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30Agost 01092010hemcentroLabcriobiologia002 180x180 - Critérios para Internamento

Critérios para Internamento

Aceita-se que a maioria dos casos de PAC podem ser tratados em domicílio, particularmente quando ocorrem em doentes com menos de 65 anos, sem co-morbilidades significativas e sem sinais de falência respiratória ou de sépsis. Este último aspecto é particularmente relevante, uma vez que os macrólidos, particularmente a azitromicina, se caracterizam por uma extensa distribuição tecidular mas, por outro lado, por concentrações plasmáticas geralmente consideradas insuficientes para o tratamento de infecções com bacteriemia, a qual embora rara, no caso da PAC, é impossível de excluir sem o recurso a exames microbiológicos.
A utilização de modelos preditivos de mortalidade (CURB, CURB-65; Pneumonia severity index – PSI) tem sido útil na valorização dos factores de risco que se associam com mau prognóstico, estratificando os doentes em classes de risco de acordo com o somatório da pontuação atribuída aos critérios individuais. Estes modelos, no entanto, podem ser pouco práticos, e a decisão quanto ao internamento deve assentar, em última análise e para cada caso, no juízo bem informado e fundamentado do clínico. De acordo com as recomendações da SPP, com base na valoração dos factores de risco preditivos da mortalidade, deverão ser internados todos os doentes que apresentem patologias associadas susceptíveis de descompensação e/ou sinais de falência orgânica estabelecida ou eminente. Para além destes, a presença de um dos seguintes critérios deve fazer ponderar o seu internamento, e a presença de dois ou mais, recomendá-lo fortemente:
– Alteração do estado de consciência.
– Temperatura <35° ou >40 °C.
– Frequência respiratória >30 ciclos/minuto.
– Frequência cardíaca > 125 ciclos/minuto.
– TA sistólica >90 mmHg ou TA diastólica >6() mmHg.
– Leucócitos <4000/mm3 ou >20000/mm3.
– Hemoglobina <9,0 g/dl ou hematócrito <30%. - Ureia >60 mg/dl.
– Acidemia (pH <7,35). - PaO2 <60 mmHg ou PaCOo >45 mm Hg (na ausência de retenção crónica) com FIO2 a 21%.
– Alterações da coagulação sugerindo coagulação intravascular disseminada.
– Envolvimento multilobar na radiografia do tórax, cavitação ou derrame pleural.
– Incapacidade de receber tratamento adequado no domicílio.
– Factores de risco para MMRA.

img 3 23 180x180 - Ascite II

Ascite II

A apresentação inaugural da ascite representa o declínio da função hepática, mais do que a elevação crítica da hipertensão portal, não havendo correlação com valor limiar para desencadear a ascite. E a forma mais frequente de descompensação inicial da cirrose hepática (50% com ascite, 35% com hemorragia digestiva alta, 15% com encefalopatia porto-sistémica, como sintoma revelador).
A sua instalação sub-reptícia correlaciona com a deterioração da doença hepática crónica e tem significado de mau prognóstico, com sobrevida ao 5.° ano de 20%, comparado com 50% após descompensação inicial com hemorragia digestiva alta e 0% com encefalopatia porto-sistémica. A presença de ascite propicia outras complicações específicas da cirrose hepática, como a peritonite bacteriana espontânea (PBE) e a síndrome hepatorenal (SHR), as quais, sem tratamento adequado, conduzem a mortalidade elevada (70% com PBE, 100% com SHR).
No entanto, a ascite pode ser precipitada por uma intercorrência extrínseca à cirrose hepática, como uma infecção ocasional (urinária, respiratória, entérica) ou a toma de fármaco hepatotóxico ou stress médico ou cirúrgico, que desencadeiam agravamento extemporâneo da função hepática, devido à reacção inflamatória sistémica, alterações metabólicas e hemodinâmicas que comprometem o equilíbrio precário da função hepática residual.
A própria cirrose hepática pode suscitar condições para descompensação adicional como um episódio de hemorragia digestiva, de peritonite bacteriana espontânea, hepatite aguda alcoólica ou exacerbação de hepatite crónica de qualquer etiologia, trombose da veia porta, ou mesmo carcinoma hepatocelular.
Nestes contextos, a apresentação é súbita e progressiva, com agravamento rápido da ascite associada a edema ascendente dos membros inferiores, oligúria, náuseas, enfartamento, lombalgias e intolerância ao esforço.
O diagnóstico clínico é evocador pela semiologia clássica de distensão abdominal, globosa ou redundante em ventre de batráquio, com macicez à percussão nos quadrantes inferiores do abdómen, definindo uma linha de transição para o timpanismo curvilínea, côncava no sentido cefálico; essa área de macicez é deslocável com a mudança de posição do doente, de decúbito dorsal para lateral direito, ficando a macicez confinada aos quadrantes laterais em posição reclinada. Pode ser detectado o sinal de onda líquida à percussão.
A associação com edema maleolar e pré-tibial é frequente, atingindo por vezes a raiz das coxas, o que revela compromisso de drenagem venosa por compressão da veia cava inferior pela ascite volumosa. Nos homens, pode disseminar para edema escrotal e hidrocelo; em casos graves de retenção hídrica progride para edema ascendente da parede abdominal e região lombossagrada, ou mesmo para anasarca.
A pressão intra-abdominal elevada do líquido ascítico pode franquear os pontos fracos da parede abdominal, ocasionando o aparecimento de hérnias inguinais ou umbilicais, preenchidas quase sempre apenas com fluido. A abordagem terapêutica destas hérnias depende do grau de insuficiência hepática e das complicações eventuais das hérnias; só deverão ser referenciadas para cirurgia urgente as hérnias encarceradas, estranguladas ou com ruptura estabelecida ou iminente por ulceração cutânea.


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pixi para crian as resmed 2 180x180 - Ventilação Mecânica Não Invasiva - III

Ventilação Mecânica Não Invasiva – III

Na IRA, as indicações para VNI passam pela seleção de doentes com descompensação respiratória grave e com necessidade de suporte ventilatório, mas não tão graves que necessitem de VMI imediata.
Numerosos estudos nestes doentes identificaram fatores preditivos de sucesso: idade mais jovem, menor gravidade da doença, maior capacidade de adaptação e coordenação, menos fugas, dentição intacta, acidemia menos grave (7,10