Parâmetros de prática clínica para suporte hemodinâmico a pacientes pediátricos e neonatais em choque séptico

Abstract

Background: the Institute of Medicine has called for the development of clinical guidelines and practice parameters to develop "best practice" and potentially improve patient outcome. Objective: to provide American College of Critical CareMedicine clinical guidelines for hemodynamic support of neonates and children with septic shock. Setting: individual members of the Society of Critical CareMedicine with special interest in neonatal and pediatric septic shock were identified from literature review and general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (1998-2001).Methods: the Medline literature database was searched with the following age specific keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and extracorporeal membrane oxygenation. More than 30 experts graded literature and drafted specific recommendations by using a modified Delphi method. More than 30 more experts then reviewed the compiled recommendations. The task force chairman modified the document until <10% of experts disagreed with the recommendations.Results: only four randomized controlled trials in children with septic shock could be identified. None of these randomized trials led to a change in practice. Clinical practice has been based, for the most part, on physiologic experiments, case series, and cohort studies. Despite relatively low American College of Critical Care Medicinegraded evidence in the pediatric literature, outcomes in children have improved from 97% mortality in the 1960s to 60% in the 1980s and 9% mortality in 1999. U.S. hospital survival was three fold better in children compared with adults (9% vs. 27% mortality) in 1999. Shock pathophysiology and response to therapies is age specific. For example, cardiac failure is a predominant cause of death in neonates and children, but vascular failure is a predominant cause of death in adults. Inotropes, vasodilators (children), inhaled nitric oxide ResumoIntrodução: o Institute of Medicine requisitou o desenvolvimento de diretrizes e parâmetros de prática clínica para promoção da "melhor prática", a fim de melhorar potencialmente a evolução de pacientes. (neonates), and extracorporeal membrane oxygenation can be more important contributors to survival in the pediatric populations, whereas vasopressors can be more important contributors to adult survival. Objetivo: fornecer ao Conclusion:American College of Critical Care Medicine adult guide lines for hemodynamic support of septic shock have little application to the management of pediatric or neonatal septic shock. Studies are required to determine whether American College of Critical Care Medicine guidelines for hemodynamic support of pediatric and neonatal septic shock will be implemented and associated with improved outcome.J Pediatr (Rio J) 2002;78(6):449-66: hemodynamic support, septic shock, sepsis, persisten pulmonary hypertension, nitric oxide.

Desafios no atendimento da criança agudamente doente: uma visão global

“…[1][2][3][4] In this sense, pediatric intensive care units (PICU) truly act as laboratories, where new and existing protocols are assessed in great detail and compared in terms of effectiveness and efficacy. 4,5 The great majority of these protocols have been conceived and created for use in a PICU environment.…”

“…[1][2][3][4][5][6][7] It is precisely here that this "global vision" for the care of critically ill children resides: to provide continuity of care from transport, through hospital admission to, finally, the PICU, following an increasing level of complexity, with the adoption of measures with proven efficacy right from the outset and without delays or omissions based on a disputable lack of equipment or experience. 1,3,7 Another aspect of this "global vision" is the universal aspect of these problems, since the majority of these acute situations are distributed across almost the entire planet, with variations in prevalence and certain local nuances. [4][5][6][7] In selecting our authors, in addition to their recognized capabilities, we intend to offer the readers of the Jornal de Pediatria a multicultural approach with work by pediatric critical care…”

Comparison of diagnostic and prognostic value of serum procalcitonin and serum lactate in pediatric sepsis

“…There is no single diagnostic tool or clinical decision rule that is both highly sensitive and specific in recognizing sepsis in its early stages. 4 The best approach is a high level of clinical suspicion, combined with the clinical history, vital signs, and physical examination. 5 Lactic acid, which is a by-product of anaerobic metabolism, can be used as a marker of tissue hypoperfusion.…”

Challenges in the critically ill child: a global vision

“…A grande maioria desses protocolos foi gerada e concebida para aplicação em ambiente de UTIP. Mas, por sua eficácia e segurança, acabaram sendo incorporados ao tratamento em ambiente de emergência [1][2][3][4][5][6][7] . Exatamente aí é que está a "visão global" no atendimento da criança agudamente doente: oferecer uma continuidade de atendimento desde seu transporte, admissão hospitalar e, finalmente, na UTIP, obedecendo a um crescendo em complexidade, com a adoção de medidas comprovadamente eficazes desde o início e sem postergações ou omissões fundamentadas na discutível falta de equipamentos ou de experiência 1,3,7 .…”