Información del artículo
Resumen
La administración perioperatoria de hemoderivados alogénicos (TSA), junto con los efectos de la anestesia y del traumatismo quirúrgico, originan un estado de inmunodepresión (inmunomodulación inducida por transfusiones alogénicas [IMITA]) que puede dar lugar a un aumento de las infecciones postoperatorias y de la recurrencia del tumor, aumentando por tanto la morbimortalidad de estos pacientes.
Para evitar o minimizar los efectos adversos de las TSA en el paciente neoplásico es necesaria una óptima preparación preoperatoria a la que deben sumarse estrategias farmacológicas o anestesicoquirúrgicas encaminadas a conseguir: a) un aumento de la masa sanguínea circulante, mediante la estimulación de la eritropoyesis con eritropoyetina, lo que eleva los valores preoperatorios de hemoglobina y/o acelera su recuperación postoperataria, y que permite, además, aumentar el predepósito de sangre autóloga en cirugía programada; b) una reducción del sangrado perioperatorio mediante desmopresina, antifibrinolíticos sintéticos (tranexámico y -aminocaproico) o aprotinina; c) un aumento de la capacidad de oxigenación, mediante el uso de transportadores artificiales de oxígeno basados en la hemoglobina o en los perfluorocarbonos, y aumentando la concentración de oxígeno en el aire inspirado, y d) una recuperación y reinfusión de la sangre autóloga que se pierde durante o después del acto quirúgico.
Para que estas medidas sean plenamente efectivas es necesaria la creación de equipos multidisciplinarios así como la implantación de una política transfusional restrictiviva. Además, cuando sea necesario transfundir, deben utilizarse hemocomponentes frescos y desleucocitados, administrándolos de uno en uno y revaluando al paciente después de cada transfusión. Cabe plantearse, además, el uso de fármacos inmunomoduladores o inmunorrestauradores que neutralicen o disminuyan los efectos inmunodepresores de la cirugía y la TSA.
Palabras clave:
Cirugía oncológica
Autotransfusión
Eritropoyetina
Aprotinina
Política transfusinonal
Leucodepleción
Inmunomodulación
Perioperative allogenic blood transfusion (ABT), together with the effect of anesthesia and surgical trauma, produce a state of immunodepression (allogenic transfusion-induced immunosuppression [ATIS]) which can increase postoperative infections and tumoral recurrence, and hence morbidity and mortality in these patients.
To avoid or minimize the adverse effects of ABT in the neoplastic patient, optimal preoperative preparation is required together with pharmacological or surgical- anesthetic strategies designed to achieve: a) an increase in the circulating blood mass, through stimulation of erythropoiesis by erythropoietin, which increases preoperative hemoglobin values and/or accelerates their postoperative recuperation and additionally increases deposits of autologous blood in elective surgery; b) a reduction in perioperative bleeding through desmopressin, synthetic antifibrinolytics (tranexamic and -aminocaproic) or aprotinin; c) an increase in oxygenation capacity through the use of hemoglobin- or perfluorocarbon-based artifical oxygen transporters, thus increasing oxygen concentration in inspired air, and d) recovery and reinfusion of the autologous blood lost during or after the intervention. For these measures to be fully effective, multidisciplinary teams should be created and a restrictive transfusion policy should be implemented. Moreover, whenever transfusion is required, fresh, leukocyte-depleted blood products should be used with one-by-one administration and the patient should be reevaluated after each transfusion. The use of immunomodulatory or immunorestorative drugs to neutralize or reduce the immunodepressive effects of surgery and ABT should also be considered.
Key words:
Oncological surgery
Autotransfusion
Erythropoietin
Aprotinin
Transfusion policy
Leukodepletion
Immunomodulation
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