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Modulo: Medicina CriticaSEPSIS Y RIS
Presenta:Rafael Eduardo Herrera Elizalde R3ACoordinador:Dr. Jesús Sánchez Calderón MA
Enero 2016
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Objetivos•Describir SRIS
•Describir Sepsis (Dx)
•Describir Tratamientos actuales
▫Basado en Metas!!
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Sepsis (Complicación de Infecciones Severas)
Cardinales
▫ Inflamación▫ Vasodilatación▫ Leucocitosis▫ Alteración
Permeabilidad microvascular
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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SRIS (Complicación de inflamación no infecciosa)
Cardinales
▫ Inflamación▫ Vasodilatación▫ Leucocitosis▫ Alteración
Permeabilidad microvascular
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Definiciones…•1991, American College of Chest
Physicians and Society of Critical Care Medicine
•2001, 2012, International Sepsis Definitions Conference (ACCP, SCCM, ATS,ESICM, SIS)http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-
definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Definiciones…
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Definiciones…
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Síndrome Respuesta Inflamatoria Sistémica
•Inflamación fuera de control
•Antes: SRIS era infecciosa y no
•Ahora: ▫SRIS▫Sepsis
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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SRIS•2 o mas
anormalidades en ciertos parámetros vitales
•Ahora:▫SRIS▫Sepsis Temprana
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Evolución Diagnostica•Infección
•Bacteriemia
•Sepsis
▫Infección o Bacteriemia
▫SRIShttp://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-
definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Criterios
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Criterios
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Evolución Diagnostica
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Evolución Diagnostica•Disfunción Orgánica Múltiple
Criterios Generales
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Factores de Riesgo
•Bacteriemia• Edad Mayor 65 a•Inmunosupresión•DM y Cáncer•NAC•Factores Genéticos
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Epidemiologia•1970, 164 mil casos año•1979 – 2000 – 1,655,000 casos
•1998 – 2009 – 13 a 78 casos por 100,000
•Bacterias: Gram Positivos, Gram Negativos▫Micoticas
•Mayor Severidad con el paso de los años!!!
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Mortalidad y Pronostico•Rango: 10 al 52%
•Mortalidad Mayor con severidad▫SIRS 7%▫Sepsis 16%▫Sepsis Severa 20%▫Choque Séptico 46%
•Con estrategias, reducción en mortalidad 50%
http://www.uptodate.com.pbidi.unam.mx:8080/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?source=search_result&search=sepsis&selectedTitle=1~150
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Tratamiento
Temprano!!!
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Temprano!•Líquidos•Antibióticos
•Medidas Soporte
▫Hipoxemia▫Hipotensión
•Dx Diferencial SIRS/Sepsis
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Manejo Inicial•AB
▫O2 complementario▫Oximetría Pulso
▫Ventilación Mecánica Protectora
▫Gasometrías (A y V)▫Rx Tórax
SIRA!!!http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-
shock-in-adults?source=see_link
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Continuamos…•Perfusión…
▫Hipotensión?▫Hipoperfusión con
Normotensión?
•Hipotensión:▫SBP <90 mmHg▫PAM <70▫Descens0 SBP >40
•Línea Arterial Indicada!
•No retirar Atención
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Evaluando Perfusión…•Sepsis temprana – Piel Rojiza, Caliente
▫Choque – Piel Fría.
•Taquicardia,•Alteraciones estado de conciencia•Oliguria o anuria (IRA)
•Comorbilidades!!! (p. eje HAS descontrolada)http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-
shock-in-adults?source=see_link
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Evaluando Perfusión•Lactato!!
▫Mayor 12 mmol/l
▫Antes que Hipotensión!!
▫>4 (Sepsis Severa)
(Plaq, INR, Cr, Bilirrubina)
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Evaluando Perfusión
•Tonometría Gástrica
(Vasopresión)
▫pCO2 Gástrico
▫Gradiente Arterial-Gástrico de CO2
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Accesos Venosos???•Periférico – De
primera línea
•Acceso Venoso Central!
▫PVC▫ScvO2
•Pulmonar…No!http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-
shock-in-adults?source=see_link
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Restableciendo el Flujo!!!
•Fluidos (Cristaloides)
•Vasopresores!
•Inotrópicos!
•Transfusionales!
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Líquidos Intravenosos
▫3 a 5 litros!
▫Luego 2 a 3 litros!
▫En 6 horas!!
1. Tx por Metas!1. Tempranas
2. Bolos 500 ml y revalorar!
3. Sensibilidad de Tejidos a Volumen!
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Tipo de Fluidos• SAFE (saline vs
Albumin Fluid Eval).▫No Diferencia!
• Scandinavian Starch for Severe Sepsis and Septic Shock▫33 ml/kg▫90 días – Mayor
Mortalidad y Sustitución Renal
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Tipo de Fluidos•Hartman vs
Pentalmidon
▫Efficacy of Volume Substitution and Insulin therapy in SS (VISEP)
▫Suspendido!!!http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-
shock-in-adults?source=see_link
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Conclusiones sobre líquidos•Cristaloides sobre todo
•Vs Albumina – Muy Caro
•Coloides – Riesgos
•Usar con Metas Especificas y Tempranas!!!
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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VASOPRESORES!!!
•Segunda Línea!
¿¿¿Seguros???
•Noradrenalina!•Fenilefrina!•Efedrina??
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Inotropismo•Choque
Refractario!
•Falla Cardiaca
•Bajo GC▫Shoemaker!!
¿Vasodilatación?http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-
shock-in-adults?source=see_link
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Transfusionales
•Hb Menor 7 mg/dl
•Restrictivo▫7 mg/dl
•Liberal▫9 mg/dl
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Metas Tempranas (6 horas)• PAM mayor 65 mmHg
• Vol Urinario > 0.5 ml/kg/hora
• CVP 8 – 12 (Estáticos)• IVS Normal (Dinámicos)
• Sat Venosa – 70% - 65%
• Descenso Lactato http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-
shock-in-adults?source=see_link
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Disponibilidad Oxigeno
• Centrales
▫ Gasto Cardiaco
▫ PaO2
▫ Hemoglobina
Periféricos
Distribución de GC en tejidos
○ Regulación microcirculación
(Humoral, Autonómico, Local)○ Afinidad Hemoglobina
Vincent Caille, Pierre Squara, Oxygen uptake-to-delivery relationship: a way to assessadequate flow, Critical Care 2011, 10(Suppl 3): S4 (doi:10.1186/cc4831)
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DO 2/ VO 2VO2
DO2
VO2
Mínimo
DO2 Critico Aporte
Consumo
Dependencia Independencia de Aporte
Aporte Critico
Consumo Minimo
Lactate
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DO2 / VO2Variable ClaveVO2 = plateau
Variables DerivadasDescenso LactatoCO =« Ok » SvO2 =« Ok »
Variables Derivadas de las DerivadasTension Arterial AdecuadaMejoria Clinica
Valor Pronostico (AUC)
0.72
0.700.54 (0.69)0.55 (0,68)
0.660.66
Squara et al J Crit Care, 1994
VO2 = CO x 1.34 x Hb x (SaO2 – SvO2)
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2
3
4
0.82 0.76 0.7 SvO2
CO
Si Hb y Sao2Estable
Choque Septico
Choque Cardiogenico50
100
150 200
Valor Basal
VO2
Disoxia (O2 aportado limita act metabolica)
VO 2
3 4 5 Ca-vO2Vincent Caille, Pierre Squara, Oxygen uptake-to-delivery relationship: a way to assess adequate flow, Critical Care 2011, 10(Suppl
3): S4 (doi:10.1186/cc4831)
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Foco Séptico
•Control de Foco Séptico
•Erradicación de foco Séptico
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Adicionales…•Nutrición
•Trombosis Venosa
•Terapéutica de Insulina
•Control de temperatura!
http://www.uptodate.com.pbidi.unam.mx:8080/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults?source=see_link
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Terapéutica Temprana!!!Usar los Recursos
disponibles!!