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Resumen
La creciente preocupación por los posibles efectos adversos de las transfusiones homólogas ha hecho que se desarrollen una serie de medidas para reducirlas al mínimo indispensable. Estas medidas pueden agruparse en tres grandes bloques: autotransfusión, medidas no farmacológicas y medidas farmacológicas. Estas últimas, cuyas ventajas, inconvenientes y aplicaciones son el objeto de esta revisión, contribuyen a una reducción efectiva del riesgo de exposición a sangre homóloga en diversos tipos de cirugía (cardíaca, ortopédica, urológica, digestiva, trasplantes, etc.) a través de alguno de los siguientes mecanismos:
1. 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. Dicho tratamiento permite, además, aumentar el predepósito de sangre autóloga en cirugía programada.
2. Reducción de la hemorragia perioperatoria, mediante desmopresina, antifibrinolíticos sintéticos (tranexámico y ε-aminocaproico), estrógenos conjugados o aprotinina, cuyo principal efecto adverso puede ser el aumento del riesgo trombótico. La aprotinina presenta, además, unos notables efectos antiinflamatorios.
3. Aumento de la capacidad de oxigenación, mediante el uso de transportadores artificiales de oxígeno basados en la hemoglobina o en los perfluorocarbonos, algunos de los cuales se encuentran ya en las fases II o III de ensayo clínico.
4. Reposición de la volemia, mediante el empleo de soluciones cristaloides (suero salino isotónico, Ringer lactato, etc.) o coloides, tanto naturales (albúmina) como sintéticos (dextranos, gelatinas, hidroxietil almidones).
Palabras clave:
Ahorro de sangre
Eritropoyetina
Aprotinina
Perfluorocarbonos
Hidroxietil almidón
Growing concern for the possible adverse effects of homologous transfusions has stimulated the development of measures to reduce such transfusions to an absolute minimum. These measures may be classified in three groups: autotransfusion, non-pharmacological measures and pharmacological measures. The latter, whose advantages, disadvantages and applications are the subject of this review, contribute to an effective reduction in the risk of exposure to homologous blood in several types of surgery (cardiac, orthopedic, urologic, digestive, transplantation, etc.) through the following mechanisms.
1. Increased circulating blood mass through stimulation of erythropoiesis with erythropoietin, which increases preoperative hemoglobin values and/or accelerates their postoperative recovery. Moreover, this treatment increases pre-surgical deposits of autologous blood in elective surgery.
2. Reduction of perioperative bleeding through desmopressin, synthetic antifibrinolytics (tranexamic and ε-aminocaproic) conjugated estrogens or aprotinin, whose main adverse effect is increased risk of thrombosis. Aprotinin also exerts considerable antiinflammatory effects.
3. Increased oxygenation through the use of artifical oxygen carriers based on hemoglobin or perfluorocarbons, some of which are currently the object of phase II or III clinical trials.
4. Restoration of normovolemia through the use of crystalloid solutions (isotonic saline solution, Ringer’s lactate, etc.) natural colloids (albumin) or synthetic colloids (dextrans, gelatins, hydroxyethyl aldimines.
Key words:
Blood saving
Erytrhopoietin
Aprotinin
Perfluorocarbons
Hydroxyethl starch
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