Medico e infermiere affrontano Sepsi severa e shock settico
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1 Medico e infermiere affrontano Sepsi severa e shock settico R. P. Dellinger Mitchell M. Levy Andrew Rhodes Djillali Annane Herwig Gerlach Steven M. Opal Jonathan E. Sevransky Charles L. Sprung Ivor S. Douglas Roman Jaeschke Tiffany M. Osborn Mark E. Nunnally Sean R. Townsend Konrad Reinhart Ruth M. Kleinpell Derek C. Angus Clifford S. Deutschman Flavia R. Machado Gordon D. Rubenfeld Steven Webb Richard J. Beale Jean-Louis Vincent Rui Moreno GUIDELINE S The Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup* Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012 Intensive Care Med (2013) 39: DOI /s
2 SEPSI INFEZIONE ( presunta o accertata) + MANIFESTAZIONI SISTEMICHE: temperatura > 38.3 C; < 36 C frequenza cardiaca > 90 bpm tachipnea ( vn 9-12/min) alterazione (acuta) del sensorio iperglicemia (>140 mg/dl in pz non diabetico) leucocitosi (GB > mm3) leucopenia (GB < 4000 mm3)
3 SEPSI SEVERA SEPSI + IPOPERFUSIONE PERIFERICA ipotensione (PAS < 90 mmhg; PAM < 70 mmhg) lattati > 1 mmol/l oliguria (flusso urinario < 0,5 ml/kg/ora) o DISFUNZIONE D ORGANO ipossiemia (PaO2/FiO2 < 250; < 200 se polmonite) creatinina > 2 mg/dl bilirubina > 2 U/L piastrine < mm3 INR > 1,5
4 SHOCK SETTICO ipotensione persistente malgrado adeguato reintegro di liquidi SHOCK CRIPTICO lattati > 4 mmol/l in assenza di ipotensione
5 Ma la diagnosi di SEPSI chi la fa? L infermiere accoglie il paziente lo osserva INFEZIONE ( presunta o accertata) + MANIFESTAZIONI SISTEMICHE: temperatura > 38.3 C; < 36 C frequenza cardiaca > 90 bpm tachipnea alterazione (acuta) del sensorio iperglicemia (>140 mg/dl in pz non diabetico) leucocitosi (GB > mm3) leucopenia (GB < 4000 mm3) il paziente è confuso e non collabora la frequenza respiratoria è aumentata rileva i parametri vitali Ha la febbre alta! La temperatura è bassa?!?! Ha una frequenza cardiaca di110 bpm! Ha una frequenza respiratoria di 26 atti al minuto!
6 e poi di SEPSI SEVERA l infermiere ancora parametri vitali la pressione arteriosa è 90/40 mmhg SEPSI + IPOPERFUSIONE PERIFERICA ipotensione (PAS < 90 mmhg; PAM < 70 mmhg) lattati > 1 mmol/l oliguria (flusso urinario < 0,5 ml/kg/ora) o e i lattati? ma la PAM? quanto urina? DISFUNZIONE D ORGANO ipossiemia (PaO2/FiO2 < 250; < 200 se polmonite) creatinina > 2 mg/dl bilirubina > 2 U/L piastrine < mm3 INR > 1,5
7 Pressione arteriosa media (PAM): l importanza della pressione diastolica pressione diastolica + pressione sistolica pressione diastolica 3 SEPSI SEVERA: ipotensione (PAS < 90 mmhg; PAM < 70 mmhg) PA 90/40 mmhg PAM = = 57 mmhg PA 90/60 mmhg PAM = = 70 mmhg Fluidi nel pz critico Colloidi (emagel, albumina) Cristalloidi (sol fisiologica, Ringer lattato)
8 e i lattati? SEPSI SEVERA: lattati>1 mmol/l SHOCK CRIPTICO Lattati >4mmol/L Emogasanalisi arteriosa ma anche l ipossiemia (PaO2/FiO2 < 250; < 200 se polmonite) AA: FiO2 21% 69/0,21= /0,40= /0,31= /0,60= 115
9 SURVIVING SEPSIS CAMPAIGN CARE BUNDLES 3-HOUR BUNDLE: Measure lactate level Obtain blood cultures prior to administration of antibiotics Administer broad spectrum antibiotics (within the first hour of recognition) Administer 30 ml/kg crystalloid for hypotension or lactate 4 mmol/ ENTRO LE PRIME 3 ORE: Esegui un EGA Esegui i prelievi per emocolture (e fallo presto, perché devi ) Somministrare antibiotici ad ampio spettro (ENTRO LA PRIMA ORA) Somministra cristalloidi (30 ml/kg di sol fisiologica in tre ore: per 70 Kg, 2000 cc) se ipotensione o lattati > 4 mmol/l Intensive Care Med (2013) 39:
10 fraction of total patients Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012 Intensive Care Med : Administration of effective IV antimicrobials within the 1 st hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) entro la prima ora, perchè survival fraction cumulative antibiotic initiation per ciascuna ora di ritardo nella somministrazione dell antibiotico nello shock settico, la sopravvivenza si riduce in modo lineare. time from hypotension onset (hrs 0-36) Kumar et al. CCM. 2006:34:
11 SURVIVING SEPSIS CAMPAIGN CARE BUNDLES 6-HOUR BUNDLE: Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): Early Goal-Directed Therapy (EGDT) ENTRO 6 ORE Applica vasopressori* (per l ipotensione che non risponda al reintegro di fluidi) in modo da mantenere una PAM >65 mmhg In caso di persistente ipotensione o lattati sempre >4 mmol/l SAR *la noradrenalina è da preferire rispetto alla dopamina (Revivan) nello shock settico.
12 Alice: E impossibile! Cappellaio matto: Solo se pensi che lo sia.
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