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Dopamina: medicação de escolha em choque séptico refratário a volume?

Apresentador "Pro”

Antonio [email protected]

Médico coordenadorUnidade de Medicina Intensiva PediátricaUnidade de Medicina Intensiva Neonatal

Hospital Padre Albino

Professor de Pediatria nível II Faculdades Integradas Padre Albino

Catanduva / SP

UTI Pediátrica & Neonatal / Hospital Padre Albino FIPA

Antonio Souto [email protected] 2011



Because of the paucity of outcome-directed, randomizedcontrolled trials, the recommendations for hemodynamicsupport of term newborns and children in this documentare primarily expert opinion rather than irrefutablevidence.

Crit Care Med 2002; 30:1365 -1378



nCI=3,3L/min/m2;

nSVRI= 800 dyne/sec/cm5

58% CI↓ + SVRI↑

20% CI↑ + SVRI↓

22% CI↑ + SVRI↑



Pediatrics 1998;102(2)

58% CI↓ + SVRI↑

20% CI↑ + SVRI↓

22% CI↑ + SVRI↑



Unlike adults, children with fluid-refractoryshock are frequently hypodynamic andrespond to inotrope and vasodilator therapy.



Because hemodynamic states are heterogeneousand change with time,

an incorrect cardiovascular therapeuticregimen should be suspected in any childwith persistent shock.



...fluid-refractory shock are frequently hypodynamic an d respondto inotrope and vasodilator therapy

Dopamina (5-15 mg/kg/min)

•Ação predominantemente beta-1 cardíaco •Efeito inotrópico positivo•Moderada vasodilatação periférica (efeito beta-2 na circulação muscular esquelética e a seu efeito delta nas circulações esplâncnica e renal)

Promove um aumento do DC e da PAM pelo aumento da F C, contratilidade, como pela redução moderada na pós-c arga apesar do mínimo efeito na resistência vascular sitêmica.

Crit Care Med 2004; 32:1928–1948




Crit Care Med 2009; 37:666–688

Many studies have tested the observations andrecommendations of the 2002 guidelines.



Crit Care Med 2009; 37:666–688

... the guidelines wereuseful and effective withoutany evidence of harm.



Crit Care Med 2009; 37:666–688

•Wills BA, Nguyen MD, Ha TL, et al: Comparison of the three fluid solutions for resuscitation in dengue shock. N Engl J Med 2005; 353:877–889

•Maitland K, Pamba A, English M, et al: Randomized trial of volume expansion with albumin or saline in childrenwith severe malaria: Preliminary evidence of albumin benefit. Clin Infect Dis 2005; 40:538–545

•Han YY, Carcillo JA, Dragotta MA, et al: Early reversal of pediatric-neonatal septic shock by communityphysicians is associated with improved outcome. Pediatrics 2003; 112:793–799

•Ninis N, Phillips C, Bailey L, et al: The role of healthcare delivery on outcome of meningococcal disease in children: Casecontrol study of fatal and non-fatal cases.BMJ 2005; 330:1475

•de Oliveira CF, de Oliveira DS, Gottschald AF, et al: ACCM/PALS haemodynamic support guidelines for paediatric septic shock: An outcomes comparison with and without monitoring central venous oxygen saturation. Intensive Care Med 2008; 34:1065–1075

•Karapinar B, Lin JC, Carcillo JA: ACCM guidelines use, correct antibiotic therapy,and immune suppressantwithdrawal are associated with improved survival in pediatric sepsis, severe sepsis, and septic shock. Crit CareMed 2004; 32(12 Suppl 3):A161

•Maat M, Buysse CM, Emonts M, et al: Improved survival in children with sepsis and purpura: Effects of age, gender, and era. Crit Care 2007; 11:172

•Odetola FO, Gebremariam A, Freed GL: Patient and hospital correlates of clinical outcomes and resourceutilization in severe pediatric sepsis. Pediatrics 2007; 119:487–494



Taken together, these studies indirectlyand directly

support the utility and efficacy

of implementation of the time sensitive, goal-directed recommendations of the2002 guidelines...

Crit Care Med 2009; 37:666–688



Crit Care Med 2009; 37:666–688



O uso de drogas vasopressoras permanece controverso. A escolha de uma droga permanece aberta.

... questão sem solidas e robustas respostas...



Sepsis is a complex, highly variable, multiple system, clinical process ...

Pediatr Crit Care Med 2005; 6[Suppl.]:S55–S60

...complex interactions between the infecting microorganismand the host immune, inflammatory and coagulation

responses...



... these terms do not allow for precise characterizationand staging of patients with this condition.

Crit Care Med 2003 Vol. 31, No. 4



TNM (Pierre Denoix, 1946)

will stratify patients on the basis of their Predisposingconditions, the nature and extent of the insult (in thecase of sepsis, Infection), the nature and magnitude ofthe host Response, and the degree of concomitantOrgan dysfunction

Crit Care Med 2003;31:1250–6



http://www.infectio-lille.com/diaporamas/2011/KIPNI S_DUACAI2011.pdf



WHAT CLINICAL SIGNS AND HEMODYNAMIC VARIABLES CAN B E USED TO DIRECT TREATMENT OF NEWBORN AND PEDIATRIC SHOCK?

... to define septic shock by clinical, hemodynamic, and oxygen use variables

only.

...to restoring normal mental status and

peripheral perfusion.



...hemodynamic states are heterogeneous andchange with time...




Podem então ser traçadas “diretrizes” uniformes para aplicação em crianças tão diferentes?

...o trabalho desenvolvido por Dr. Carcillo e a força-tarefa procuram pôr alguma ordem e sistematização nas condutas

das diferentes apresentações clínicas...



Clinical criteria generally used to definite septic shock do not allow for early identification of patients with good or bad prognosis.



Our hypothesis is that “dopamine-sensitive” patients have a better prognosis than those with a “dopamine-resistant” profile.



Mortality rate was 16% (seven of 44 patients) for the Dopa-S group

comparedwith 79% (52 of 66

patients) for the Dopa- R group (p

.0006)



… the use of dopamine is controversial since it could delay the use of norepinephrine, hence leading to persistent circulatory failure.



The present results clearly demonstrate that the rapid administration of incremental doses of dopamine followed by a switch to epinephrine or norepinephrine

does not increase mortality rate when compared with other septic shock studies .



We have demonstrated that the use of dopamine responsiveness is a reliable and independent predictive factor for mortality.



The use of dopamine allows discrimination between two very differing groups with regard to mortality outcomes,

thereby enabling the inclusion of homogeneous groups, in terms of severity, in multiple -center studies .



Dopamina: medicação de escolha em choque séptico refratário a volume?Apresentador "Pro”



Vasopressors/ inotropes should

only be used after appropriate

volume resuscitation in septic

shock... Parker et al. CCM 2004;32 (suppl): s591



... to define septic shock by clinical, hemodynamic, and oxygen use .

Crit Care Med 2002; 30:1365 -1378



Hospital Padre Albino

Hospital Emílio Carlos

Escola de medicina

Obrigado !

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