113: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/113.jpg)
Normal Saline vs Plasma-Lyte in Abdominal Surgical Patients: Shaw et al
– Retrospective cohort study (Premier database)
– Major abdominal surgery– Patients either received saline
or Plasma-Lyte
Shaw AD, et al. Ann Surg. 2012 May; 255(5):821-9. *Major morbidity: respiratory failure, cardiac complications, major gastrointestinal dysfunction, infectious complications, and acute renal failure. **Minor complications: Gastrointestinal dysfunction and electrolyte disturbances
Major Open Abdominal Surgery467,131 cases
Received Balanced Fluid (Plasma-Lyte) During
Hospitalization9,905 cases
Received Balanced Fluid on Procedure Date
8,285 cases
Only Balanced Fluid on Procedure Date
926 cases
Balanced Fluid Cohort926 cases
Received 0.9% Saline During Hospitalization346,901 cases
Received 0.9% Saline on Procedure Date262,904 cases
Only 0.9% Saline on Procedure Date
30,994 cases
3:1 Propensity Match
0.9% Saline Cohort2,778 cases
![Page 114: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/114.jpg)
Risk Adjusted Outcomes: Shaw Study
Patients who received Plasma-Lyte:– Received less total fluid 1.7 L vs 2.0 L (p<0.001)– Less likely to be transfused 1.8% vs 11.5% (p<0.001)
• Less blood if transfused 2.7 U vs 2.9 U (p=0.005)– Fewer days on the ventilator 2.5 d vs 3.0 d (p<0.001)– Fewer major infections 5.5% vs 8.2% (p<0.001)– Less likely to be dialyzed 1.0% vs 4.8% (p<0.001)
Large scale observational data support pre-clinical and small trial data: Plasma-Lyte results in less fluid use, fewer complications and less risk of acute kidney injury compared with saline1. Shaw AD, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann
Surg. 2012 May; 255(5):821-9.
![Page 115: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/115.jpg)
Acidosis interventions: Shaw Study
Buffers Blood transfusion ABG Lactic Acid Dialysis0
5
10
15
20
25
Plasma-Lyte Saline
Perc
ent
*
+
+
++
* P<0.05+ P<.001
1. Shaw AD, et al., Ann Surg. 2012 May; 255(5):821-9.
1. Shaw AD, et al., Ann Surg. 2012 May; 255(5):821-9.* P<0.05+ P<.001
![Page 116: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/116.jpg)
Saline Hipertônica
![Page 117: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/117.jpg)
NaCl 7,5%
![Page 118: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/118.jpg)
Colóides
?
![Page 119: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/119.jpg)
![Page 120: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/120.jpg)
![Page 121: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/121.jpg)
![Page 122: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/122.jpg)
Albumina
• Apresentações: 20% hiperoncótica– Transporta para intravascular 5x volume
• Alto custo• Grande efeito “farmacocinético”• Pequeno efeito “farmacodinâmico”
• Indicações – Hipovolemia intra-operatória ???– Grandes queimados ???– Cirurgias hepáticas ??? >40% ressecção ?– Cirróticos: peritonite, paracentese volumosa, S. hepato-renal– Peritoniectomias
![Page 123: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/123.jpg)
Pacientes com TCE tendência pior prog
![Page 124: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/124.jpg)
TCE
SAFE N Engl J Med 2007; 357:874-84.
Aumento da mortalidade no grupo albumina
N = 400
![Page 125: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/125.jpg)
TCE
![Page 126: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/126.jpg)
Rev bras ter intensiva 2011
Uso de albumina humana em pacientes graves: controversias e recomendacoes
![Page 127: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/127.jpg)
ESTUDO ALIAS INICIO 2006
![Page 128: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/128.jpg)
![Page 129: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/129.jpg)
![Page 130: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/130.jpg)
![Page 131: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/131.jpg)
![Page 132: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/132.jpg)
![Page 133: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/133.jpg)
![Page 134: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/134.jpg)
Gelatinas
• Atualmente existem 3 tipos de gelatinas:
– As oxipoligelinas Hisocel® e Polisocel ®– As com cadeias de uréia Haemacel ®
– As gelatinas succiniladas Gelafundin®• Menor incidência de reações anafiláticas
Expansão por 3 horasExpande 80% volume infundido
Duração média 2,5hsApós 1 hora apenas 50% na circulação
Sem limite terapeutico
![Page 135: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/135.jpg)
![Page 136: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/136.jpg)
• As gelatinas são colóides sintéticos com boa performance hemodinâmica e poucos efeitos colaterais sobre o rim, o sistema imunológico e a coagulação.
• No entanto, seu uso permanece restrito pelo receio quanto as reações anafiláticas 0,1-0,6%
![Page 137: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/137.jpg)
![Page 138: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/138.jpg)
CUIDADO Mais fibrinólise, elevação da amilase
![Page 139: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/139.jpg)
HES - 6% hidroxietilamido + NaCl 0,9%VOLUVEN®
• Alta permanência no intravascular é muito mais duradoura que a dos cristalóides.
• Principal problema coagulopatia. • A anafilaxia é um fenômeno raro.
Com freqüência, aumentos nos níveis séricos da amilase têm sido relatados, podendo atingir até o triplo dos valores de referência, sem no entanto ter-se observado quaisquer alterações na função pancreática
![Page 140: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/140.jpg)
Amidos – hidroxietilamidos (HEA)
• Produz diurese osmótica– Débito urinário: reflete perfusão renal e não volume plasmático
• Anafilaxia : usar dose teste 10-20ml• Altera coagulação: < plaquetas, > TTPA, >TP, <adesão • coágulo, < fator VIII• Função renal: diurese hiperoncótica = lesão tubular• Prurido: pode durar 10 meses
• MONITORAR COAGULAÇÃO E FUNÇÃO RENAL• NÃO USAR POPULAÇÃO DE RISCO
![Page 141: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/141.jpg)
![Page 142: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/142.jpg)
Cristalóides x Colóides
![Page 143: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/143.jpg)
![Page 144: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/144.jpg)
Alemanha 42 pacientes prospectivamente randomizados
Inglaterra Revisão
![Page 145: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/145.jpg)
Holanda 67 pacientes prospectivamente randomizados
Alemanha 66 pacientes prospectivamente randomizados
![Page 146: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/146.jpg)
Métodos: Neste estudo randômico e controlado, 48 pacientes agendados para artroplastia de quadril com raquianestesia foram alocados em dois grupos: 24 receberam uma pré-carga de HES 130/0,4 (15 mL.kg-1) e 24 receberam uma pré-carga de solução de Ringer lactato (30 mL. kg-1) antes da cirurgia
Resultados: A transfusão de hemácias foi necessária em 17% dos pacientes do grupo HES e em 46% dos pacientes do grupo Ringer lactato (p = 0,029). Infecções pós-operatórias foram observadas com mais frequência no grupo de Ringer lactato (17%) em comparação com o grupo HES (0), p = 0,037.
![Page 147: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/147.jpg)
![Page 148: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/148.jpg)
INTERVENTIONS Colloids(n=1414; gelatins, dextrans, hydroxyethylstarches, or 4% or20% of albumin) or
crystalloids (n = 1443; isotonic or hypertonic saline or Ringer lactate solution) for all fluid interventions other than
fluid maintenance throughout the ICU stay.
JAMA. 2013;310(17):1809-1817.
In the crystalloids group, about 86% of patients were resuscitated with isotonic saline and about 17% with buffered
solutions. In the colloids group, about 70% of patients received hydroxyethyl starches and about 35% received gela- tins.
These features are in keeping with routine practices in the participating countries.
![Page 149: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/149.jpg)
JAMA. 2013;310(17):1809-1817.
![Page 150: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/150.jpg)
• Resultados conflitantes• 456 estudos que selecionou 19 trabalhos pequenos não encontrou
aumento de mortalidade ou IRenal.• Recomendação dos HES em pacientes cirúrgicos?• Maioria dos estudos demonstrando ausência de benefícios.• Autores concluíram não haver recomendação em continuar uso HES 6%.
![Page 151: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/151.jpg)
Lancet 2012; 380: 1059−1065Br J Anaesth 2011; 107: 693−702.
the CRYSTMAS study. Crit Care 2012; 16: R94.The CRISTAL randomized trial. JAMA 2013; 310: 1809−1817.
Anesthesiology 2013; 118: 387−394.Anesth Analg 2013; 166: 35−48.
![Page 152: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/152.jpg)
![Page 153: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/153.jpg)
O quanto repor ?: Restritivo x Liberal
![Page 154: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/154.jpg)
Quanto? Liberal Restritivo Repor as perdas
![Page 155: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/155.jpg)
• Estudo observacional com 479 pacientes cirúrgicos de alto risco.
• BH >2000ml associado a complicações neurológicas, respiratórias e CVs.
• Maiores taxas de infecção.• Maior tempo de ventilação mecânica e
terapia intensiva.• Associação entre balanço positivo e
mortalidade em pacientes cirúrgicos.
![Page 156: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/156.jpg)
N = 156
![Page 157: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/157.jpg)
O que não fazer
O Endotélio vascular saudável é revertido pelo glicocálix. Essa camada externa à membrana celular, formada por uma rede frouxa de carboidratos que recobre a membrana plasmática, tem função de:Repor volume indiscriminadamente lava o glicocálix, piorando a microcirculação, afetandodiretamente a resposta inflamatória e piorando as trocas sangue/tecido.
![Page 158: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/158.jpg)
![Page 159: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/159.jpg)
Estratégia guiada por metas
LIBERAL RESTRITIVO
Terapia individualizada
guiada por metas
![Page 160: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/160.jpg)
www.anesthesia-analgesia.org
March 2012 • Volume 114 • Number 3
![Page 161: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/161.jpg)
Pneumonia
Edema pulmonar
![Page 162: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/162.jpg)
Tempo de internação
Tempo de internação
![Page 163: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/163.jpg)
Mortalidade
Mortalidade
![Page 164: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/164.jpg)
JAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305
![Page 165: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/165.jpg)
![Page 166: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/166.jpg)
![Page 167: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/167.jpg)
Date of download: 4/23/2015Copyright © 2015 American Medical Association.
All rights reserved.
From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery: A Randomized Clinical Trial and Systematic Review
JAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305
Cumulative Incidence of Mortality Up to 180 Days After Surgery Using a Cardiac Output–Guided Hemodynamic Therapy Algorithm Intervention vs Usual Care
Figure Legend:
![Page 168: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/168.jpg)
From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery: A Randomized Clinical Trial and Systematic Review
JAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305
Meta-analysis of Number of Patients Developing Complications After Surgery
![Page 169: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/169.jpg)
![Page 170: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/170.jpg)
• Revisão da literatura usando MEDLINE, EMBASE e Cochrane (ate set 2013).
• 14 estudos (961 participantes). • GDFT reduziu a morbimortalidade PO.• ↓ infecções, complicações cardiacas e abdominais.• ↓ permanência no CTI.• Parâmetros dinâmicos podem representar alternativa para guiar a
reposição de fluidos no perioperatório.
![Page 171: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/171.jpg)
![Page 172: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/172.jpg)
![Page 173: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/173.jpg)
![Page 174: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/174.jpg)
COMO? Avaliar parâmetros
Parâmetros de avaliação da pré-carga e volemia
• PVC• POP• Diâmetro diastólico final VE• ∆ PP > 13%Cannesson at allAnesthesiology 2011;115:231–41.
Perfusão tissular
• Lactato• Déficit de base• SvO2 • SvcO2
Doppler transesofágico
![Page 175: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/175.jpg)
Uso clínico – responsividade volêmica
Anesth Analg 2009;108:513–7
![Page 176: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/176.jpg)
Uso clínico – responsividade volêmica
![Page 177: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/177.jpg)
![Page 178: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/178.jpg)
![Page 179: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/179.jpg)
![Page 180: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/180.jpg)
![Page 181: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/181.jpg)
![Page 182: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/182.jpg)
![Page 183: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/183.jpg)
SARA
![Page 184: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/184.jpg)
![Page 185: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/185.jpg)
![Page 186: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/186.jpg)
![Page 187: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/187.jpg)
![Page 188: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/188.jpg)
Lesões do SNC
Traumatismos cranioencefálicos estão presentes em mais de 50% dos politraumas e a hipotensão é sabidamente nociva nessas condições, com aumento da morbimortalidade.
Vane, LA e Silva ED. Reposição Volêmica, Transfusão Peroperatória e Monitorização.Atualização em Anestesiologia, volume 15, SAESP. Ed. Manole. 2013.
![Page 189: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/189.jpg)
![Page 190: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/190.jpg)
![Page 191: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/191.jpg)
![Page 192: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/192.jpg)
Lesões do SNC
Balancear a reposição volêmica é mandatório nessas situações, permitindo a perfusão da medula e do encéfalo sem aumentar excessivamente a PA a ponto de causar ou reativar focos de sangramento.
Esse objetivo geralmente é alcançado com PAS acima de 90 mmHg, ou seja, quando há pulso radial palpável.
Vane, LA e Silva ED. Reposição Volêmica, Transfusão Peroperatória e Monitorização.Atualização em Anestesiologia, volume 15, SAESP. Ed. Manole. 2013.
![Page 193: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/193.jpg)
Journal of Anaesthesiology, Clinical Pharmacology, 29(3), 299–302.
![Page 194: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/194.jpg)
Journal of Anaesthesiology, Clinical Pharmacology, 29(3), 299–302.
TCE esta associado a IRA em 9-23%
Amidos estão associados com o aumento das chances de IRA e diálise no paciente critico e aumento da mortalidade nesse cenário
Os colóides não parecem ser o fluido de escolha para o paciente com TCE
![Page 195: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/195.jpg)
![Page 196: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/196.jpg)
![Page 197: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/197.jpg)
?
![Page 198: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/198.jpg)
From: Effect of Erythropoietin and Transfusion Threshold on Neurological Recovery After Traumatic Brain Injury: A Randomized Clinical Trial
JAMA. 2014;312(1):36-47. doi:10.1001/jama.2014.6490
![Page 199: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/199.jpg)
![Page 200: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/200.jpg)
![Page 201: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/201.jpg)
78 A 144
![Page 202: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/202.jpg)
![Page 203: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/203.jpg)
![Page 204: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/204.jpg)
![Page 205: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/205.jpg)
![Page 206: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/206.jpg)
SEPSE
![Page 207: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/207.jpg)
![Page 208: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/208.jpg)
![Page 209: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/209.jpg)
![Page 210: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/210.jpg)
![Page 211: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/211.jpg)
![Page 212: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/212.jpg)
![Page 213: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/213.jpg)
Hydroxyethyl Starch 130/0.42 versus Ringer's Acetate in Severe Sepsis
Conclusions
Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer's acetate. (Funded by the Danish Research Council and others; 6S ClinicalTrials.gov number, NCT00962156.)
This article was published on June 27, 2012, and updated on July 12, 2012, at NEJM.org.
800 pacientes 200 morreram no grupo
Coloide vs 170 no grupo ringer
![Page 214: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/214.jpg)
![Page 215: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/215.jpg)
![Page 216: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/216.jpg)
Intensive Care Med (2013) 39:165–228
![Page 217: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/217.jpg)
EGDT
![Page 218: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/218.jpg)
![Page 219: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/219.jpg)
![Page 220: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/220.jpg)
![Page 221: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/221.jpg)
![Page 222: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/222.jpg)
![Page 223: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/223.jpg)
Choque Hemorrágico
![Page 224: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/224.jpg)
![Page 225: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/225.jpg)
• Controle precoce evitar coagulopatia e trombocitopenia, e reduzir o uso de hemoderivados
• Uso limitado de cristaloides evita prevenir coagulopatia dilucional• Uso limitado de SF 0,9% evitar acidose adicional• Ressuscitação hipotensiva PAS entre 80 e 100 mmHg• Uso precoce de plasma, plaquetas e concentrado de hemácias• Fibrinogênio > 150 mg/dl• Tromboelastograma ******
![Page 226: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/226.jpg)
• Uso restrito de hemoderivados• Concentrado de hemácias hemoglobina < 7 g/dl• Normovolemia com cristalóides mais colóides
![Page 227: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/227.jpg)
![Page 228: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/228.jpg)
![Page 229: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/229.jpg)
?
![Page 230: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/230.jpg)
![Page 231: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/231.jpg)
N = 300, e o estudo foi feito em pacientes que se recusaram a receber sangue !!!
![Page 232: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/232.jpg)
![Page 233: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/233.jpg)
![Page 234: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/234.jpg)
![Page 235: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/235.jpg)
![Page 236: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/236.jpg)
![Page 237: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/237.jpg)
Então, qual a alternativa ?
![Page 238: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/238.jpg)
![Page 239: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/239.jpg)
![Page 240: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/240.jpg)
![Page 241: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/241.jpg)
• Hemoblogina de 7 mg/dl• Fibrinogenio de 200 mg/dl ou Fibtem > 9• Plaquetas de 50.000 (TCE 100.000)• Calcio, pH e temperatura normais• Acido Tranexamico• TP, TTPA e INR
![Page 242: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/242.jpg)
![Page 243: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/243.jpg)
RISCOS DAS TRANSFUSAO• Reacoes por incompatibilidade• Reacoes transfusionais agudas e tardias• Imunossupressao• Transmissao de infeccoes (infeccoes bacterianas, virais e prions)• Doenca do enxerto versus hospedeiro• Imunomodulacao• Resposta inflamatoria sistemica• Complicacoes metabolicas (acidose, hiperpotassemia, hipotermia)• Lesao de reserva ou estocagem• TRALI• Sobrecarga circulatoria relacionada a transfusao (TACO)• Aumento da morbimortalidade em pacientes clinicos e cirurgicos
![Page 244: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/244.jpg)
![Page 245: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/245.jpg)
Conduta Anestésica Baseada em Metas
![Page 246: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/246.jpg)
Conduta Anestésica Baseada em Metas
![Page 247: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/247.jpg)
Conduta Anestésica Baseada em Metas
![Page 248: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/248.jpg)
![Page 249: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/249.jpg)
![Page 250: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/250.jpg)
![Page 251: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/251.jpg)
![Page 252: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/252.jpg)
![Page 253: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/253.jpg)
![Page 254: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/254.jpg)
![Page 255: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/255.jpg)
![Page 256: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/256.jpg)
![Page 257: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/257.jpg)
![Page 258: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/258.jpg)
Coagulopatia
![Page 259: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/259.jpg)
![Page 260: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/260.jpg)
![Page 261: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/261.jpg)
![Page 262: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/262.jpg)
Manuseio da Coagulopatia
PFC, plaquetas, crioprecipitado, complexo protrombinico e fatorVIIr parecem ser o principal tratamento da coagulopatia relacionada ao trauma. A terapia deve ser dirigida por metas e proporcional, equilibrando o uso de hemocomponentes
![Page 263: Anestesia em Urgencias e Trauma 2015](https://reader037.vdocuments.pub/reader037/viewer/2022102817/55d275dbbb61eb8d208b469e/html5/thumbnails/263.jpg)
Anestesiologia é pioneira em segurança e muda o prognóstico dos pacientes.
www.sadif.com.br