Avaliação do papel prognóstico do balanço hídrico na sepse grave e no choque séptico
Data
2014-01-31
Autores
Oliveira, Fernando Saes Vilaça de 
Orientadores
Machado, Flavia Ribeiro
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
A sepse grave e o choque séptico possuem elevadas incidência, prevalência, morbidade e mortalidade. Seu tratamento adequado demanda a administração considerável de líquidos, que, por vezes, se estendem além de um período de 24 horas e se refletem no balanço hídrico (BH) cumulativo. Diversas linhas de evidências apontam para morbidade associada a balanços hídricos positivos em vários contextos, como na lesão pulmonar aguda, na síndrome do desconforto respiratório agudo, cirurgias abdominais e mesmo em situações de lesão renal aguda. O presente estudo teve o objetivo de avaliar o papel prognóstico do balanço hídrico positivo em pacientes com sepse grave e choque séptico em diferentes momentos da história natural da doença. Buscou-se também avaliar se existe relação entre o balanço hídrico positivo, também em diferentes momentos da sepse, e a lesão renal aguda. Para tanto, conduzimos um subestudo a partir de uma coorte prospectiva, incluindo um total de 116 pacientes com diagnóstico de sepse grave ou choque séptico, conforme definições padronizadas. Colheram-se dados demográficos, relacionados à adesão aos pacotes de tratamento de das primeiras 6 horas da campanha sobrevivendo a sepse, dados relacionados a morbidade, disfunções orgânicas e mortalidade. O balanço hídrico foi calculado considerando-se três momentos distintos: a instalação da primeira disfunção orgânica atribuída à sepse (BH1), o momento do diagnóstico (BH2) e, nos pacientes em choque, o início do vasopressor (BH3). Em cada um desses períodos foi aferido o BH em 6, 12 e 24 horas, além do BH entre a 24ª e 48ª horas. A diurese foi registrada nos primeiros cinco dias de evolução, tanto a partir do momento da primeira disfunção como a partir do momento do início do vasopressor. A partir desses dados foram realizados três modelos de regressão logística. O primeiro avaliando fatores de risco para mortalidade na população geral (n-116) e o segundo apenas na população com choque (n-85). O terceiro modelo de regressão logística avaliou fatores de risco para lesão renal aguda grave (escore de RIFLE F ou pior). Os resultados foram considerados significativos quando p<0,05. Na população geral, foram fatores de risco independentes para mortalidade o BH2 maior que 3.400mL entre a 24a e a 48a hora, a lesão renal aguda e a diurese menor que 900mL no segundo dia a partir da instalação da disfunção orgânica. Na população com choque foram fatores de risco o BH3 maior que 3.400mL entre a 24a e a 48a hora e a diurese menor que 850 ml no primeiro dia da instalação do choque. Foram identificados como fatores de risco independentes para lesão renal aguda a creatinina D0 menor que 1,2 e o escore Avaliação Sequencial da Disfunção Orgânica no D1 acima de 9. Conclui-se que o balanço hídrico positivo entre a 24 e a 48ª hora após o diagnóstico da disfunção foi fator prognóstico independente para mortalidade em pacientes com sepse grave e choque séptico. O mesmo não ocorreu com os balanços antes das primeiras 24 horas. Não foi possível associar o balanço hídrico positivo como fator de risco para o surgimento de lesão renal aguda. Por outro lado, ele também não se associou com proteção para essa lesão.
Severe sepsis and septic shock not only have a high incidence and prevalence but also high morbidity and mortality. An adequate management demands infusions of high amounts of IV fluids, sometimes beyond the first 24h, which reflects on the cumulative fluid balance (FB). Several evidences suggest that positive fluid balances may be associated with morbidity in different clinical situations, as acute respiratory dystress syndrome, abdominal surgeries and even acute kidney injury. This study aimed to evaluate the prognostic value of the positive fluid balance among patients with severe sepsis and septic shock in different moments of the natural history of the disease. It also proposed to analyze if there was a association between a positive fluid balance in different moments of the sepsis and acute kidney injury. Thus, we conducted a sub-study of a prospective cohort study, with a total of 116 patients diagnosed with severe sepsis or septic shock, in accordance with established definitions. We collected demographic data, compliance with the 6-hours treatment bundle of the Surviving Sepsis Campaign and also data related to morbidity, organ dysfunctions and mortality. The fluid balances were calculated considering three distinct moments: the onset of sepsis-related organ dysfunction (FB1), the time of its diagnosis (FB2) and, in the case of septic shock, the time vasopressor was started (FB3). In each of these moments, we calculated the FB at 6, 12, 24 hours and between the 24th and the 48th hour. The diuresis was also registered on the first five days considering both the onset of organ dysfunction and the start of the vasopressors. We generated from these data three logistic regression models. The first two evaluated risk factors for mortality on the whole population (n = 116) and only in patients with shock (n = 85). The third model evaluated risk factors for severe acute kidney injury (RIFLE score F or worse). The results were considered significant if p<0.05. On the whole population we found an independent association between mortality and the FB2 higher than 3400mL between the 24th and 48th, the presence of acute renal injury and a diuresis bellow 900mL on the second day after the first organ dysfunction. Among the shock patients a FB3 higher than 3400mL between the 24th and 48th and a urine output bellow 850 ml in the first day after shock onset were associated with mortality. We identified as independent risk factors for severe acute kidney injury a creatinine on day 0 higher than 1.2mg/dL and a Sequential Organ Failure Assessment score on D1 higher than 9. In conclusion, a positive FB between the 24th and 48th hour after the dysfunction was an independent prognostic factor for mortality both in patients with severe sepsis and septic shock. The same did not occur with the FB in the first 24 hours. It was not possible to show that FB was a risk factor for acute renal injury. However, it was not a protective factor either.
Severe sepsis and septic shock not only have a high incidence and prevalence but also high morbidity and mortality. An adequate management demands infusions of high amounts of IV fluids, sometimes beyond the first 24h, which reflects on the cumulative fluid balance (FB). Several evidences suggest that positive fluid balances may be associated with morbidity in different clinical situations, as acute respiratory dystress syndrome, abdominal surgeries and even acute kidney injury. This study aimed to evaluate the prognostic value of the positive fluid balance among patients with severe sepsis and septic shock in different moments of the natural history of the disease. It also proposed to analyze if there was a association between a positive fluid balance in different moments of the sepsis and acute kidney injury. Thus, we conducted a sub-study of a prospective cohort study, with a total of 116 patients diagnosed with severe sepsis or septic shock, in accordance with established definitions. We collected demographic data, compliance with the 6-hours treatment bundle of the Surviving Sepsis Campaign and also data related to morbidity, organ dysfunctions and mortality. The fluid balances were calculated considering three distinct moments: the onset of sepsis-related organ dysfunction (FB1), the time of its diagnosis (FB2) and, in the case of septic shock, the time vasopressor was started (FB3). In each of these moments, we calculated the FB at 6, 12, 24 hours and between the 24th and the 48th hour. The diuresis was also registered on the first five days considering both the onset of organ dysfunction and the start of the vasopressors. We generated from these data three logistic regression models. The first two evaluated risk factors for mortality on the whole population (n = 116) and only in patients with shock (n = 85). The third model evaluated risk factors for severe acute kidney injury (RIFLE score F or worse). The results were considered significant if p<0.05. On the whole population we found an independent association between mortality and the FB2 higher than 3400mL between the 24th and 48th, the presence of acute renal injury and a diuresis bellow 900mL on the second day after the first organ dysfunction. Among the shock patients a FB3 higher than 3400mL between the 24th and 48th and a urine output bellow 850 ml in the first day after shock onset were associated with mortality. We identified as independent risk factors for severe acute kidney injury a creatinine on day 0 higher than 1.2mg/dL and a Sequential Organ Failure Assessment score on D1 higher than 9. In conclusion, a positive FB between the 24th and 48th hour after the dysfunction was an independent prognostic factor for mortality both in patients with severe sepsis and septic shock. The same did not occur with the FB in the first 24 hours. It was not possible to show that FB was a risk factor for acute renal injury. However, it was not a protective factor either.
Descrição
Citação
OLIVEIRA, Fernando Saes Vilaca de. Avaliação do papel prognóstico do balanço hídrico na sepse grave e no choque séptico. 2014. Dissertação (Mestrado) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2014.