Sepsis Generalidades

Dr. Yannis Amador

Especialista Medicina de Emergencias XLV JORNADAS MDICAS NACIONALES DE LA CSS SIMPOSIO EN MEDICINA DE EMERGENCIAS Panam 2008

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El arte de la medicina est en evitar malos hbitos, entre ellos el hbito de considerar a la fiebre y leucocitosis como evidencia de infeccin Paul Marino, MD

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Historia

1992 ACCP/SCCM creacin definiciones y conceptos 2001

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Sepsis Generalidades

Primera causa de muerte en el paciente crticamente enfermo 2-11% de los ingresos nuevos 200-300/100mil nuevos casos en USA Mortalidad alta 28-50%
Bianco et al. Management of Severe Sepsis and Septic Shock: Challenges and Recommendations. Crit Care Clin 22 (2006) 489 501

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Sepsis Poblacin en Riesgo

Pacientes criticamente enfermos BNAC severa Ciruga intra-abdominal Meningitis Enfermedades Crnicas Compromiso Inmune Celulitis ITU
Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006.

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Sepsis Poblacin en Riesgo Alto

Adulto mayor Comorbilidad asociada Alto IMC

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006. Perl Tm, et al. Long-Term Survival and Function after suspected Gram-negative Sepsis. JAMA. 1995; 274 (4): 338-345.

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Sepsis Definiciones

Presencia o presuncin de infeccin acompaada de evidencia de respuesta sistmica RESPUESTA INFLAMATORIA SISTEMICA
Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006.

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Sepsis Respuesta inflamatoria Sistmica

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Severe Sepsis and septic shock: Review of the Literature and Emergency Department Mangement Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006.

Sepsis Definiciones

Presuncin de infeccin con mnima respuesta clnica Sepsis Severa sepsis + disfuncin orgnica Shock sptico + hipotensin refractaria Bacteremia 50% SepSev y ShockSep
Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Richard S. Hotchkiss, et al. The Pathophysiology of Sepsis. NEJM 348:2. Jan 2003

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Sepsis Definiciones Resumen

Fiebre + leucositosis = SRIS SRIS + INFECCIN = SEPSIS SEPSIS + Disfuncin Multiorgnica = SEPSIS SEVERA

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Sepsis Fisiopatologa
Respuesta inflamatoria

Infeccin, trauma o quemadura Deleterea al estar aumentada NO, enz. proteolticas, lisosomas

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Sepsis Fisiopatologa

ENDOTELIO COAGULACION RESPUESTA INFLAMATORIA

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Bianco et al. Management of Severe Sepsis and Septic Shock: Challenges and Recommendations. Crit Care Clin 22 (2006) 489 501 Carrillo y Carvajal. Sepsis. Conceptos Actuales. Revisin Facultad de Medicina Crtica UNAM. Dic 2004.

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Sepsis Fisiopatologa

Endotelio Interfase Extensin Endocrino

Weil et al. The Endothelium in Intensive Care. Critical Care Clinics. 21 (2005).

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Sepsis Fisiopatologa : ENDOTELIO

Modulacin anticoagulante Regulacin de la microcoagulacin Expresin de la molculas de adhesin Modulacin del tono vascular

Weil et al. The Endothelium in Intensive Care. Critical Care Clinics. 21 (2005).

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Sepsis Fisiopatologa : ENDOTELIO

Sustancias Vasodilatadoras Oxido ntrico Prostaciclina

Vasoconstrictoras Endotelina

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Bianco et al. Management of Severe Sepsis and Septic Shock: Challenges and Recommendations. Crit Care Clin 22 (2006) 489 501

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Sepsis Fisiopatologa : ENDOTELIO

vasodilatacin vasodilataci n Vasoconstriccin Vasoconstriccin

coagulopat a coagulopata

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006. Paul Marino. ICU Book. 2001

Sepsis Fisiopatologa
SRIS ENDOTELIO FNT & IL-1, 6 Cascada de Coagulacin

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Sepsis Fisiopatologa : ENDOTELIO

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Sepsis Fisiopatologa : ENDOTELIO

NOXA Estimulacin de endotelio Liberacin de mediadores Disminucin de NO con PC Heparan Sulfato-inhb Antitrombina FTPI
The Endothelium in the ICU. Critical Care Clinics NO 21: Agost 2005.

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Sepsis Fisiopatologa : ENDOTELIO

Weil et al. The Endothelium in Intensive Care. Critical Care Clinics. 21 (2005).

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Sitio de Infeccin

Pulmn Abdomen Urinario Tejido Blando

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Bianco et al. Management of Severe Sepsis and Septic Shock: Challenges and Recommendations. Crit Care Clin 22 (2006) 489 501

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Sepsis Diagnstico

Historia Clnica Laboratorio

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Bianco et al. Management of Severe Sepsis and Septic Shock: Challenges and Recommendations. Crit Care Clin 22 (2006) 489 501

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Sepsis Diagnstico Respuesta inflamatoria Sistmica

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Tratamiento

Hemodinamia Control de Lquidos Glicemia Esteroides

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Bianco et al. Management of Severe Sepsis and Septic Shock: Challenges and Recommendations. Crit Care Clin 22 (2006) 489 501

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Tratamiento

Restauracin Hemodinmica temprana Finalidad aumento de LIBERACION O2 Monitoreo Gradiente O2

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TX Hemodinamia

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Tratamiento

Esteroides Control Glicemia

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Bianco et al. Management of Severe Sepsis and Septic Shock: Challenges and Recommendations. Crit Care Clin 22 (2006) 489 501

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Estatinas

Estatinas Bloquean la modulacin de la inflamacin Disminucin de la migracin celular Aumenta la expresin del endotelio al NO

Severe Sepsis and septic shock: Review of the Literature and Emergency Department Management Guidelines Infectious Disease/Review Article Vol 48, NO 1: July 2006 Statins: Panacea for Sepsis. Lancet Inft Desease. 2006, 6.

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Protena C

David E. Joyce, MD et al. Leukocyte and endothelial cell interactions in sepsis: Relevance of the protein C pathway. Crit Care Clin 2004 Vol. 32, No. 5(suppl.)

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Perlas

Inflamacin vs infeccin Grupos de riesgo Ser mal pensado Encimo-terapia Recolectar cultivos Terapia Emprica

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Gracias
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