LÍQUIDOS EN SEPSIS

TERESA DE LA TORRE LEON

hor Manuscript
Trzeciak et al. Page 21

NIH-PA Author Manuscript

NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Figure 3.
Conceptual framework of the importance of the microcirculation in septic shock and
resuscitation. Conventional resuscitation targets optimization of “upstream” (i.e.
METAS DE REANIMACION HIDRICA
macrocirculatory) hemodynamic parameters (e.g. mean arterial pressure, cardiac output), with
NIH Public Access
monitoring of “downstream” markers of tissue perfusion (e.g. acidosis, organ function) to
determine the effectiveness of resuscitation efforts. The microcirculation represents a critical
intermediary. Although Author Manuscript
the macrocirculation circulates blood throughout the body, an intact
and functional microcirculation is necessary
Acad Emerg Med. Author for effective blood flow
manuscript; to tissues.
available in PMCTherefore,
2009 August 16.
intrinsic microcirculatory failure may contribute to sepsis-associated tissue hypoperfusion.
Publishedblood
in final edited formbeas:visualized directly in sepsis clinical
NIH-PA Au

Sublingual microcirculatory flow can now

NIH-PA A

research
Figure 3.using a hand-held Emerg Med. 2008(shown
Acad videomicroscope May ; 15(5): 399–413.
on left). doi:10.1111/j.1553-2712.2008.00109.x.
In this paper, we present a
Conceptual
scientific framework
rationale for a of the importance
clinical of theagent
trial of a novel microcirculation in septic
(e.g. exogenous nitricshock
oxideand
resuscitation. Conventional
administration, shown on right) resuscitation
to reduce targets optimization
microcirculatory of “upstream”
dysfunction (i.e.
and augment
macrocirculatory) hemodynamic parameters (e.g. mean arterial pressure, cardiac output), with
NIH-PA Author Manuscript
NIH-PA Author Manuscript Trzeciak et al. Page 24

NIH Public Access

Author Manuscript
Acad Emerg Med. Author manuscript; available in PMC 2009 August 16.
Published in final edited form as:
NIH-PA Autho

Acad Emerg Med. 2008 May ; 15(5): 399–413. doi:10.1111/j.1553-2712.2008.00109.x.

Resuscitating the Microcirculation in Sepsis: The Central Role of

N
SEPSIS PROBLEMA SALUD
PUBLICA

300 CASOS/ 100 000

HABITANTES

MORTALIDAD 20%

INESTABILIDAD
HEMODINAMICA
INCREMENTA LA
MORTALIDAD HASTA 50%
 ES UN PASO
INICIAL
IMPORTANTE
PARA EL MANEJO
DE SEPSIS Y
CHOQUE
SEPTICO.

REANIMACIÓN CON VOLUMEN

 OBJETIVOS
MEJORAR LA PERFUSIÓN
INCREMENTAR EL GASTO
CARDIACO

REANIMACION AGRESIVA NO ES
BENEFICA PARA EL PACIENTE
CRITICAMENTE ENFERMO

QUE TANTO VOLUMEN ES

NECESARIO ???????
EL BALANCE POSITIVO = INCREMENTA
LA MORTALIDAD
A 12 HORAS DE INICIO DE LA
REANIMACION
BALANCE NEUTRO O NEGATIVO
POSTERIOR A LA REANIMACION INICIAL
CUANTO??????
DE CUAL??????
ALBUMINA VS CRISTALOIDES
PROTEINA MAS ABUNDANTE EN EL PLASMA 50 A 60%
ES LA SOLUCION MAS UTILIZADO PARA LA EXPANSION DE VOLUMEN EN
PACIENTES CRITICAMENTE ENFERMOS.

ALBUMINA
COCHRANE RR MORTALIDA 1.46 PX SEPTICOS CON ALBUMINA
INCREMENTA MORTALIDAD 4%
DISMINYE LA MORTALIDAD 30.7 VS 35.5% EN CHOQUE SEPTICO
REANIMADO CON ALBUMINA
DISMINUYE VOLUMEN TOTAL INFUNDIDO
NO EXISTEN DIFERENCIAS DIAS DE UTI, DIAS DE VENTILACION.

HIPOALBUMINEMIA INCREMENTA LA MORTALIDAD

PACIENTES CON ALB MENOR 3.1 MG/DL SE DEBE
REANIMAR CON ALBUMINA
ALMIDON SINTETICO
USO INDISCRIMINADO EN UTI
MAIZ, PAPA ------- AMILOPECTINA + SUBUNIDADES GLUCOSA
HIDROLISADO POR ALFA AMILASA

INCREMENTA LESION RENAL

INCREMENTA MORTALIDAD A 90 DIAS (41 VS 33.9%)
LESION RENAL (34.9 VS 22.8%)
REEMPLAZO RENAL (18.3 VS 9.2)

70 ML/KG Y LA OSMOLARIDAD. ESTUDIO VISEP

SOLUCION SALINA = NORMAL O FISIOLOGICA????
INCREMENTO CLORO A NIVEL TUBULAR

SE ASOCIA CON DISMINUCION FLUJO SANGUINEO RENAL 1 A 30 MIN POSTERIOR AL INICIO DE LA

INFUSION

MORTALIDAD SE INCREMENTA EN PACIENTES CON SOL SALINA QUE CON BALANCEADAS (5.6 VS 9.2%)

USAR SOLUCIONES BALANCEADAS

ACIDOSIS METABOLICA
ACIDOSIS LACTICA
HIPOPERFUSION

DISMINUYE NIVELES DE BICARBONATO = DISMINUYE pH

ACIDOSIS HIPERCLOREMICA IATROGENICA QUE SE CONSIDERA

PROINFLAMATORIA

CAMBIO EN ESTADO ACIDO-BASE

 ACIDOSIS

MAS SOLUCION SE INFUNDE SOL

SALINA SALINA

HIPERTENSION ACIDOSIS
ABDOMINAL HIPERCLOREMICA

INCREMENTA
EDEMA AGUDO MAS LIQUIDO
PULMONAR

MAS ACIDOSIS

INCREMENTA TASA DE LESION

RENAL Y TSFR
(TRATAMIENTO SUSTITUTIVO DE LA FUNCION RENAL)
NO OLVIDEMOS EL
GLICOCALIX

SU ESTRUCTURA SE
PIERDE POSTERIOR A LA
INFUSION DE
SOLUCIONES
PARENTERALES
TODAS LAS FUNCIONES DEL GLICOCALIX SE ALTERAN
ENDOTELIO
PERMEABILIDAD
COAGULACION
INFLAMACION
 van den Berg et al Glycocalyx Prevents Capillary Edema 593

Figure 2. Distribution of glycocalyx thickness within normal cap-

illaries (no treatment) and hyaluronidase-treated capillaries. Box
plots indicate median values with 5th and 95th percentiles.
*P 0.001 by means of Mann-Whitney U nonparametric test.

surrounding tissue was significantly (P 0.001) affected on

treatment with hyaluronidase (Figures 3A and 3B). Although
most of the normal vessels were surrounded by an intersti-
tium with a median dimension of 0.28 m (Figure 3A),

Figure 1. A, Electron microscopic overview of an Alcian blue

8GX–stained rat left ventricular myocardial capillary (bar 1 m).
14 June 2013
EMA/349341/2013

PRAC recommends suspending marketing authorisations

for infusion solutions containing hydroxyethyl-starch

The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee (PRAC) has
concluded following a review of the available evidence that the benefits of infusion solutions containing
hydroxyethyl-starch (HES) no longer outweigh their risks and therefore recommended that the
marketing authorisations for these medicines be suspended.

Infusion solutions containing HES are medicines mainly used to replace lost blood volume in
hypovolaemia (low blood volume caused by dehydration or blood loss) and hypovolaemic shock (a
steep fall in blood pressure caused by drop in blood volume). They are used in critically ill patients
including patients with sepsis (bacterial infection of the blood) or burn or trauma injuries, or patients
who are undergoing surgery.
 CONCLUSIONES
• Reanimación con Volumen es uno de los principales pasos en el manejo de los
pacientes con sepsis /sepsis grave/ choque séptico.
• La elección del fluido debe basarse en la fisiopatología subyacente
• En los pacientes críticos con hipoalbuminemia y sepsis se debe de infundir
albumina endovenosa.
• NO USAR HES en pacientes sépticos. SOBRE NINGUNA CONDICION
• Fluidos balanceadas deben considerarse TODOS LOS PACIENTES
• De la reanimación inicial depende el pronóstico del paciente.
• Es la herramienta terapéutica más importante en el choque hipovolémico y en la
sepsis/sepsis grave/choque séptico.
 Shock: Terapia Hídrica Inicial

RECUERDA
TODOS LOS
LIQUIDOS
ENDOVENOSOS A
INFUNDIR
TIENEN ALGO
BUENO
MALO Y FEO.

www.reeme.arizona.edu