SHOCK SPTICO

Fluidoterapia, vasopresores e
ionotrpicos
MEDICINA INTERNA - I
DOCENTE: DR. AMILCAR TINOCO HURTADO

Integrante:
Rubina Montoya,
Amanda

Seminario 7

OBJETIVOS - RECOMENDACIONES

Dr. R. Phillip Dellinger; Dr. Mitchell M.Levy; Dr. Andrew Rhodes; Dr. Djillali Annane; Dr. Herwig Gerlach; Dr.
Steven M. Opal. Campaa para sobrevivir a la sepsis: recomendaciones internacionales para el

RESUSCITATION FLUIDS
The physiology of fluid
resuscitation

John A. Myburgh, M.B., B.Ch., Ph.D., and Michael G. Mythen, M.D., M.B., B.S. Resuscitation Fluids. N

al ion
e
Id itat
sc
u
s
idIt produces a predictable and
Rre Flu

sustained
increase
in
intravascular volume,
It has a chemical composition
as close as possible to that of
extracellular fluid
It
is
metabolized
and
completely excreted without
accumulation in tissues
It does not produce adverse
metabolic or systemic effects,
and is cost-effective in terms
of
improving
patient
outcomes.

Albmina
(coloide
natural):El uso durante la
reanimacin es controvertido,
adems de tener indicaciones
especficas
como
la
hipoalbuminemia. Es cara y no
se descarta la transmisin de
enfermedades por priones.

Coloides
Mayor
Dextranos: Se utilizan poco debido a sus efectos
expansin
secundarios, fundamentalmente sobre coagulacin,
plasmtica
disminuyendo la agregacin plaquetaria, riesgo de
que los
shock anafilctico y falla renal.
cristaloides.
Se obtienen
los objetivos
de la
resucitacin
en menor
Current evidence onthe use of solutions colloids
semisintticos
tiempo y con Coloides
versus crystalloids during the reanimation
(Hidroxietilalmidn): Prolonga el tiempo de
menor
patient-with shock. Gac Med Bol v.35 n.2
expansin intravascular. Altera homeostasis, falla
volumen.

 Solucin
salina
0,9%:
Ligeramente
hipertnico con respecto al plasma.
Contiene Na 154 mEq/L; Cl 154 mEq/L; sin
cantidades de K o Ca. La infusin de
grandes volmenes podra resultar en
hipernatremia e hipercloremia. Acidosis
hiperclormica

Cristaloides
Las soluciones
cristaloides, estn
compuestas por
pequeas partculas
disueltas en agua,
las mismas que
pasan fcilmente a
travs de laEn
barrera
se
Ringer
lactato:
por Na 130
general
necesitan
dosisCompuesto
elevadas de
endotelial, cristaloides
poseen
mEq/L; Cl 109 mEq/L,
K 4 mEq/L,
Ca 3
para-aumentar
la precarga.
Un
corto tiempo intramEq/L;
28 a mEq/L,
litro de solucin
salina Lactato
expande 100
200 cc posee
vascular . Son fluidos
osmolaridad
de de
2751 mOsm/L,
por tanto es
con
una
vida
media
hora
altamente
considerada una solucin hipotnica y a
disponibles, de bajo
dosis altas genera agua libre. Hipotonicidad,
costo y bien
sobrecarga de lactato.
Current evidence toleradas
onthe use of solutions colloids versus crystalloids during the reanimation
patient-with shock. Gac Med Bol v.35 n.2 Cochabamba dic. 2012

TABLA 1. CARACTERSTICAS GENERALES DE LAS SOLUCIONES EN SHOCK. ADAPTADO DE HARTOG CS ET AL

Albmina
5% 25%
Osmolaridad
(mOsm/L)
Presin
onctica
(mmHg)

13
.

Hidroximetilalmidn (6%)

Dextrn (10%)

Salina

Cristaloides
Ringer Lactato

290

310

300 a 310

280 a 324

285 a 308

250 a 273

20 a 30

70 a 100

23 a 50

20 a 60

Volumen
expansin (%)

70 a 100

300 a 350

100 a 200

100 a 200

20 a 25

20 a 25

Duracin de
expansin
(horas)

12 a 24

12 a 24

8 a 36

1a2

1a4

1a4

Vida media en
plasma (horas)

16 a 24

16 a 24

50

4a6

0,5

0,5

Potencialesefe
ctos adversos

++

++

+++

Current evidence onthe use of solutions colloids versus crystalloids during the reanimation
patient-with shock. Gac Med Bol v.35 n.2 Cochabamba dic. 2012

Background
It remains uncertain whether the
choice of resuscitation fluid for
patients in intensive care units
(ICUs)
affects
survival.
We
conducted
a
multicenter,
randomized, double-blind trial to
compare
the
effect
of
fluid
resuscitation with albumin or saline
Methods
on mortality
We randomly assigned patients who had been admitted
to theinICUa toheterogeneous
receive either
population ofresuscitation
patients in the
ICU. the
4 percent albumin or normal saline for intravascular-fluid
during
next 28 days. The primary outcome measure was death from any cause during the
28-day period after randomization.
Conclusions
In patients in the ICU, use of either 4 percent albumin or normal saline for
*The Saline versus results
Albumin Fluid
Evaluationoutcomes
(SAFE) Study. at
N Engl
Med 2004;350:2247-56.
fluid resuscitation
in similar
28 J days.

Results
Of the 6997 patients
who
underwent
randomization,
3497
were
assigned
to
receive albumin and
3500 to receive saline;
the two groups had
similar
baseline
characteristics.
There were 726 deaths
in the albumin group,
as compared with 729
deaths in the saline
group. The proportion
of patients with new
single-organ
and
multiple-organ failure
was similar in the two
groups. There were no
*The Saline versus Albumin Fluid Evaluation (SAFE) Study. N Engl J Med 2004;350:2247-56.
significant differences

Background
The safety and efficacy of hydroxyethyl
starch (HES) for fluid resuscitation have
not been fully evaluated, and adverse
effects of HES on survival and renal
function have been reported.
Methods
We randomly assigned 7000 patients who had been admitted to an intensive care unit (ICU) in a
1:1 ratio to receive either 6% HES with a molecular weight of 130 kD and a molar substitution
ratio of 0.4 (130/0.4, Voluven) in 0.9% sodium chloride or 0.9% sodium chloride (saline) for all
fluid resuscitation until ICU discharge, death, or 90 days after randomization. The primary
outcome was death within 90 days.
Secondary outcomes included acute kidney injury and failure and treatment with renalreplacement therapy.
Conclusions
In patients in the ICU, there was no significant difference in 90-day mortality
between
patientsStarch
resuscitated
with
6%
HES (130/0.4)
or saline.
Hydroxyethyl
or Saline for
Fluid
Resuscitation
in Intensive
Care. NHowever,
Engl J Med more
patients who received
resuscitation with
HES were treated with renal-replacement
2012;367:1901-11.
DOI: 10.1056/NEJMoa1209759
therapy.

Results
A total of 597 of 3315
patients (18.0%) in the HES
group and 566 of 3336
(17.0%) in the saline group.
There was no significant
difference in mortality in six
predefined subgroups. Renalreplacement
therapy
was
used in 235 of 3352 patients
(7.0%) in the HES group and
196 of 3375 (5.8%) in the
saline group. In the HES and
saline groups, renal injury
occurred in 34.6% and 38.0%
of patients, respectively (P =
0.005), and renal failure
occurred in 10.4% and 9.2%
of patients, respectively (P =
Hydroxyethyl Starch or Saline for Fluid Resuscitation in Intensive
0.12). Care.
HESN Engl
was J Med
associated

Background
Hydroxyethyl starch (HES) is widely
used for fluid resuscitation in
intensive care units (ICUs), but its
safety and efficacy have not been
established in patients with severe
sepsis.
Methods
In this multicenter, parallel-group, blinded trial, we randomly assigned patients with
severe sepsis to fluid resuscitation in the ICU with either 6% HES 130/0.42 (Tetraspan)
or Ringers acetate at a dose of up to 33 ml per kilogram of ideal body weight per day.
The primary outcome measure was either death or end-stage kidney failure
(dependence on dialysis) at 90 days after randomization.
Conclusions
Patients with severe sepsis assigned to fluid resuscitation with HES
130/0.42
had an
increased
ofRingers
death Acetate
at dayin90
andSepsis.
were Nmore
to
Hydroxyethyl
Starch
130/0.42risk
versus
Severe
Engl J likely
Med

Results
Of the 804 patients
who
underwent
randomization,
798
were included in the
modified intention-totreat population. The
two
intervention
groups had similar
baseline
characteristics. At 90
days
after
randomization, 201 of
398 patients (51%)
assigned
to
HES
130/0.42 had died, as
compared with 172 of
400 patients (43%)
assigned to Ringers
Hydroxyethyl Starch 130/0.42 versus Ringers Acetate in Severe Sepsis. N Engl J Med
acetate; 1 patient in

Background
Although
previous
studies
have
suggested the potential advantages of
albumin administration in patients with
severe sepsis, its efficacy has not been
fully established.

Methods
In this multicenter, open-label trial, we randomly assigned 1818 patients with severe sepsis, in
100 intensive care units (ICUs), to receive either 20% albumin and crystalloid solution or
crystalloid solution alone. In the albumin group, the target serum albumin concentration was 30
g per liter or more until discharge from the ICU or 28 days after randomization. The primary
outcome was death from any cause at 28 days. Secondary outcomes were death from any
cause at 90 days, the number of patients with organ dysfunction and the degree of dysfunction,
and length of stay in the ICU and the hospital.
Conclusions
In patients with severe sepsis, albumin replacement in addition to crystalloids, as
Albumin
in alone,
Patientsdid
withnot
Severe
Sepsisthe
or Septic
Shock.
N Engl
Medand 90
compared
withReplacement
crystalloids
improve
rate of
survival
atJ 28
2014;370:1412-21. DOI: 10.1056/NEJMoa1305727

Results
During the first 7 days, patients in
the albumin group, as compared with
those in the crystalloid group, had a
higher mean arterial pressure (P =
0.03) and lower net fluid balance
(P<0.001). The total daily amount of
administered fluid did not differ
significantly between the two groups
(P = 0.10). At 28 days, 285 of 895
patients (31.8%) in the albumin
group and 288 of 900 (32.0%) in the
crystalloid group had died. At 90
days, 365 of 888 patients (41.1%) in
the albumin group and 389 of 893
(43.6%) in the crystalloid group had
died. No significant differences in
other secondary outcomes were
Albumin
Replacement
in Patients
with Severe
observed
between the
two groups.
Sepsis or Septic Shock. N Engl J Med

TRATAMIENTO CON FLUIDOS PARA SEPSIS GRAVE

TRATAMIENTO CON FLUIDOS PARA SEPSIS GRAVE
1. Cristaloides como la opcin inicial

de fluidos en la reanimacin de sepsis severa y choque septicmico

(grado 1B)

2.
3.

Evitar el uso de hidroxietilalmidn para la reanimacin con fluidos de sepsis severa y choque septicmico (grado 1B)
Albmina en la reanimacin con fluidos de sepsis severa y choque septicmico cuando los pacientes requieren cantidades
importantes de cristaloides (grado 2C)

4.

Sobrecarga lquida inicial en pacientes con hipoperfusin tisular inducida por sepsis con sospecha de hipovolemia para alcanzar un
mnimo de 30 ml/Kg de cristaloides (una porcin de esto puede ser un equivalente de albmina). En algunos pacientes, pueden ser
necesarias una administracin ms rpida y cantidades mayores de fluidos (grado 1C)

5.

La tcnica de sobrecarga lquida debe aplicarse donde se contine con la administracin de fluidos, siempre que exista una mejora
hemodinmica basada en variables dinmicas (por ej., cambio en la tensin diferencial o variacin en el volumen sistlico) o
estticas (por ej., presin arterial o frecuencia cardaca) (UG).

Dr. R. Phillip Dellinger; Dr. Mitchell M.Levy; Dr. Andrew Rhodes; Dr. Djillali Annane; Dr. Herwig Gerlach; Dr.
Steven M. Opal. Campaa para sobrevivir a la sepsis: recomendaciones internacionales para el

Objective: To investigate the therapeutic effects of a novel fluid resuscitation protocol (early
fluid resuscitation plus 2% hydrogen inhalation) on acute kidney injury during septic shock
induced by lipopolysaccharide in rats.
Methods: Sixty male Wistar rats were randomly divided into four groups (n = 15 per group):
control group (C), septic shock group (S), septic shock with early fluid resuscitation
group (R), and septic shock with early fluid resuscitation plus 2% hydrogen
inhalation group (R+H2). The rats were ventilated, and a 2% hydrogen mixture was used in
Group R+H2. Lipopolysaccharide (10 mg/kg) was administered to establish the septic shock
model in rats and fluid resuscitation was performed in Groups R and R+H2.
Results: Fluid resuscitation with 2% hydrogen inhalation decreased serum creatinine, blood
urea nitrogen, and neutrophil gelatinase-associated lipocalin. It also reduced oxidative stress
Wei
Liu, Xue-Song
Dong, Yu-Qiang
Sun, Zhinecrosis
Liu.. A novel
fluid resuscitation
protocol:levels
providecompared
more protection
injury
and decreased
renal tumor
factor-
and interleukin-6
with on
acute kidney injury during septic shock in rats. Int J Clin Exp Med 2014;7(4):919-926

The kidneys in
Group C
presented normal
glomeruli and
tubules

Tubular epithelial
cell damage was
ameliorated in
Groups R and
R+H2, but the
improvements
were more
significant in
Group R+H2

in Group S, renal
tubular epithelial cells
exhibited significant
edema, brush border
damage, and
interstitial edema
with hemorrhage

antioxidant,
inhibition of
apoptosis, and
inhibition of an
excessive
inflammatory response. Hydrogen
molecules likely
improve capillary
Wei Liu, Xue-Song Dong, Yu-Qiang Sun, Zhi Liu.. A novel fluid resuscitation protocol: provide
more protection
permeability
and on
acute kidney injury during septic shock in rats. Int J Clin Exp Med 2014;7(4):919-926
reduce the volume

TRATAMIENTO CON VASOPRESORES

La dopamina ejerce su efecto

dependiendo de la dosis que se
administra. A medida que sta
aumenta, se estimulan distintos
receptores:
1.
Dopamingicos:
0.5

3
g/kg/min.

FISIOPATOLOGIA DE LA FALLA RENAL AGUDA

La insuficiencia renal se define como una
disminucin del flujo renal glomerular con el
consecuente aumento de la creatinina y urea
plasmtica, asociado o no a disminucin de la

1996, Auriculin Anaritide Acute Renal Failure

Study (AAARFS) Group USA: Objetivo fue
determinar la relacin que exista entre la infusin
de 3 g/kg/min de dopamina y la recuperacin de
la funcin renal. Resultados: 36% de mortalidad y
52% de pacientes que requirieron dilisis,
porcentajes similares al grupo que recibi placebo.
Incertidumbre que existe sobre su seguridad y
eficacia
1999, NORASEPT II Study USA: Concluy que
la dosis renal de dopamina no prevena la
insuficiencia renal aguda en pacientes con shock
sptico y oliguria.
Kellum y Decker, en el ao 2001, realizaron

Si se debe eliminar la
dopamina de la prctica
mdica, qu otro agente
Si el podra
objetivo essuplantar
conseguir o aumentar
sus
la diuresis recomienda el uso de
beneficios?

furosemida, agente ms efectivo y ms

seguro. Si se quiere aumentar el
inotropismo, una buena alternativa es
la dobutamina; en cambio, si el
paciente se encuentra en un estado
hiperdinmico
con
una
gran
vasodilatacin, una buena eleccin
sera la norepinefrina. Una terapia que

Methods: Utilizing a well-established database, relevant

information including duration of time to vasopressor
administration following the initial documentation of
recurrent/persistent hypotension associated with septic shock
was assessed in 8,670 adult patients from 28 ICUs in Canada,
the United States of America, and Saudi Arabia. The primary
endpoint was survival to hospital discharge. Secondary
endpoints were length of ICU and hospital stay as well as
duration of ventilator support and vasopressor dependence.
Analysis involved multivariate linear and logistic regression

Introduction: Despite recent

advances in the management
of septic shock, mortality
remains unacceptably high.
Earlier
initiation
of
key
therapies including appropriate
antimicrobials
and
fluid
resuscitation appears to reduce
the mortality in this condition.
This study examined whether
early initiation of vasopressor
therapy is associated with
improved survival in fluid
therapy-refractory septic shock.

TRATAMIENTO CON VASOPRESORES

VASOPRESORES
1. Tratamiento con vasopresores al inicio para lograr un obejtivo de presin
arterial media (PAM) de 65 mmHg (grado 1C)
2. Norepinefrina como vasopresor de primera eleccin (grado 1B)
3. Epinefrina (aadida a la norepinefrina o como posible sustituto de esta) cuando se necsita otro agente para mantener una presin
arterial adecuada (grado 2B)

4.
5.

Se puede aadir 0,03 U/min de vasopresina a norepinefrina (NE) con el intento de aumentar la PAM o disminuir la dosis de NE (UG)
La vasopresina de baja dosis no se recomioenda como vasopresor inicial nico para el tratamiento de hipotensin inducida por sepsis
y la dosis de vasopresina ms altas que 0,03-0,04 U/min deben reservarse para tratamientos de rescate (fracaso al tratar de lograr
una PAM adecuada con otros agentes vasopresores) (UG)

6.

Dopamina como agente vasopresor alternativo a noreprinefina solo en pacoientes sumamente selccionados (por ej., pacientes con
riesgo bajo de taquiarritmias y bradicardia absoluta o relativa) (grado 2C)

Dr. R. Phillip Dellinger; Dr. Mitchell M.Levy; Dr. Andrew Rhodes; Dr. Djillali Annane; Dr. Herwig Gerlach; Dr.
Steven M. Opal. Campaa para sobrevivir a la sepsis: recomendaciones internacionales para el

TRATAMIENTO CON VASOPRESORES

VASOPRESORES
7. No se recomienda fenilefrina en el tratamiento del choque septicmico excepto en las siguientes circunstancias: (a) norepinefrina
asociada con arritmias graves, (b) gasto cardaco alto y presin arterial continuamente baja, o (c) como tratamiento de rescate cuando la
combinacin de frmacos inotrpicos/vasopresores y vasopresina de baja dosis no logra el objetivo PAM (grado 1C)
8. No utilizar dopamina de baja dosis para proteccin renal (grado 1A)
9. Todos los pacientes que requieren vasopresores deben tener un catter arterial colocado tan pronto como sea posible si se dispone de
recursos (UG)

Dr. R. Phillip Dellinger; Dr. Mitchell M.Levy; Dr. Andrew Rhodes; Dr. Djillali Annane; Dr. Herwig Gerlach; Dr.
Steven M. Opal. Campaa para sobrevivir a la sepsis: recomendaciones internacionales para el

TRATAMIENTO CON IONOTRPICOS

La dobutamina incrementa el IC y el ITVI con
dosis media de 5 12 g/k/min.
Disminuye la diferencia mucosa-arterial de PCO2
e incrementa el flujo sanguneo de la mucosa
gstrica.
En pacientes con choque sptico con bajo dbito
cardiaco y/o saturacin venosa baja (SVO2 <
70%) la dobutamina es el inotrpico de primera
eleccin en la presencia de presiones de llenado
del ventrculo izquierdo y PAM adecuadas.
Los objetivos
de la terapia
hemodinmica
Cuando
los finales
pacientes
presentan
PAM
en el choque sptico son restaurar la perfusin
inadecuadas (PAM < 65) la terapia combinada
tisular efectiva y normalizar el metabolismo
norepinefrina
+ dobutamina es la ms
celular.
recomendada.
La hipoperfusin tisular no solo resulta de presin
de perfusin disminuida sino adems de una
alteracin en el flujo sanguneo microvascular y

TRATAMIENTO CON IONOTRPICOS

TRATAMIENTO CON IONOTRPICOS
1. Se debe administrar o incorporar un tratamiento de prueba con perfusin
de dobutamina de hasta 20 ug/Kg/min al vasopresor (si se usa) en
presencia de: (a) disfuncin miocrdica, como lo indican las presiones
cardacas de llenado elevadas y bajo gasto cardaco, o (b) signos
continuos de hipoperfusin, a pesar de lograr un volumen intravascular adecuado y PAM adecuada (grado
1C)

2.

Evitar el uso de una estrategia para aumentar el ndice cardaco a los niveles supranormales predeterminados (grado 1B)

Dr. R. Phillip Dellinger; Dr. Mitchell M.Levy; Dr. Andrew Rhodes; Dr. Djillali Annane; Dr. Herwig Gerlach; Dr.
Steven M. Opal. Campaa para sobrevivir a la sepsis: recomendaciones internacionales para el