Abordagem à Vítima com Suspeita de Sépsis ou Choque Séptico: Recomendações Clínicas para o Contexto Pré-Hospitalar Português
DOI:
https://doi.org/10.20344/amp.24178Palavras-chave:
Ambulâncias Aéreas, Choque Séptico, Guia de Prática Clínica, Sépsis, Portugal, Serviços Médicos de EmergênciaResumo
A sépsis é uma emergência médica tempo-dependente, associada a elevada morbilidade e mortalidade. O reconhecimento precoce e a abordagem adequada no pré-hospitalar são determinantes para o prognóstico. Apesar da existência da via verde de sépsis normatizada pela Direção-Geral da Saúde, verificou-se a subnotificação dos casos de suspeita de sépsis, urgindo a necessidade de revisão dos critérios de alerta. Além disso, faltavam em Portugal orientações específicas para a sua ativação e gestão no contexto pré-hospitalar. Por esse motivo, este artigo visa estabelecer recomendações baseadas na evidência para a uniformização do reconhecimento e tratamento da sépsis e do choque séptico no pré-hospitalar português, alinhadas com as orientações internacionais mais recentes e com as capacidades operacionais do Sistema Integrado de Emergência Médica. A presente orientação técnica resultou de uma revisão exaustiva da literatura, integrando consensos internacionais e adaptando-os à realidade nacional. Deste modo, são definidos critérios de inclusão e exclusão para o alerta de sépsis em contexto pré-hospitalar, priorizando a identificação precoce através da suspeita de infeção ou alterações da temperatura e disfunção orgânica ou indicadores clínicos de gravidade, como National Early Warning Score (NEWS)/NEWS2 ≥ 5, Índice de Choque ≥ 0,7, Mottling ≥ 2, tempo de preenchimento capilar > 2 segundos. O tratamento depende do tipo de meio interveniente, incluindo oxigenoterapia, posicionamento e controlo de temperatura para meios de suporte básico de vida; cristaloides balanceados, antipiréticos parentéricos e início precoce de suporte vasopressor para meios diferenciados, mediante algumas premissas para os meios de suporte imediato de vida. Recomenda-se ainda a antibioterapia empírica nos casos de choque séptico abordados por meios com médico, nomeadamente Viaturas Médicas de Emergência e Reanimação e Serviço de Helicópteros de Emergência Médica. O documento uniformiza também os registos clínicos e a ativação de alertas através do iTeams® e do Verbete Nacional de Socorro. Esta primeira orientação técnica nacional para a sépsis no pré-hospitalar estabelece procedimentos uniformes e baseados na evidência para o reconhecimento e tratamento precoces neste contexto, contribuindo para a melhoria dos resultados clínicos, otimização de recursos e reforço da articulação inter-hospitalar no âmbito da via verde de sépsis.
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Moutinho A, Fontes J, Ferreira L, Lopes J, Martins F, Mega S, et al. Sepsis alerts in the pre-hospital setting: an observational retrospective study of emergency medical services’ response in Portugal (2020–2023). Cureus. 2025;17:e82528. DOI: https://doi.org/10.7759/cureus.82528
Rudd K, Johnson S, Agesa K, Shackelford K, Tsol D, Colombara D, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395:200-11. DOI: https://doi.org/10.1016/S0140-6736(19)32989-7
Taylor SP, Kowalkowski MA, Skewes S, Chou SH. Real-world implications of updated surviving sepsis campaign antibiotic timing recommendations. Crit Care Med. 2024;52:1002-6. DOI: https://doi.org/10.1097/CCM.0000000000006240
Marshall T, Dysert K, Young M, DuMont T. Pathophysiology of sepsis. Crit Care Nurs Q. 2025;48:88-92. DOI: https://doi.org/10.1097/CNQ.0000000000000552
Shappell CN, Klompas M, Rhee C, Surveillance strategies for tracking sepsis incidence and outcomes. J Infect Dis. 2020;222:S74-83. DOI: https://doi.org/10.1093/infdis/jiaa102
Pinto-Villalba RS, Balseca-Arellano D, Leon-Rojas JE. Septic shock in the prehospital setting: a scoping review. Scand J Trauma Resusc Emerg Med. 2024;32:113. DOI: https://doi.org/10.1186/s13049-024-01282-2
Mellhammar L, Wollter E, Dahlberg J, Donovan B, Olséen C, Wiking P, et al. Estimating sepsis incidence using administrative data and clinical medical record review. JAMA Netw Open. 2023;6:e2331168. DOI: https://doi.org/10.1001/jamanetworkopen.2023.31168
Direção-Geral da Saúde. Norma n.º 010/2016: via-verde-sepsis-no-adulto. Lisboa: DGS; 2017.
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith C, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49:e1063-143.
Schlapbach LJ, Watson RS, Source LR, Argent AC, Menon K, Hall MW, et al. International consensus criteria for pediatric sepsis and septic shock. JAMA. 2024;331:665-74. DOI: https://doi.org/10.1001/jama.2024.8202
James S, Abate D, Abate K, Abay S, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1789-858. DOI: https://doi.org/10.1016/S0140-6736(18)32279-7
Patrizio E, Zambon A, Mazzola O, Massariello F, Galeazzi M, Cavalieri d’Oro L, et al. Assessing the mortality risk in older patients hospitalized with a diagnosis of sepsis: the role of frailty and acute organ dysfunction. Aging Clin Exp Res. 2022;34:2335-43. DOI: https://doi.org/10.1007/s40520-022-02182-0
Torvik MA, Nymo SH, Nymo SH, Bjornsen LP, Kvarenes HW, Ofstad EH. Patient characteristics in sepsis-related deaths: prevalence of advanced frailty, comorbidity, and age in a Norwegian hospital trust. Infection. 2023;51:1103-15. DOI: https://doi.org/10.1007/s15010-023-02013-y
Okoye C, Piazzoli A, Ferrara MC, Finazzi A, Ornago AM, Pinardi E, et al. Enhancing in-hospital mortality prediction in older patients with sepsis: the role of frailty indices and multidrug-resistance status in non-ICU wards—a proof-of-concept study. Aging Clin Exp Res. 2025;37:1-9. DOI: https://doi.org/10.1007/s40520-025-02955-3
Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186:1264-71. DOI: https://doi.org/10.1164/rccm.201204-0713OC
Guarino M, Perna B, Cesaro A, Mariatati M, Spampinato M, Contini C, et al. 2023 Update on sepsis and septic shock in adult patients: management in the emergency department. J Clin Med. 2023;12:3188. DOI: https://doi.org/10.3390/jcm12093188
Hechtman RK, Kipnis P, Cano K, Seelye S, Liu V, Prescott H. Heterogeneity of benefit from earlier time-to-antibiotics for sepsis. Am J Respir Crit Care Med. 2024;209:852-60. DOI: https://doi.org/10.1164/rccm.202310-1800OC
Long B, Gottlieb M. Emergency medicine updates: management of sepsis and septic shock. Am J Emerg Med. 2025;90:179-91. DOI: https://doi.org/10.1016/j.ajem.2025.01.054
Vardy ER, Lasserson D, Barker RO, Hanratty B. NEWS2 and the older person. Clin Med. 2022;22:522-4. DOI: https://doi.org/10.7861/clinmed.2022-0426
Jacob A, Qudsi A, Kumar NS, Trevarthen T, Awad WI. Utilisation of the National Early Warning Score (NEWS) and Assessment of Patient Outcomes Following Cardiac Surgery. 2024;13:6850. DOI: https://doi.org/10.3390/jcm13226850
Oanesa RD, Su TW, Weissman A. Evidence for use of validated sepsis screening tools in the prehospital population: a scoping review. Prehosp Emerg Care. 2024;28:485-93. DOI: https://doi.org/10.1080/10903127.2023.2224862
Shu E, Ives Tallman C, Frye W, Boyajian J, Farshidpour L, Young M, et al. Pre-hospital qSOFA as a predictor of sepsis and mortality. Am J Emerg Med. 2019;37:1273-8. DOI: https://doi.org/10.1016/j.ajem.2018.09.025
Usul E, Korkut S, Kayipmaz AE, Halici A, Kavalci C. The role of the quick sequential organ failure assessment score (qSOFA) and modified early warning score (MEWS) in the pre-hospitalization prediction of sepsis prognosis. Am J Emerg Med. 2021;41:158-62. DOI: https://doi.org/10.1016/j.ajem.2020.09.049
Middleton DJ, Smith TO, Bedford R, Neilly M, Myint PK. Shock index predicts outcome in patients with suspected sepsis or community-acquired pneumonia: a systematic review. J Clin Med. 2019;8:1144. DOI: https://doi.org/10.3390/jcm8081144
Morris E, McCartney D, Lasserson D, Van Den Bruel A, Fisher R, Hayward G. Point-of-care lactate testing for sepsis at presentation to health care: a systematic review of patient outcomes. Br J Gen Pract. 2017;67:e859-70. DOI: https://doi.org/10.3399/bjgp17X693665
Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock: the ANDROMEDA-SHOCK randomized clinical trial. JAMA. 2019;321:654-64. DOI: https://doi.org/10.1001/jama.2019.0071
Ait-Oufella H, Lemoinne S, Boelle P, Galbois A, Baudel J, Lemant J, et al. Mottling score predicts survival in septic shock. Intensive Care Med. 2011;37:801-7. DOI: https://doi.org/10.1007/s00134-011-2163-y
Mahapatra S, Heffner AC. Septic shock. Treasure Island: StatPearls Publishing; 2026.
Vincent JL, Jones G, David S, Olariu E, Cadwell KK. Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. Crit Care. 2019:23:196. DOI: https://doi.org/10.1186/s13054-019-2478-6
Herbert A, Pearn J, Wilson S. Normal percentiles for respiratory rate in children—reference ranges determined from an optical sensor. Children. 2020;7:160. DOI: https://doi.org/10.3390/children7100160
Pinto MP, Martins S, Mesquita E, Fernandes L. European Portuguese version of the clinical frailty scale: translation, cultural adaptation and validation study. Acta Med Port. 2021;34:749-60. DOI: https://doi.org/10.20344/amp.14543
Lee HY, Lee J, Jung Y, Kwon W, Oh D, Park M, et al. Preexisting clinical frailty is associated with worse clinical outcomes in patients with sepsis*. Crit Care Med. 2022;50:780-90. DOI: https://doi.org/10.1097/CCM.0000000000005360
Nickel CH, Kellett J. Assessing physiologic reserve and frailty in the older emergency department patient: should the paradigm change? Clin Geriatr Med. 2023;39:475-89. DOI: https://doi.org/10.1016/j.cger.2023.05.004
Kabell NS, Rueegg M, Carpenter C, Kaeppeli T, Busch J, Fournaise A, et al. Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs. J Am Geriatr Soc. 2023;71:1250-8. DOI: https://doi.org/10.1111/jgs.18170
Jiahui D, Wang L, Xiong R, Liu X, Guo Z, Sun W, et al. 基于衰弱综合征建立老年脓毒症患者180 d病死率的预测评分. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2021;33:257-62.
Rockwood K, Theou O. Using the clinical frailty scale in allocating scarce health care resources. Can Geriatr J. 2020;23:254-9. DOI: https://doi.org/10.5770/cgj.23.463
Monnet X, Lai C, Teboul JL. How I personalize fluid therapy in septic shock? Crit Care. 2023;27:123. DOI: https://doi.org/10.1186/s13054-023-04363-3
Verras C, Ventoullis I, Bezati S, Matsiras D, Parissis J, Polyzogopoulou E. Point of care ultrasonography for the septic patient in the emergency department: a literature review. J Clin Med. 2023;12:1105. DOI: https://doi.org/10.3390/jcm12031105
Dalla-Betta M, Esener D, Swanson W, Kaddis A, Aguayo Romero F, Fields J. The frequency of pocus in the treatment of sepsis in the emergency department: a retrospective cohort study. POCUS J. 2023;8:71-80. DOI: https://doi.org/10.24908/pocus.v8i1.15683
Polyzogopoulou E, Veliou M, Verras C, Ventoulis I, Parissis J, Osterwalder J, et al. Point-of-care ultrasound: a multimodal tool for the management of sepsis in the emergency department. Medicina. 2023;59:1180. DOI: https://doi.org/10.3390/medicina59061180
Choi Y, Oh S, Huh J, Joo H, Lee H, You W, et al. Deep reinforcement learning extracts the optimal sepsis treatment policy from treatment records. Commun Med. 2024;4:245. DOI: https://doi.org/10.1038/s43856-024-00665-x
Srzić I, Adam VN, Pejak DT. Sepsis definition: what’s new in the treatment guidelines. Acta Clin Croat. 2022;61:67-72. DOI: https://doi.org/10.20471/acc.2022.61.s1.11
Weiss SJ, Guerrero A, Root-Bowman C, Ernst A, Krumperman K, Femling J, et al. Sepsis alerts in EMS and the results of pre-hospital ETCO2. Am J Emerg Med. 2019;37:1505-9. DOI: https://doi.org/10.1016/j.ajem.2018.11.009
Cherpanath TG, Hirsch A, Geerts B, Lagrand W, Leeflang M, Schultz M, et al. Predicting fluid responsiveness by passive leg raising. Crit Care Med. 2016;44:981-91. DOI: https://doi.org/10.1097/CCM.0000000000001556
Seitz KP, Qian ET, Semler MW. Intravenous fluid therapy in sepsis. NutrClin Pract. 2022;37:990-1003. DOI: https://doi.org/10.1002/ncp.10892
Russo A, Salini S, Gava G, Merra G, Piccioni A, De Mattels G, et al. Reduced prognostic role of serum PCT measurement in very frail older adults admitted to the emergency department. Antibiotics. 2023;12:1036. DOI: https://doi.org/10.3390/antibiotics12061036
Rodríguez MR, Roca FL, Díaz RR, García DE, Julián-Jiménez A. Administración precoz de la antibioterapia empírica en los pacientes atendidos con sospecha de sepsis en el servicio de urgencias: revisión sistemática. Emergencias. 2025;37:44-55.
Abdul-Aziz MH, Hammond N, Brett S, Cotta M, De Waele J, Devaux A, et al. Prolonged vs intermittent infusions of β-lactam antibiotics in adults with sepsis or septic shock: a systematic review and meta-analysis. JAMA. 2024;332:638-48. DOI: https://doi.org/10.1001/jama.2024.9803
Schoffelen T, Papan C, Carrara E, Eljaaly K, Paul M, Keuleyan E, et al. European society of clinical microbiology and infectious diseases guidelines for antimicrobial stewardship in emergency departments (endorsed by European association of hospital pharmacists). Clin Microbiol Infect. 2024;30:1384-407. DOI: https://doi.org/10.1016/j.cmi.2024.05.014
Cajander S, Kox M, Scicluna B, Weigand M, Mora R, Flohé S, et al. Profiling the dysregulated immune response in sepsis: overcoming challenges to achieve the goal of precision medicine. Lancet Respir Med. 2024;12:305-22. DOI: https://doi.org/10.1016/S2213-2600(23)00330-2
Burgunder L, Heyrend C, Olson J, Stidham C, Lane RD, Workman JK, et al. Medication and fluid management of pediatric sepsis and septic shock. Pediatric Drugs. 2022;24:193-205. DOI: https://doi.org/10.1007/s40272-022-00497-z
Marchetto L, Zanetto L, Comoretto RI, Padrin D, Menon K, Amigoni A, et al. Outcomes of pediatric fluid-refractory septic shock according to different vasoactive strategies: a systematic review and meta-analysis. Shock. 2024;62:599-611. DOI: https://doi.org/10.1097/SHK.0000000000002427
Ordem dos Médicos (Colégio de Medicina Intensiva) e Sociedade Portuguesa de Cuidados Intensivos. Transporte de Doentes Críticos Recomendações. 2023. [consultado 2025 jul 15]. Disponível em: https://www.spci.pt/media/documentos/15827260365e567b2411424.pdf.
García-Uribe J, Lopera-Jaramillo D, Gutiérrez-Vargas J, Arteaga-Noriega A, Bedoya OA. Adverse effects related with norepinephrine through short peripheral venous access: scoping review. Enfermería Intensiva. 2023;34:218-26.10.1016/j.enfie.2022.09.001 DOI: https://doi.org/10.1016/j.enfie.2022.09.001
Hanna M, Balintescu A, Glassford N, Lipcsey M, Eastwood G, Oldner A, et al. Glycemic lability index and mortality in critically ill patients—a multicenter cohort study. Acta Anaesthesiol Scand. 2021;65:1267-75. DOI: https://doi.org/10.1111/aas.13843
Lu Z, Tao G, Sun X, Zhang Y, Jiang M, Liu Y, et al. Association of blood glucose level and glycemic variability with mortality in sepsis patients during ICU hospitalization. Front Public Health. 2022;10:857368. DOI: https://doi.org/10.3389/fpubh.2022.857368
Fujishima S, Gando S, Saitoh D, Kushimoto S, Ogura H, Abe T, et al. Incidence and impact of dysglycemia in patients with sepsis under moderate glycemic control. Shock. 2021;56:507-13. DOI: https://doi.org/10.1097/SHK.0000000000001794
Drewry A, Ablordeppey E, Murray E, Stoll C, Izadi S, Dalton C, et al. Antipyretic therapy in critically ill septic patients: a systematic review and meta-analysis. Crit Care Med. 2017;45:806-13. DOI: https://doi.org/10.1097/CCM.0000000000002285
Portugal. Portaria n.º 135/2018. Diário da República, II Série, n.º 135 (2018/07/16). DOI: https://doi.org/10.1055/a-0622-7171
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