Está en la página 1de 32

Sepsis Generalidades

Dr. Yannis Amador


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

www.aspame.net

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

www.aspame.net

Historia

1992 ACCP/SCCM creacin definiciones y conceptos 2001

www.aspame.net

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

www.aspame.net

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.

www.aspame.net

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.

www.aspame.net

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.

www.aspame.net

Sepsis Respuesta inflamatoria Sistmica

www.aspame.net

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

www.aspame.net

Sepsis Definiciones Resumen

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

www.aspame.net

Sepsis Fisiopatologa
Respuesta inflamatoria

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

www.aspame.net

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.

www.aspame.net

Sepsis Fisiopatologa

Endotelio Interfase Extensin Endocrino

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

www.aspame.net

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).

www.aspame.net

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

www.aspame.net

www.aspame.net

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

www.aspame.net

Sepsis Fisiopatologa : ENDOTELIO

www.aspame.net

www.aspame.net

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.

www.aspame.net

Sepsis Fisiopatologa : ENDOTELIO

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

www.aspame.net

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

www.aspame.net

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

www.aspame.net

Sepsis Diagnstico Respuesta inflamatoria Sistmica

www.aspame.net

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

www.aspame.net

Tratamiento

Restauracin Hemodinmica temprana Finalidad aumento de LIBERACION O2 Monitoreo Gradiente O2

www.aspame.net

TX Hemodinamia

www.aspame.net

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

www.aspame.net

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.

www.aspame.net

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.)

www.aspame.net

Perlas

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

www.aspame.net

Gracias
www.aspame.net