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SIRS E SEPSE
Consenso II e III, identificação e tratamento
Prof.: Diogo da Motta Ferreira
PROFESSOR DA UNIVERSIDADE TUIUTI DO PARANÁ
ANESTESIOLOGIA
FARMACOLOGIA
EMERGÊNCIAS VETERINÁRIAS
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INTRODUÇÃO _________________________________________
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DEFINIÇÃO: _________________________________________
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SEPSE II – SIRS + FOCO DE INFECÇÃO _________________________________________
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SEPSE III – DISFUNÇÃO ORGÂNICA _________________________________________
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OUTRAS DEFINIÇÕES _________________________________________
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» BACTEREMIA
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» SIRS
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» SEPSE
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» CHOQUE SEPTICO _________________________________________
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» SÍNDROME DA DISFUNÇÃO MÚLTIPLA DE _________________________________________
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ÓRGÃOS _________________________________________
» SÍNDROME DO ESTRESSE RESPIRATÓRIO _________________________________________
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AGUDA _________________________________________
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CAPANHA DE SOBREVIVÊNCIA A SEPSE II _________________________________________
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AGENTE ETIOLÓGICO _________________________________________
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» E. COLI
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» QUALQUER MICROORGANISMO
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ORIGEM _________________________________________
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» CÃES • GATOS _________________________________________
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• ABDOME • PERITONITE _________________________________________
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• TRATO RESPIRATÓRIO • PIOTÓRAX _________________________________________
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• ABSCESSO HEPÁTICO_________________________________________
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FONTE: LAFORCADE ET AL, 2003 FONTE: COSTELO ET AL, 2004 _________________________________________
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SEPSE _________________________________________
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» SIRS + FOCO DE INFECÇÃO _________________________________________
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CRITÉRIOS DE AVALIAÇÃO DA SÍNDROME DA RESPOSTA INFLAMATÓRIA _________________________________________
SISTÊMICA _________________________________________
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CÃO GATO
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TEMP. CENTRAL > 39,2 OU < 37,2 > 39,7 OU < 37,8 _________________________________________
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FC (bat/min) > 140 > 225 OU < 140 _________________________________________
FR (mov. resp. / min) > 40 > 40 _________________________________________
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CONTAG. DE CEL. BR. LEUCOCITOSE OU DDE LEUCOCITOSE OU DDE _________________________________________
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Idade T°C FC (bpm) FR (rpm) Leucócitos Segmentados Bastonetes _________________________________________
7 anos 38,8 148 40 15080 12551 815 _________________________________________
13 anos 37,9 124 36 18110 14900 2110 _________________________________________
13 anos 38,2 120 40 21100 17100 1601 _________________________________________
5 anos 37,9 124 36 71400 17200 41412 _________________________________________
10 anos 38,1 120 32 11210 9600 818 _________________________________________
4 anos 38,6 112Taquipneico 14050 12660 773
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6 anos 39,3 154 36 14100 11160 2461
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10 anos 38,7 136 40 9630 6450 1928
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13 anos 39,3 120 24 15530 8220 6206
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2 anos 38,1 124Taquipneico 6580 2100 3397
10 anos 39,6 140 28 16720 13370 2509
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10 anos 38,6 120 48 16430 11010 5138 _________________________________________
4 anos 38,2 120 64 13200 10400 2176 _________________________________________
6 anos 38,3 168Taquipneico 12900 12100 525 _________________________________________
14 anos 38,1 140Taquipneico 11530 4600 6523 _________________________________________
3 anos 39,1 148Taquipneico 16700 12500 4153 _________________________________________
8 anos 38,9 160 40 14230 12900 1064 _________________________________________
13 anos 38,6 140Taquipneico 20600 15250 4742 _________________________________________
9 anos 38,6 100Taquipneico 17600 8400 8381 _________________________________________
4 anos 38 159 40 27900 21400 5315 _________________________________________
2 anos 39 138 36 19700 17520 1752 _________________________________________
10 anos 39,2 120 60 30700 20260 9061 _________________________________________
4 anos 40 140 44 41700 27500 10470 _________________________________________
9 anos 39,5 153 40 61000 42090 14387 _________________________________________
15 anos 38,4 120Taquipneica 116600 99110 9328
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SINAIS Frequência _________________________________________
Temperatura 8% _________________________________________
FC 48% _________________________________________
FR 48% _________________________________________
Leucograma 100% _________________________________________
Sepse 76% _________________________________________
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Apenas 1 paciente demostrou todos os sinais _________________________________________
associados a SIRS _________________________________________
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Todos os pacientes tem alterações no _________________________________________
leucograma, seja por leucocitose ou por desvio _________________________________________
degenerativo a esquerda. _________________________________________
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Temperatura central tem baixa correlação com
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outros sinais da sepse, incluindo a
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lecucocitose.
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O desvio degenerativo a esquerda é mais
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frequênte do que a leucocitose
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FONTE: UTP, 2015 _________________________________________
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SOFA ESCORE – SEQUENTIAL ORGAN FAILURE ESCORE
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SOFA ESCORE _________________________________________
0 1 2 3 4 _________________________________________
CARDIOVASCULAR ≥ 90 < 90 Dopamin Dopamina > Dopamina_________________________________________
(PAS OU a <5 ou 5 > 15 _________________________________________
VASOPRESSORES) dobutam Epinefrina ≤ Epinefrina_________________________________________
ina 0,1 > 0,1 _________________________________________
Norepinefrin Norepinef _________________________________________
a≤1 rina > 1 _________________________________________
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RESPIRATÓRIO > 400 < 400 < 300 < 200 < 100 _________________________________________
(PaO2/FiO2) (ventilado) (ventilado)_________________________________________
NEUROLÓGICO > 14 13 - 10 – 12 6–9 <6 _________________________________________
(GLASGOW MODIF) 14 _________________________________________
RENAL (CREATININA) < 1.4 1.4 - 2.0 – 3.4 3.5 – 4.9 >5 _________________________________________
1.9 _________________________________________
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HEPÁTICO < 0.6 0,6 – 1.5 – 5 5,1 – 11 > 11 _________________________________________
(BILIRRUBINA) 1.4 _________________________________________
PLAQUETAS > 150 100 – 50 – 100 20 – 50 ≤ 20 _________________________________________
150 _________________________________________
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FONTE: GOGGS, 2015 _________________________________________
SOFA ESCORE – INTERPRETAÇÃO DOS VALORES_________________________________________
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AVALIAÇÃO SOFA ESCORE _________________________________________
ESCORE MORTALIDADE _________________________________________
0a6 < 10 % _________________________________________
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7a9 15 a 20 % _________________________________________
10 a 12 40 a 50 % _________________________________________
13 a 14 50 a 60 % _________________________________________
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15 > 80 % _________________________________________
15 a 24 > 90 % _________________________________________
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FONTE: GOGGS, 2015
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FONTE: GOGGS, 2015_________________________________________
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QUICK SOFA (SEPSE 3)
FONTE: GOGGS, 2015 _________________________________________
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COMPARAÇÃO CONSENSO II E III _________________________________________
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ANTIGO NOVO _________________________________________
INFECÇÃO (SUSPEITA OU _________________________________________
DIAGNOSTICADA) _________________________________________
SIRS + _________________________________________
SEPSE + 2 OU 3 qSOFA _________________________________________
FONTE DE INFECÇÃO OU _________________________________________
AUMENTO DE 2 PONTOS _________________________________________
EM SOFA _________________________________________
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SEPSE
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SEPSE GRAVE PAS < 90 OU PAM < 65 DEFINIÇÃO RETIRADA
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LACTATO > 2,5
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DISFUNÇÃO ORGÂNICA
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SEPSE _________________________________________
SEPSE + _________________________________________
+ VASOPRESSORES _________________________________________
CHOQUE SEPTICO
HIPOTENSÃO NÃO + _________________________________________
RESPONSIVA A FLUIDOS LACTATO > 2,5 (APÓS _________________________________________
FLUIDO) _________________________________________
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DISFUNÇÕES ORGÂNICAS
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ASSOCIADAS A SEPSE _________________________________________
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» CARDIOVASCULAR
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» RIM
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» HEPÁTICO
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» SNC _________________________________________
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» RESPIRATÓRIO _________________________________________
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» COAGULAÇÃO _________________________________________
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SEPSE E SISTEMA
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CARDIOVASCULAR _________________________________________
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» VASODILATAÇÃO
» TAQUICARDIA
» DIMINUIÇÃO DA FORÇA DE CONTRAÇÃO
» QUEDA DO DÉBITO CARDÍACO
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SEPSE E SISTEMA URINÁRIO _________________________________________
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» OLIGÚRIA OU ANÚRIA
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» LESÃO RENAL AGUDA
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SEPSE E FUNÇÃO HEPÁTICA
» ALTA IRRIGAÇÃO
» MUITO CONTATO COM FATORES
INFLAMATÓRIOS
» DISFUNÇÃO OCORRE MAIS TARDIAMENTE
» PIOR PROGNÓSTICO
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PULMÃO _________________________________________
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» ATIVAÇÃO DE NEUTRÓFILOS _________________________________________
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» EDEMA INTERSTICIAL _________________________________________
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» PERDA DE SURFACTANTE ALVEOLAR (ATELECTASIAS) _________________________________________
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» EXSUDATO ALVEOLAR RICO EM FIBRINA _________________________________________
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» INDUÇÃO DE SARA _________________________________________
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SNC
» ALTERAÇÕES DE NÍVEL DE CONSCIÊNCIA
» COMA
» ESTIMULAÇÃO NEURO-ENDÓCRINA
HIPOTÁLAMO-PITUITÁRIA-ADRENAL
SISTEMA NERVOSO SIMPÁTICO
SISTEMA NERVOSO PARASSIMPÁTICO
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COAGULAÇÃO _________________________________________
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» AUMENTO DE FATORES PRÓ COAGULAÇÃO

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» DIMINUIÇÃO DE FATORES ANTICOAGULANTES

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» CID
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» DIMINUIÇÃO DE PERFUSÃO _________________________________________
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» MAIS INFLAMAÇÃO _________________________________________
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» MAIS LESÃO TECIDUAL _________________________________________
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TRATAMENTO
» RESSUSCITAÇÃO INICIAL
ELIMINAR CAUSA DE BASE:
• ATB NA PRIMEIRA HORA
• TRATAMENTO CIRÚRGICO
HEMODINÂMICA:
EXPANSÃO VOLÊMICA
• FLUIDOS ISOTÔNICOS
• SOLUÇÃO HIPERTÔNICA
NÃO RESPONSIVO A FLUIDOTERAPIA
• VASOPRESSORES
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ASSOCIAÇÕES ANTIBIÓTICAS
» AMPICILINA + ENROFLOXACINA
» AMPICILINA + GENTAMICINA
» AMPICILINA + AMICACINA
» CEFAZOLINA + GENTAMICINA
» CEFAZOLINA + AMICACINA
» CLINDAMICINA + GENTAMICINA
» CLINDAMICINA + AMICACINA
» MEROPENEM
» IMIPINEM
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TRATAMENTO SEPSE _________________________________________
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» AMPLO ESPECTRO
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GRAM + GRAM -
» BACTERICIDA
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» RÁPIDA _________________________________________

BIODISPONIBILIDADE AERÓBIA ANAERÓBIA_________________________________________

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COMBATE AO AGENTE
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ETIOLÓGICO _________________________________________
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OBJETIVO CONSIDERAÇÕES _________________________________________
Administração na primeiro hora após _________________________________________
USO PRECOCE DE ATB identificação/diagnóstico de sepse _________________________________________
Administração IV _________________________________________
Considerar doses de ataques _________________________________________
Agentes bactericidas _________________________________________
Dependência de tempo e concentração _________________________________________
MAXIMIZAÇÃO DA PONTÊNCIA DO ATB
Associações de ATB
Combate aos 4 quadrantes
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Considerar penetração do ATB no foco _________________________________________
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ELIMINAÇÃO OU REDUÇÃO DA EXPOSIÇÃO AO Controle da fonte via cirurgia
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AGENTE ETIOLÓGICO _________________________________________
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FONTE: MODIFICADO DE KUMAR A. 2014 _________________________________________
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FLUIDOS _________________________________________
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» ISOTÔNICOS
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» NaCl 0,9% _________________________________________
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» Ringer simples (0,6% NaCl + K + Ca) _________________________________________
» Ringer com lactato (0,6% NaCl + K + Ca + Lactato) _________________________________________

»
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Glicosada 5% _________________________________________
» Glicofisiológico (NaCl 0,45% + Glicose 2,5%) _________________________________________

» EXPANSORES
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» NaCl 7,5% _________________________________________
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» COLÓIDE _________________________________________
» PLASMA _________________________________________
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VASOPRESSORES
» Efedrina – 0,1 a 0,3 mg/Kg
» Dopamina – 5 a 15 mcg/Kg/min
» Noradrenalina – 0,25 a 1,5 mcg/Kg/min
» Dobutamina – 5 a 20 mcg/Kg/min
» Vasopressina – 0,5 a 5 mU/Kg/min
FONTE: BOLLER & OTTO, 2015
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METAS DO TRATAMENTO
INICIAL
» METAS NAS PRIMEIRAS 6 HORAS:
» PVC = 8 a 12 cmH2O
» PAM > 65 mmHg ou PAS > 90 mmHg
» Diurese > 1 mL/Kg/h – induzida por fluidoterapia
» Diminuir hiperlactatemia 20% em 2 horas
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TRATAMENTO A LONGO
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PRAZO _________________________________________
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NUTRIÇÃO MANUTENÇÃO _________________________________________
ENFERMAGEM HEMOD.
ENTERAL _________________________________________
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OXIGENAÇÃO NUTRIÇÃO TRATAMENTO _________________________________________
TECIDUAL ENTERAL DE DOR _________________________________________
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ENTERAL (PREF)
TUBOS PARA ALIM.
TERAPIA SEPSE BACTERIANA
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PARENTERAL _________________________________________
PROTETORES GI NUTRIÇÃO
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TRAT. FERIDAS _________________________________________
TERAPIA A LONGO PRAZO RESSUSCITAÇÃO INICIAL
FISIOTERAPIA _________________________________________
MANEJO TGU ENFERMAGEM
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MAN. PAM HEMODINÂMICA ELIMINAÇÃO DA CAUSA
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MANTER CAR. O2 OXIGENAÇÃO _________________________________________
SUPL. O2 TECIDUAL _________________________________________
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OPIOIDES (IC) FLUIDOS ADM PREC. ATB
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ANTAG. NMDA (IC) DOR VASOPRESSORES CIRÚRGICO
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NÃO USAR METAS DAS 6 HORAS
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AINE OU CORT. _________________________________________
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HEMODINÂMICA _________________________________________
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FONTE: MODIFICADO DE DeCLUE, 2017
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CONCLUSÃO _________________________________________
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»
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IDENTIFICAÇÃO PRECOCE _________________________________________
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»
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TRATAR NA PRIMEIRA HORA APÓS IDENTIFICAR_________________________________________
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» TRATAMENTO INICIAL E A LONGO PRAZO _________________________________________
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» MONITORIZAR O PACIENTE ATÉ ALTA _________________________________________
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HOSPITALAR _________________________________________
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