Avalia????o din??mica e evolutiva da disfun????o mioc??rdica em crian??as s??pticas com choque refrat??rio a l??quidos: aplica????o do ??ndice de desempenho mioc??rdico e doppler esof??gico

Abstract

Objetivos: Este estudo descreve a evolu????o da fun????o card??aca de 34 crian??as s??pticas admitidas na UTI Pedi??trica de um hospital p??blico do Rio de Janeiro, com base em crit??rios ecocardiogr??ficos e de Doppler esof??gico (DE). ?? a primeira proposta de aplica????o do ??ndice de desempenho mioc??rdico (IDM) para avalia????o de disfun????o mioc??rdica associada a sepse em crian??as, mostrando sua correla????o com dados do Doppler esof??gico. Visava-se calcular a confiabilidade intraobservador das medidas do IDM, correlacionar a FE e Fenc com o IDM-VE, todas as medidas com os ??ndices progn??sticos: PIM e PRISM e mostrar as mudan??as evolutivas na fun????o mioc??rdica atrav??s do IDM biventricular. M??todos: De 2005 a 2007, foram selecionadas crian??as da UTI Pedi??trica do Instituto Fernandes Figueira com crit??rios de choque s??ptico refrat??rio a l??quidos, que foram submetidas a ecocardiograma seriado nas fases aguda e evolutiva da doen??a, com medidas dos di??metros cavit??rios, fra????o de eje????o (FE), fra????o de encurtamento (Fenc) e IDM biventricular. Parte dos pacientes foi monitorizada com DE. Resultados: Foram examinadas 34 crian??as, 17 destas foram monitorizadas com DE. Nove crian??as (26,5%) tinham FE < 65% na fase aguda. A sensibilidade da FE na fase aguda foi maior do que o IDM para o diagn??stico de disfun????o ventricular esquerda. Nove crian??as (26,5%) apresentavam IDM-VD alterado na fase aguda. Corroborouse uma alta confiabilidade das medidas do IDM biventricular com coeficiente de correla????o de concord??ncia entre 0,95 e 0,99. Houve correla????o negativa entre as medidas de FE e IDM-VE (r= -0,42, p=0,01), bem como houve diferen??a significativa do IDM-VE entre as fases: diferen??a m??dia = 0,07 com IC 95% (0,02; 0,12). N??o se confirmou o valor progn??stico do IDM. Os dados do DE, apesar de sua utilidade na pr??tica cl??nica, n??o se correlacionaram com os dados ecocardiogr??ficos. Conclus??es: O estudo conclui que o IDM n??o ?? um par??metro mais precoce para o diagn??stico de disfun????o ventricular esquerda do que a FE, entretanto pode ser um par??metro evolutivo importante. A avalia????o da fun????o ventricular direita pelo IDM mostrou incid??ncia de disfun????o do VD precoce significativa. O estudo sugere que o IDM pode ter aplica????o no diagn??stico evolutivo da disfun????o mioc??rdica associada a sepse em associa????o ??s medidas j?? tradicionalmente utilizadas.Objectives:The present study describes the outcome of 34 septic children admited in a public hospital PICU in Rio de Janeiro based on echocardiografic and Esophageal Doppler (ED) parameters. It???s the first to use the Tei index, or myocardial perfomance index (MPI), to diagnose myocardial disfunction in septic children, correlating it to ED parameters. The objective of the study was to calculate the intraobserver variability, to correlate EF and SF to LV-MPI, to correlate EF, SF and LV-MPI to prognostic index: PIM / PRISM, to show evolutive changes in cardiac function through biventricular MPI. Methods: From 2005 to 2007, children admited to the Fernandes Figueira Institute PICU with refractory to fluids shock criteria were submited to echocardiography in the acute and evolutive phases of the disease. The following measures were done: ejection fraction (EF), shortening fraction (SF), RV-MPI and LV-MPI. Part of these children were also monitorized with esophageal Doppler. Results: 34 children were examined, 17 (50%) were monitorized with ED. Nine children (26,5%) had EF < 65% in the acute phase. EF showed better sensitivity than LV-MPI to diagnose myocardial disfunction in the acute phase. Nine children (26,5%) had altered RV-MPI in the first exam. The findings could corroborate the IDM high liability with concordance correlation coefficient between 0,95 and 0,99. There was a negative correlation between EF and LVMPI ( r= -0,42, p=0,01) and a significant difference between phases to LV-MPI (mean difference=0,07; 95%CI 0,02:0,12). The study was not able to confirm the MPI prognostic value. ED parameters were not significatively correlated to echocardiographic data, although useful in clinical practice. Conclusions: MPI was not better than EF to diagnose sooner LV disfunction, although it can be important in follow-up. RV disfunction evaluated through MPI was relatively frequent in the acute phase. This study suggested that the MPI may have an application in evolutive diagnosis of myocardial disfunction associated to sepsis when included in the standard echocardiographic protocol