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Objetivos de la reanimación hemodinámica

Mesquida, J.; Borrat, X.; Lorente, J.A.; Masip, J.; Baigorri, F.

Publicado en Med Intensiva.2011; 35 :499-508 - vol.35 núm 08

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Resumen

La insuficiencia cardiovascular o shock, de cualquier etiología, se caracteriza por la inadecuada perfusión de los tejidos del organismo, produciendo una situación de desequilibrio entre el aporte y la demanda de oxígeno. La disminución de la disponibilidad de oxígeno en el área celular se traduce en un aumento del metabolismo anaerobio, con producción de lactato e hidrogeniones, derivando en la acidosis láctica. El grado de hiperlactatemia y acidosis metabólica va a correlacionarse directamente con el desarrollo de fracaso orgánico y mal pronóstico del individuo.

La llegada de oxígeno a los tejidos depende fundamentalmente de una presión de perfusión del tejido suficiente y de un transporte de oxígeno adecuado. La adecuación de estos dos parámetros fisiológicos va a posibilitar la restauración del equilibrio entre aporte y demanda celular de oxígeno, revirtiendo el proceso de anaerobiosis. La monitorización de variables como el lactato y las saturaciones venosas de oxígeno (central o mixta) durante la fase aguda del shock serán útiles en la determinación de persistencia o resolución de la hipoxia tisular. En los últimos años, han aparecido nuevas tecnologías capaces de evaluar la perfusión local y la microcirculación, como la tonometría gástrica, la espectroscopia en el límite de la luz infrarroja y la videomicroscopia. Aunque la monitorización de parámetros de carácter regional ha demostrado su valor pronóstico, no se dispone de evidencia suficiente que le otorgue utilidad en la guía del proceso de reanimación.

En conclusión, a la espera de disponer de parámetros capaces de proporcionarnos información útil de perfusión local, la reanimación hemodinámica sigue basada en la consecución rápida de valores de presión de perfusión del tejido adecuados, y seguir el proceso de reanimación mediante la modificación de variables de transporte de oxígeno, con la intención de conseguir la restauración de valores fisiológicos de SvO₂/SvcO₂, así como a la resolución de la acidosis láctica y/o hiperlactatemia.

Palabras clave Shock. Monitorización hemodinámica. Transporte de oxígeno. Hipoxia tisular. Microcirculación.

Introducción

Introducción En la práctica diaria de la medicina crítica, una de las principales preocupaciones del clínico es asegurar el bienestar del tejido mientras se trata de forma específica la enfermedad causante del insulto primario. Cuando nos referimos a bienestar del tejido, nos referimos concretamente a asegurar el aporte de oxígeno y nutrientes a la célula para que esta pueda seguir desarrollando sus funciones básicas, tanto en cuanto al funcionalismo celular intrínseco como la organización del tejido/órgano. Cuando la utilización de oxígeno por parte de las células se ve comprometida, los procesos biológicos resultan afectados, dando lugar a un deterioro de la función del órgano. En caso de persistencia del insulto o de la situación de disoxia, las alteraciones metabólicas que se dan en el interior de la célula pueden desembocar en la muerte celular, con el consiguiente desarrollo de daño orgánico instaurado, fracaso multiorgánico, e incluso la muerte del individuo. En el paciente crítico, la incapacidad para mantener una adecuada perfusión de los órganos se traduce en una situación de disoxia celular, caracterizada por un aumento del metabolismo anaerobio con el fin de mantener la producción de ATP. Como consecuencia de este cambio de metabolismo aerobio a anaerobio, se produce un acúmulo de lactato, iones de hidrógeno y fosfatos inorgánicos en la célula. Esta generación de lactato e hidrogeniones, al pasar al torrente circulatorio, va a darnos el perfil biológico de acidosis láctica. El grado de hiperlactatemia y acidosis metabólica va a correlacionarse directamente con el desarrollo de fracaso orgánico y mal...

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Mesquida, J.^a; Borrat, X.^b; Lorente, J.A.^c; Masip, J.^a; Baigorri, F.^a

^aÁrea de Críticos, Hospital de Sabadell, Institut Universitari Parc Taulí, Sabadell, Barcelona, España

^bUCI Quirúrgica, Servicio de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España

^cServicio de Medicina Intensiva, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Universidad Europea de Madrid, Madrid, España