Este documento descreve o caso de um menino de 12 anos que apresentou choque séptico devido a uma infecção grave em sua perna esquerda. Ele foi internado em uma unidade de terapia intensiva pediátrica onde recebeu tratamento intensivo, incluindo antibióticos, suporte hemodinâmico e cirurgia. Apesar dos esforços, seu estado clínico permaneceu instável nos primeiros dias de internação.
2. Decisões clínicas difíceis
Antonio Souto
acasouto@bol.com.br
Unidade de Medicina Intensiva Pediátrica
Faculdades Integradas Padre Albino
Hospital Padre Albino – Catanduva / SP
3. Escolha do caso
• Caso difícil ?
• Doença de base pouco freqüente
(relatos de casos e pequenas séries)
• Falta de consenso com relação a conduta
• Complicação importante dentro da medicina
intensiva
• Discussão da aplicação de guidelines
estabelecidos
• Importância clínica
4. Coleta de dados
Informantes (Subjetivos)
• Mãe
• Equipe médica
• Revisão do prontuário (Objetivo)
• Aspectos mais importantes
5. Paciente
• Masculino
• Branco
• Nasc: 22/01/1998 – 12 a
• 35 Kg
• Vacinação adequada
• Sem AP importantes
6. HMA D1
• 14h: Ferida perfuro-cortante, 10 cm, em 1/3 médio
anterior de perna esquerda quando nadava em açude
(potencialmente contaminada)
• 16h: Posto de saúde:
• “Relatou ferimento no portão de casa”
• CD: Sutura + curativo
• Antiinflamatório
12. HMA D3
Internação hospitalar (enfermaria)
• HD: Ferida PC infectada + Celulite de MIE
• Internação 19h
• Ceftriaxona + Clindamicina 22 h
• Ranitidina
• Sem diurese durante a noite
• PA 80/30 21:15h
13. HMA D3
Hb 9,6 / Ht 28,2 TP 18,9s Gaso arter
L 3000 INR 2,24 Ar ambiente
N 81% (2430) PH 7,34
M/Mt 0/0 TTPA 40s PaCO2 31
B 2% PaO2 68
S 79% BE – 9
E 1% Bic 16
Lf 10% CO2t 15
Mn 8% Sat 91%
Pl 98000
14. HMA D4
• Avaliação pelo cirurgião geral
• Drenagem de material purulento
(Necrótico)
• Ceftriaxona + Clindamicina
• Ranitidina
• Clexane (enoxaparina)
20 mg SC
• Sem Diurese durante a noite
• PA 80/30 21:15h
15. HMA D1/4
UTI Pediátrica 11 h
• Ferida aberta em MIE com drenagem de
material purulento
• Edema de MIE e sinais flogísticos até a coxa
• Hematomas em perna esquerda
• MEG, torporoso, AA, febril, taquidispneico
• Glasgow = 8
• MV + S S/RA
• Abdome Fl, RHA+, Indolor à palpação
16. HMA D1/4
UTI Pediátrica 11 h
• Palidez
• Taquicardia
• Extremidades frias
• Pulso fino
• Enchimento capilar > 2 s
• Hipotenso (NI)
20. UTI Ped D1/4
• Suporte hemodinâmico
• Via
• Solução
• Volume
• Drogas
21. UTI Ped D1/4
• Suporte hemodinâmico
• Veia periférica
• S Fisiológico 0,9%
–500 ml 11:15h
–500 ml 12:15h
–500 ml 12:45h ----- Lactato 4,5
–500 ml 13:15h
• 2000 ml (60 ml/Kg) em 2 h
22. UTI ped D1/4
Gaso arter 11:00 13:00 Gaso arter 12:59
O2 inalatório 1500 ml SF 0,9% VPM
PH 7,23 PH 7,23
PaCO2 28 S/ Diurese PaCO2 34,1
PaO2 114 PAni 60/40 PaO2 73,2
BE – 16 FC 95 – 110 BE – 16,2
Bic 12 Lactato 4,5 12:30 Bic 12,3
CO2t 11 CO2t 12
Sat 97% Sat 88%
23. UTI Ped D1/4
• Antibioticoterapia:
–Clindamicina
–Ceftriaxona
26. UTI ped D1/4
Hb 10 / Ht 29,7 TP 17,1 s Gaso arter
L 8900 INR 1,88 O2 inalatório
N 89% PH 7,23
M/Mt 2/3 TTPA 46,7 s PaCO2 28
B 31% PaO2 114
S 53% Ur 69/ Cr 1,1 BE – 16
Lf 5% Bic 12
Mn 6% Glicemia 79 CO2t 11
Pl 122000 AST/ALT Sat 97%
normais
PCR 384 Coagulo normal
27. UTI ped D1/4
• Suporte hemodinâmico
• Veia periférica
• S Fisiológico 0,9%
• 500 ml 11:15h
• 500 ml 12:15h
• 500 ml 12:45h ----- Lactato 4,5
–500 ml 13:15h
• 2000 ml (60 ml/Kg) em 2 h
28. UTI ped D1/4
• Suporte hemodinâmico
–500 ml 13:15h
2000 ml (60 ml/Kg) em 2 h
–500 ml 16h
• Diurese 800 ml
• FC 110 bpm
• PAni 90/50
29. UTI ped D1/4
• 17:00 Gaso arterial
PH = 7,20
PCO2 = 33,9
• 11-17 h
PO2 = 215,2
• 2500 ml SF0,9% BE = - 14,9
Bic = 13
CO2T = 11,9
Sat = 99,5%
30. UTI ped D1/4
• 17:00 Gaso arterial
PH = 7,20
PCO2 = 33,9
• Bicarbonato de sódio
PO2 = 215,2
BE = - 14,9
• NaHCO3 8,4% 40 ml
Bic = 13
• S Fisiol 0,9% 500 ml
CO2T = 11,9
(1,5% 115 mEq Na)
Sat = 99,5%
• EV em 1 h
31. UTI ped D1/4
• 17:00
• Importante edema em MIE
• Diminuição dos pulsos periféricos
• Síndrome compartimental
• Indicada Fasciotomia
69. UTI ped D4/7
• Estável hemodinamicamente
• Epinefrina 0,2 a 0,15 mcg/Kg/min
• PAni 100/50 a 130/80
• FC 100 (82 a 126)
• PVC +15 a + 18
• SatVC 78,4% a 84,5%
• FEBRE
70. UTI ped D4/7
Gaso VC 12h Gaso VC 17h Gaso VC 23h
PH = 7,29 PH = 7,4 PH = 7,4
PO2 = 49 PO2 = 45,1 PO2 = 49,2
BE = -8,1 BE = -2,7 BE = -1,3
Bic = 18,3 Bic = 22,1 Bic = 23,4
Sat = 78,4% Sat = 80,6% Sat = 84,5%
Hb 11,5/HT 34,5
71. UTI ped D4/7
• Edema importante
• “Pouca diurese”
• S Fisiológico 0,9% 500 ml
• Furosemida 1mg/Kg = diurese de 1800 ml
• Albumina 1,8 g/dl
• Albumina 1 g/kg
78. UTI ped D5/8
• Conduta cirúrgica pediátrica
• Debridamento extenso de todo MIE
com retirada de grande quantidade de
material necrótico, grande quantidade
de secreção purulenta, grande perda
de tecido
79. UTI ped D5/8
• Conduta cirúrgica pediátrica
• Debridamento extenso de todo MIE
com retirada de grande quantidade de
material necrótico, grande quantidade
de secreção purulenta, grande perda
de tecido
• AMPUTAÇÃO ?
87. UTI ped D6/9
Gaso VC 12h
PH = 7,43
PCO2 = 45,1
PO2 = 40,3
BE = 4,9
Bic = 29,2
CO2T = 25,5
Sat = 77,8%
Hb/Ht
88. UTI ped resumo
• Fasciíte necrosante MIE
• Complicações
• Lesão aguda pulmonar
• Aumento do suporte ventilatório
– PEEP 12/15
• VPM por 6 dias após estabilidade
hemodinâmica, totalizando 11 dias
89. UTI ped resumo
• Fasciíte necrosante MIE
• 23 dias de internação
• 5 dias c/ drogas cardiovasculares
• 11 dias em VPM/sedação
• 2 esquemas antibióticos
• Jejum por 7 dias- NP/NE
• Alta da UTI neuro normal, RE em ar ambiente,
suplementação c/ dieta enteral, antibióticos por 6
semanas (osteomielite), cirurgia pediátrica
90. UTI ped resumo
• Conduta cirurgica pediátrica
• Curativos diários
• Novos Debridamentos
• Sutura elástica
• Enxerto
• Alta hospitalar no 39º dia de internação
92. UTI ped
• Questionamentos restrospectivos
– Abordagem inicial na cidade de origem
– Indicação da internação
– Diagnóstico de choque/encaminhamento para UTI
– Terapêutica hemodinâmica (volume/drogas)
– Profilaxia de TVP
– Esquema antibiótico inicial
– Uso de corticosteróide no choque
– Uso de bicarbonato de sódio
– Transfusão de hemoderivados
– Monitorização hemodinâmica (PAinvasiva)
– Abordagem cirúrgica/debridamento/amputação
93. PEDIATRICS Vol. 112 No. 4 October 2003, pp. 793-799
Early Reversal of Pediatric-Neonatal Septic Shock by
Community Physicians Is Associated With Improved
Outcome
Early resuscitation with fluid and inotropic therapies improves survival in a
time-dependent manner (American College of Critical Care Medicine-
Pediatric Advanced Life Support (ACCM-PALS) Guidelines )
95. Fluid challenge revisited
Jean-Louis Vincent, MD, PhD, FCCM; Max Harry Weil, MD, PhD, ScD (Hon), FCCM
Crit Care Med 2006; 34:1333–1337
The fluid challenge is reserved for hemodynamically unstable
patients and offers three major advantages:
1. Quantitation of the cardiovascular response
during volume infusion.
2. Prompt correction of fluid deficits.
3. Minimizing the risk of fluid overload and its
potentially adverse effects, especially on the
lungs.
96. What’s going on inside your body?
• Vasoconstriction and thrombosis
• edema hypoxia necrosis of the fascia, skin, soft tissue,
and muscles.
• Additional necrosis involving the subcutaneous nerves.
Justina Du, Thao Nguyen, Camille Thorsen
97. Description of NF
• Clinical features
– Fulminant destruction of tissue
– Systemic signs of toxicity
– High rate of mortality
• Pathological features
– Extensive tissue destruction
– Thrombosis of blood vessels
– Abundant bacteria spreading along fascial planes
– Unimpressive infiltration of acute inflammatory cells
David Hough MSIII
Penn State College of Medicine
98. Biology and Pathogenesis of Thrombosis and
Procoagulant Activity in Invasive Infections Caused by
Group A Streptococci and Clostridium perfringens
Amy E. Bryant*
CLINICAL MICROBIOLOGY REVIEWS, July 2003, p. 451–462
Occlusive microvascular thrombosis participates
in the rapid destruction of viable tissue in gram-
positive necrotizing infections
CONCLUSIONS
result from
The severe pain and rapid tissue destruction probably
hypercoagulation and vascular occlusion mediated by
unique interactions of the organisms and their toxins with the human
coagulation system
99. Corticosteroids for severe sepsis and septic shock: a
systematic review and meta-analysis
Djillali Annane, Eric Bellissant, Pierre Edouard Bollaert, Josef Briegel, Didier
Keh, Yizhak Kupfer
BMJ, doi:10.1136/bmj.38181.482222.55 (published 2 August 2004)
Conclusions
For all trials, regardless of duration of treatment and dose, use of
corticosteroids did not significantly affect mortality.
With long courses of low doses of corticosteroids,
however, mortality at 28 days and hospital
morality was reduced.
CORTICÓIDE PARA TODOS NA SEPSE?
Suzana M. A. Lobo
100. Is there a role for sodium bicarbonate in treating lactic
acidosis from shock?
John H. Boyd and Keith R. Walley
Current Opinion in Critical Care 2008, 14:379–383
Recent findings
The most recent 2008 Surviving Sepsis guidelines strongly recommend
against the use of bicarbonate in patients with pH
at least 7.15, while deferring judgment in more severe acidemia.
There is little rationale or evidence for the use of bicarbonate therapy for
lactic acidosis due to shock.
Effective therapy of lactic acidosis due to
shock is to reverse the cause.
101. Impact of adequate empirical antibiotic therapy on the
outcome of patients admitted to the intensive care unit
with sepsis
Garnacho-Montero, Jose MD, PhD; Garcia-Garmendia, Jose Luis MD, PhD; Barrero-
Almodovar, Ana MD; Jimenez-Jimenez, Francisco J. MD, PhD; Perez-Paredes, Carmen MD;
Ortiz-Leyba, Carlos MD, PhD
Volume 31(12), December 2003, pp 2742-2751
In patients admitted to the ICU for sepsis, the adequacy of
initial empirical antimicrobial treatment is crucial in terms
of outcome
102. Volume 32(11) Supplement November 2004 pp S513-S526
Source control in the management of severe
sepsis and septic shock: An evidence-based
review
[Scientific Reviews]
Marshall, John C. MD; Maier, Ronald V. MD, FACS; Jimenez, Maria MD; Dellinger, E Patchen MD
Conclusion:
Source control represents a key component of success in
therapy of sepsis.
It includes drainage of infected fluids, debridement of infected soft tissues,
removal of infected devices or foreign bodies, and finally, definite measures
to correct anatomic derangement resulting in ongoing microbial
contamination and to restore optimal function.
103. Necrotizing Fasciitis Report of 39 Pediatric Cases
Antonio Fustes-Morales, MD; Pedro Gutierrez-Castrellon, MD; Carola Duran-
Mckinster, MD; Luz Orozco-Covarrubias, MD; Lourdes Tamayo-Sanchez, MD;
Ramon Ruiz-Maldonado, MD
Arch Dermatol. 2002;138:893-899
Conclusions:
Necrotizing fasciitis in children is frequently misdiagnosed, and several
features differ from those of NF in adults..
Early surgical debridement and
antibiotics were the most important
therapeutic measures.
104. Biology and Pathogenesis of Thrombosis and
Procoagulant Activity in Invasive Infections Caused by
Group A Streptococci and Clostridium perfringens
Amy E. Bryant*
CLINICAL MICROBIOLOGY REVIEWS, July 2003, p. 451–462
Tissue destruction progresses rapidly to involve an entire extremity and
such patients require emergent amputation or extensive
surgical debridement and prolonged hospitalization.
In fact, a recent article in the American Journal of Surgery
recommended radical debridement to maximize limb salvage
and survival in cases of severe soft tissue infection
radical amputation remains the single best
life-saving treatment.
105. Treatment of NF- Surgery
• Surgery
– Early and aggressive surgical exploration and
debridement
– This should be done in the first 24 hours of symptoms
– Repeat debridement should be repeated daily until all
necrotic tissue has been removed (typically 2-4 times)
106. Necrotizing Soft Tissue Infections
• Extensive tissue destruction
• High mortality rate
• Mixed aerobic and anaerobic
– gram-negative and gram-positive bacteria
• Recognize early and treat promptly
– Surgical Rx: debride all necrotic tissue
– May require amputation
Return to OR daily until wound is under control
– Worry about reconstruction later
• Hyperbaric O2 controversial
Michael A. West, MD, PhD
Department of Surgery
University California San Francisco
San Francisco, CA, USA
107. COMMON ANTIBIOTIC CHOICES FOR NECROTIZING SOFT TISSUE
INFECTION
There are several alternatives
Review antibiotics after 48 hours
Mixed infection (80%)
Carbapenem or Piperacillin/tazobactam + Aminoglycoside
Monomicrobial (20%)
High dose clindamycin or High-dose penicillin
Michael A. West, MD, PhD
Department of Surgery
University California San Francisco
San Francisco, CA, USA
108. Hospital Padre Albino
Obrigado !
Hospital Emílio carlos
Escola de medicina
Antonio Souto
acasouto@bol.com.br
Unidade de Medicina Intensiva Pediátrica
Faculdades Integradas Padre Albino
Hospital Padre Albino – Catanduva / SP