RESUMO
Objetivo: Estudo realizado a partir da revisão deprontuários de pacientes internados na Unidade deTerapia Intensiva Pediátrica do Hospital Universitárioda Universidade de São Paulo, no período dedezembro de 2001 a dezembro de 2004, descreveoito casos de choque séptico refratário a catecolaminas.Método: Observou-se que predominou perfilhemodinâmico, baseado em informações obtidasdo cateter de artéria pulmonar (CAP). Resultados:Houve elevado índice cardíaco e baixa resistênciavascular sistêmica. Conclusão: Os achados desseestudo diferem da descrição de Ceneviva et al.Novos estudos necessitam ser realizados visandoesclarecer o perfil hemodinâmico de crianças comchoque séptico refratário a volume e catecolaminase definir o papel da monitorização com CAP nesses casos.
Objectives: Study done from the revision of charts ofhospitalized patients from the Pediatric Intensive CareUnit of Hospital of the University of São Paulo, in periodof December 2001 to December 2004, describes 8 casesof catecholamine-resistant septic shock. Methods: It wasobserved that the predominant hemodynamic profile, basedon information obtained from pulmonary artery catheter(PAC). Results: There was high cardiac index and lowsystemic vascular resistance. Conclusion: It was differentfrom description of Ceneviva et al. New studies must beundertaken to clarify the hemodynamic profile of childrenwith volume and catecholamine-resistant septic shock andto define the role of PAC monitoring in these cases.
Assuntos
Humanos , Masculino , Feminino , Recém-Nascido , Lactente , Pré-Escolar , Criança , Adolescente , Artéria Pulmonar/cirurgia , Catecolaminas , Cateterismo de Swan-Ganz , Choque Séptico , HemodinâmicaRESUMO
OBJECTIVES: To analyze mortality rates of children with severe sepsis and septic shock in relation to time-sensitive fluid resuscitation and treatments received and to define barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines in a pediatric intensive care unit in a developing country. METHODS: Retrospective chart review and prospective analysis of septic shock treatment in a pediatric intensive care unit of a tertiary care teaching hospital. Ninety patients with severe sepsis or septic shock admitted between July 2002 and June 2003 were included in this study. RESULTS: Of the 90 patients, 83% had septic shock and 17% had severe sepsis; 80 patients had preexisting severe chronic diseases. Patients with septic shock who received less than a 20-mL/kg dose of resuscitation fluid in the first hour of treatment had a mortality rate of 73%, whereas patients who received more than a 40-mL/kg dose in the first hour of treatment had a mortality rate of 33% (P < 0.05). Patients treated less than 30 minutes after diagnosis of severe sepsis and septic shock had a significantly lower mortality rate (40%) than patients treated more than 60 minutes after diagnosis (P < 0.05). Controlling for the risk of mortality, early fluid resuscitation was associated with a 3-fold reduction in the odds of death (odds ratio, 0.33; 95% confidence interval, 0.13-0.85). The most important barriers to achieve adequate severe sepsis and septic shock treatment were lack of adequate vascular access, lack of recognition of early shock, shortage of health care providers, and nonuse of goals and treatment protocols. CONCLUSIONS: The mortality rate was higher for children older than 2 years, for those who received less than 40 mL/kg in the first hour, and for those whose treatment was not initiated in the first 30 minutes after the diagnosis of septic shock. The acknowledgment of existing barriers to a timely fluid administration and the establishment of objectives to overcome these barriers may lead to a more successful implementation of the American College of Critical Care Medicine guidelines and reduced mortality rates for children with septic shock in the developing world.
Assuntos
Hidratação , Fidelidade a Diretrizes , Guias de Prática Clínica como Assunto , Ressuscitação/métodos , Sepse/terapia , Choque Séptico/terapia , Fatores Etários , Brasil/epidemiologia , Criança , Pré-Escolar , Estudos de Coortes , Comorbidade , Infecção Hospitalar/microbiologia , Infecção Hospitalar/mortalidade , Infecção Hospitalar/terapia , Países em Desenvolvimento , Diagnóstico Precoce , Feminino , Hidratação/métodos , Mortalidade Hospitalar , Hospitais de Ensino/estatística & dados numéricos , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Masculino , Estudos Prospectivos , Estudos Retrospectivos , Sepse/microbiologia , Sepse/mortalidade , Choque Séptico/diagnóstico , Choque Séptico/microbiologia , Choque Séptico/mortalidade , Fatores de Tempo , Recursos HumanosRESUMO
INTRODUCTION: The ACCM/PALS guidelines address early correction of paediatric septic shock using conventional measures. In the evolution of these recommendations, indirect measures of the balance between systemic oxygen delivery and demands using central venous or superior vena cava oxygen saturation (ScvO(2) > or = 70%) in a goal-directed approach have been added. However, while these additional goal-directed endpoints are based on evidence-based adult studies, the extrapolation to the paediatric patient remains unvalidated. OBJECTIVE: The purpose of this study was to compare treatment according to ACCM/PALS guidelines, performed with and without ScvO(2) goal-directed therapy, on the morbidity and mortality rate of children with severe sepsis and septic shock. DESIGN, PARTICIPANTS AND INTERVENTIONS: Children and adolescents with severe sepsis or fluid-refractory septic shock were randomly assigned to ACCM/PALS with or without ScvO(2) goal-directed resuscitation. MEASUREMENTS: Twenty-eight-day mortality was the primary endpoint. RESULTS: Of the 102 enrolled patients, 51 received ACCM/PALS with ScvO(2) goal-directed therapy and 51 received ACCM/PALS without ScvO(2) goal-directed therapy. ScvO(2) goal-directed therapy resulted in less mortality (28-day mortality 11.8% vs. 39.2%, p=0.002), and fewer new organ dysfunctions (p=0.03). ScvO(2) goal-directed therapy resulted in more crystalloid (28 (20-40) vs. 5 (0-20 ml/kg, p<0.0001), blood transfusion (45.1% vs. 15.7%, p=0.002) and inotropic (29.4% vs. 7.8%, p=0.01) support in the first 6 h. CONCLUSIONS: This study supports the current ACCM/PALS guidelines. Goal-directed therapy using the endpoint of a ScvO(2)> or =70% has a significant and additive impact on the outcome of children and adolescents with septic shock.