Post on 05-Jul-2018
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Socul Pediatric
.
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Definitie Sindrom caracterizat prin:
Aport inadecvat de oxigen pentru satisfacereanevoilor metabolice tisulare
alterarea schimburilor circulatie / tesuturi (O2,substante nutritive, preluarea produselor de catabolismlocal)
metabolism tisular de hipoie, producerea insuficientade ener!ie biolo!ica, acidoza metabolica
perturbarea microcirculatiei suferinta celulara difuza afectare multior!anica ("O#S) lezarea inte!ritatii celulelor necroza (ireversibilitatea
socului,deces,sechele in cazul supravietuirii)
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$evoieoi!en
%port
oi!en
2% la pacientii spitalizati
Mortalitate 10% la copii (fara MODS), 30-40% la adulti
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%PO&' O*+$
D+' -%&D%- -O$'$' O*+$ S%$*+ %&'+&%
Debit cardiac -ontinut oi!en s!. art
#recventa 0olum bataie
Presarcina
Postsarcina
-ontractilitate
1emo!lobina
Saturatie oi!en
Presiune partiala oi!en
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-antitatea de oi!en la tesut
Oi!en la tesut: Debit cardiac
-oncentratia arteriala de oi!en
Debit cardiac 3 #rcventa cardiaca 0olum
bataie
0olumul bataie depinde de presarcina,
postsarcina si contractilitate
Oi!en arterial 4 1b SaO2 5.67 8
(9.996 PaO2)
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#actori
*radient %lveolar 3 arterial
+chilibrul %cidobazic (ph ; O2 <)
'emperatura (' < ; O2 <)
2,6Diphospho!l=cerate> (DP* < ; O2 <)
locanti
>2,6Diphospho!l=cerate 3 produs de de!radare al !lucozei care influenteaza afinitatea 1b
pentru Oi!en
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#actori
0olum bataie
-omplianta ventriculara
Presiunea venoasa centrala
'onus venos
'onus autonom
Postsarcina
Sistem de conducere
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Stadii
-ompensat 3 functii vitale mentinute, '%
normala
Decompensat 3 microperfuzie periferica
deficitara. #unctii celulare si or!ane
afectate ("OD#). 1ipotensiune
Soc ireversibil
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"ecanisme compensatorii
aroreceptori 3 la nivelului arcului aortic si
sinusului carotidian, '% scazuta duce la
vasoconstrictie, crestere '%, frecventacardiaca, fractie de e?ectie
-hemoreceptori 3 raspuns la acidoza
celulara cu vasoconstrictie si stimularerespiratorie
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"ecanisme compensatorii
&enina 3 %n!iotensina 3 %ldosteron 3
scaderea perfuziei renale duce la
vasoconstrictie prin an!iotensina siretentie de apa prin aldosteron
&aspuns umoral 3 catecolamine
%utotransfuzie 3 reabsorbtie de lichidintestinal
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SO- -O"P+$S%' -$-
ritabilitate,anietate
+tremitati palide,reci
1ipersudoratie
'ahipnee
Sete vie
Oli!urie
P&+S$+% %&'+&%% SS'+"-%
$O&"%%
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#@OP%'OO*% SO-
D+-O"P+$S%' Sechestrarea san!elui la nivelul microcirculatiei
Plasmeodie (plasma iese din patul vascular)
"odificarea constantelor biolo!ice ale san!elui /slud!e
-D, microtromboze diseminate
schemie tisulara,metabolism tisular dehipoie,acidoza metabolica severa
Suferinta celulara severa,!eneralizata("O#S)
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SO- D+-O"P+$S%'
-$- 1PO'+$S$+ %&'+&%% SS'+"-%
'ahicardie
'ahipnee
Semne de perturbare a microcirculatiei
Oli!urie,retentie azotata acidozametabolica severa
Somnolenta, obnubilare, hiporeactivitate
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S+"$++ SO-
&+0+&S -ompromiterea microcirculatiei,necroze
&espiratie periodica, apnee
-oma Puls imperceptibil la arterele mari,prabusirea '%
'ulburari de ritm cardiac
-D, san!erari "O#S (plaman de soc, rinichi de soc,
insuficienta hepatica etc)
Stop cardiorespirator D+-+S
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'erapie 3 masuri comune 5.Sustinerea functiilor vitale
%si!urarea libertatii cailor aeriene,administrarea de O2 pe
masca
O',0%
"-+
%bord venos(inclusiv cai de abord eceptionale)
"onitorizare cardiocirculatorie si respiratorie
$oninvaziva: #&,%0,+-*,P%,pulsoimetrie,'% eco-*
nvaziva:presiunea !azelor san!uine,P0-,constante
hemodinamice etc
Diureza
&eactivitatea,starea de constienta,++*
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'erapie 3 masuri comune
Dia!nosticul de laboratorA1*,iono!ramaserica,!licemia,lactacidemia,creatinina serica,ureeasan!uina,%S'/%',bilirubina serica,testele de coa!ulare
'erapia volemica Solutii saline(S#, &in!er bicarbonat) Solutii coloidale albumina umana B59C -orectarea acidozei metabolice ($a1-O6 sol 7,2C)
'erapia inotrop pozitiva si vasoactiva %drenalina/$oradrenalina soproterenol Dobutamina/Dopamina
$itroprusiatul de sodiu
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'ipuri de soc
1ipovolemic
Distributiv
-ardio!enic
Obstructiv
Disociativ
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-az clinic 5
aiat in varsta de ani cu istoric de san!erari din variceesofa!iene se prezinta la *- cu san!erare di!estivasuperioara. -onstient, raspunde la stimuli. 1&56B, &&
6E, PEE/F9, Sats2C. 1b7.2-e fel de socG
Hipovolemic
Prima masuraOxigen
-ompensat / Decompensat
Compensat
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Socul hipovolemic 1emora!ie
Postraumatic
1emora!ie *
1emora!ie intracraniana
Pierdere plasma %rsuri
Sindrom nefrotic
+nteropatii cu pierdere proteine
Peritonita
Pierdere lichid etracelular
0arsaturi, diaree
Diureza osmotica
Sector lichidian partizator 3 ocluzie intestinala
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Socul hipovolemic clinic
Semne de deshidratare incercanat, buze
uscate, mucoase uscate, tur!or
Sete vie 0ene periferice colabate
-ord de dimensiuni normale
D- scazut, presarcina scazuta, tahicardie 'ahipnee
ocul pierderii lichidiene poate fi vizibil sau
ascuns
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-az clinic 5
Dia!nostic bazat pe perfuzia tisulara
+tremitati reci, paloare, cianoza, reumplere
capilara deficitara, puls slab, tonus muscular
deficitar 'ahicardie, tahipnee
rina concentrata
#luctuatii in statusul neurolo!ic
1ipotensiunea este un semn tardiv si este Hstea!ul
rosuI pentru socul decompensat
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Socul hipovolemic biolo!ic
1emo!rama
*rup / &h
*licemie
+lectroliti
-oa!ulare / #ibrino!en
*aze san!uine, acidobazic (+%)
-ulturi
ma!istica
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-az clinic 5 mana!ement
-restere aport oi!en, scadere cerere
oi!en
Oi!en
#luide
San!e
-ontrol temperatura
-orectare +% si 1+
"edicatie inotropa 3 la nevoie
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-az clinic 2
#etita, B ani, cu simptomatolo!ie de infectie de cai
aeriene superioare in urma cu doua saptamani, se
prezinta la -* cu scaderea tolerantei la effort, tahipnee
(J9/min), tahicardie (5E2 bpm), '% sist 3 7B mm 1!,1epatome!alie, raluri subcrepitante bilateral, ritm de
!alop, fara sufluri
-e fel de socG
Cardiogenic
-ompensat / Decompensat
Decompensat
Dia!nostic G
? Miocardita
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Socul cardio!en
nsuficienta cardiaca severa
tamponada cardiaca
embolia pulmonara
aritmiile severe
'rauma
%nomalii con!enitale de cord
nfectios
"etabolic
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Soc cardio!enic clinic
%fectare cardiaca, tulburari de ritm +deme
'ur!escenta ?u!ularelor 1epatome!alie +dem pulmonar acut -ardiome!alie&! / ecocardio!rafic
Debit cardiac scazut, Presarcina crescuta,postsarcina crescuta, perfuzie tisulara deficitara
%nomalii +-* (suprasolicitare ventriculara,tulburari de ritm si conducere severe)
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"ana!ement soc cardio!enic
-restere aport oi!en, asi!urare cai aeriene
*ri?a la lichide
8 Diuretic mbunatatire presarcina, postsarcina, contractilitate
"iofilin
-orectare anemie
Scaderea nevoilor de oi!en -ontrolul temperaturii
Sedare
&educerea consumului de oi!en miocardic
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#luidele in socul cardio!enic
1idratare cu cantitati mici de fluide B59
ml/K!
-azul prezentat are miocardita cudisfunctie diastolica 3 cantitati mari de
fluide suprasolicita cordul.
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"edicatie notropa /
-ardiotonica Dopamina 3 doza mica creste fluul san!uin in
circulatia renala si splahnica, doze crescute
cresc frecventa cardiaca si rezistenta vascularasistemica
Dobutamina 3 creste contractilitatea, poate
reduce rezistenta vasculara sistemica, reduce
rezistenta vasculara pulmonara "ilrinona 3 imbunatateste contractilitatea si
scade postsarcina
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"edicatie notropa /
-ardiotonica +pinefrina creste frecventa cardiaca, rezistenta
vasculara sistemica si contractilitatea
$orepinefrina (9.9B5.9mc!/K!/min), cresterezistenta vasculara sistemica
a cazul clinic cu miocardita 3 administrare cu
precautie a acestor medicamente 3 creste
nevoia de oi!en a miocardului
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59 ml/K! bolus cu S# 3 crestere minima a'%
Dopamina 3 Bmc!/K!/min "ilrinona 3 9.B mc!/K!/min
Stabilizata 3 transport P
ntubare
-az clinic 2 mana!ement
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-az clinic 6
aiat, 7 ani, se prezinta la *- cu stare de rau,
febra inalta de 6 zile. storic de sindrom nefrotic.
"inim responsiv la stimuli, te!umente calde,tur!or. %0 3 5J9 bpm, '% sist 3 79 mm 1!, Sat
O2 3 EEC.
-e fel de socG
Decompensat, distributiv. Soc septic cald"edicatie
Fluide, antibiotice, steroii, vasopresoare
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Socul Distributiv
Socul anafilactic Socul infectios !"cald#,#rece#$
Socul neuro!enic:+-%1-
intoicatii cu substante deprimante ale S$-stari comatoase
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Socul septic
+liberare de mediatori eo!eni si
endo!eni cu redistribuirea san!elui,
dezechilibru inre nevoia si aportul deoi!en
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SOC%&#CA&D#
nfectii severe cu coci *8 0asodilatatie,deschiderea
canalelor preferentiale 1ipertermie
'e!umenteuscate,fierbinti,hiperemice Puls amplu,depresibil Scade rezistenta
periferica, creste debitul
cardiac Oli!urie %!itatie,obnubilare,hipore
activitate,somnolenta %cidoza metabolica
SOC%& "'(C(#!()DO*O+)C$
L+ndotoinele !ermenilor *L0asoconstrictie,activarea sistemelor biolo!ice,eliberarede citoKine4S$D&O" $#%"%'O& SS'+"-L1ipovolemieLDeprimarea functieimiocardiceL1ipotensiune arterialasistemica
Leziune endoteliala-DLPerturbare metabolicacelulara prin actiunea directaa toine lor "O#S
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'+&%P% SO-
$#+-'OS %si!urarea -% administrare de O2 DA-)OS*C AC*('O&O-C D( %'-()*A/ 'erapie volemica a!resiva -orectarea acidozei metabolice %!enti vasoactivi:Dopamina in socul HreceI,%drenalina/ $oradrenalina
in soculIcaldI %$'O'-O'+&%P+ D+ &*+$'%M
nitial empirica "eronem 8 inezolid 8 "etronidazol
5929 m!/K!c 59 m!/K!c 69B9 m!/K!c a E h iv la E h iv Pev de 5 h la Eh interval A)*O*CO*('A0( "*)**A# dupa 12345 ore/ &ezolvarea chirur!icala a focarelor de infectie 'erapia complicatiilor ma?ore:-D, +-%, insuficienta hepatica acuta,
insuficienta renala acuta etc
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-az clinic 6 mana!ement
Prima ora 29 ml/K! 3 bolus S#
599 ml/K!/27 h S#
-orectare hipo!licemia, hipocalcemia Prima doza antibiotic 3 -eftriaon 8
0ancomicina
0asopresor $orepinefrina
Steroid 3 1idrocortizon 2 m!/K!
1emocultura
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Soc Obstructiv
Pneumotora
'amponada
Disectii aorta
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Soc Disociativ
-aldura
"onoid de carbon
-ianuri
Soc endocrin
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'ip de soc Presarcina Debitcardiac Postsarcina Perfuzietisulara
1ipovolemic
Distributiv Sau 4
Sau 4
-ardio!enic >
Obstructiv
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'+&%P% SO-
%$%#%-'- ntreruperea contactului cu aler!enul
declansator
%si!urarea caii aeriene,administrarea deO2 %drenalina sol,5/59999 iv,in perfuzie controlata
'erapie volemica
-orectarea acidozei metabolice
-orticoterapie iv in doze mari
%ntihistaminice
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+0O'% S P&O*$OS'- $
SO- P+D%'&- 0ar arsta copilului +tiolo!ia socului
Precocitatea dia!nosticului -alitatea si ur!enta instituirii terapiei de
desocare
-alitatea monitorizarii Stadiul socului/prezenta complicatiilor &aspunsul la terapie
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-oncluzii
Socul este un proces pro!resiv
&apid recunoasteti socul 3 tahicardia este semn
timpuria, hipotensiunea este semn tardiv
dentificarea si clasificarea socului este foarte importanta
%cces vascular rapid, daca este nevoie folositi acces
intraosos
"ana!ementul trebuie sa fie indreptat spre restabiliriiperfuziei tisulare si tensiunii arteriale
Daca pacientul nu raspunde la manevre 3 alte cauze /
tipuri de soc
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-oncluzii
Soc 6ipovolemic %dministrati sol coloidaladupa cristalod daca eistahipoalbuminemie
$u intarziait administrarea demasa eritrocitara daca
suspectai hemora!ie. Soc Septic
Daca '% nu creste dupa F9ml/K! corp de cristalodi,considerati medicatievasopresaore.
Dopamina (B5B mc!/K!/min)de prima intentie.
$orepinephrina in caz de soccald (vasodilatatei
+pinephrine in caz de socrece (vasoconstrictie).
Cardiogenic s6oc7 De considerat la orice pacienta carui stare se inrautatestela administrarea de lichide.
Dopamina 3 a!ent prima linie. De considerat milrinona in
caz de disfunctie diastolica,dobutamina in caz derezistenta sistemica crescutacu disfunctie or!anica.
Soc Obstructiv
nterventie specifica in functiede cauza
'ub toracic pentrupneumotoraA indepartarelichid in caz de tamponadaA.