Cuadro 7 | Recomendaciones pragmáticas basadas en la evidencia para la Fluido terapia 2 ¿Historia Clínica Compatible? ¿Signos y Síntomas Compatibles? ¿Exámenes de Laboratorios Compatibles? Hidratación habitual + Observación No Realice la Medición Basal de Uno de los Parámetros Válidos Predictores de Respuesta a Fluidos (Paciente Semisentado: 30° - 45°) 4 Paciente Probablemente Respondedor a Volumen? 5 Sí 1 Posibilidad de Hipovolemia Absoluta o Relativa (Volumen Sanguíneo Circulante Inadecuado para la Condición del Paciente) Sí 2 3 ¿Paciente con Hipotensión e Hipoperfusión? No ¿Paciente con Hipoperfusión? No Administre 400 - 500 ml (6 - 7 ml/kg) en 20 - 30 min. del Fluido más adecuado según condición clínica. (No haga cambios en la terapia durante este intervalo, ni movilice al paciente). Realice la Medición Posterior del Parámetro Válido Predictor de Respuesta a Fluidos Elegido en la Medición Basal (Paciente Semisentado: 30° - 45°) Sí 1 ¿Radiografía de Tórax Compatible? ¿Parámetros Estáticos de Presión Compatibles? ¿Parámetros Estáticos de Volumen Compatibles? Fluidoterapia Agresiva Cristaloides (Idealmente balanceados) 20 - 50 ml/kg en 1 a 2 horas Iniciar u Optimizar Drogas Vasopresoras Inotrópicas 5 No ¿La Sospecha Clínica es muy fuerte a favor de Déficit de Volumen y el Riesgo de la Fluidoterapia es bajo? Medición Posterior del Volumen Sistólico 6 Medición Basal del Volumen Sistólico Sí ¿Incremento Volumen Sistólico (∆VS) ≥ 10 - 15%? No NO RESPONDEDOR RESPONDEDOR Sí ¿Qué? ¿Dónde? ¿Cuándo? ¿Por qué? ¿Cómo? Use soluciones salinas isotónicas, tamponadas, como fluidos de resucitación de primera línea. Considere la solución salina isotónica en pacientes hipovolémicos, alcalóticos. Use sangre fresca o componentes sanguíneos en pacientes con hemorragia activa. Considere los coloides en pacientes severamente hipovolémicos como fluidos de resucitación de segunda línea. Emplee los cristaloides por su fácil disponibilidad en escenarios pre-hospitalarios, militares, y de bajos ingresos. Emplee productos sanguíneos para la hemorragia aguda en la resucitación quirúrgica y del trauma. Los requerimientos de fluidos cambian en el tiempo. La resucitación con fluidos son una intervención clave durante la fase de salvataje de la resucitación (0-24 horas) El requerimiento de fluidos disminuye durante las fases de optimización y estabilización de la resucitación (24-96 horas) Los fluidos se deben reducir o restringir durante la fase de de-escalación (> 96 horas) La resucitación con fluidos se debe utilizar principalmente para tratar la hipovolemia sintomática. Los fluidos de mantenimiento solo deben emplearse en los pacientes que son incapaces de mantener una adecuada hidratación enteral. Considere la historia, la etiología, y el curso de la enfermedad cuando seleccione y administre los fluidos de resucitación. Ningún parámetro clínico o fisiológico mide exactamente el volumen intravascular. Identifique y reemplace los fluidos que más probablemente se hayan perdido con volúmenes equivalentes. Considere la osmolaridad sérica y el estado ácido-base cuando seleccione un fluido de resucitación. Considere el uso temprano de vasopresores además de fluidos, particularmente durante las fases de salvataje y optimización. Considere el balance de fluidos acumulado cuando seleccione la dosis del fluido de resucitación. No use fluidos para tratar perturbaciones fisiológicas aisladas tales como la oliguria. Emplee bolo de fluidos con precaución en pacientes con shock compensado, particularmente niños. Emplee la menor cantidad de volumen en bolo necesario para tratar la hipovolemia, particularmente cuando la fase de salvataje se ha completado. Emplee reto de fluidos con precaución para diagnosticar la respuesta a fluidos, particularmente cuando la fase de salvataje se ha completado. Todos los fluidos causan edema intersticial; evite volúmenes excesivos de cristaloides. Independientemente del resultado, no administre fluidos si ya se recuperaron los signos de perfusión y el paciente está estable Figura 23: Flujograma para la Fluido terapia del Paciente Crítico con Hipoperfusión Sistémica. neo Pulmonar (VSP), nos permite tener una idea aproximada si el exceso de APEV es debido a procesos que incrementan la presión hidrostática a nivel capilar (IPPV de 1 a 2,5-3), o a un fenómeno de incremento de la permeabilidad vascular pulmonar (IPPV > 2,5-3). En un estudio multicéntrico, un IPPV > 2,6 asociado a APEVi incrementada (> 10 ml/kg) estuvo relacionado con el diagnóstico de SDRA 144 . CONCLUSIONES 1. La medición exacta de la volemia o VSC de un paciente no es factible en la práctica clínica diaria. 2. La historia clínica, síntomas y signos, así como los exámenes de laboratorio son útiles para sospechar la presencia de déficit de VSC pero no son suficientes para determinar si un paciente va a responder o no a la administración de fluidos. 3. La Rx Tx, los Parámetros Estáticos tanto de Presión como Volumétricos, contribuyen a reforzar la sospecha clínica de déficit de volumen pero no tienen la suficiente capacidad para discriminar al respondedor del no respondedor al reto de fluidos. 4. Son principalmente los Parámetros Dinámicos basados en la Interacción Corazón-Pulmón del paciente en Ventilación Mecánica y la Elevación Pasiva de Miembros Inferiores las principales estrategias que nos permiten discriminar mejor aquellos pacientes que van a responder al reto con fluidos de quienes no lo harán. ¿Quién? La albúmina tiene un rol potencialmente beneficioso como un fluido adjunto en los pacientes con sepsis y shock séptico. La albúmina está contraindicada en pacientes con traumatismo encéfalo craneano. No se ha establecido la seguridad de otros coloides en pacientes con traumatismo encéfalo craneano. La solución salina es el fluido de elección en los pacientes con traumatismo encéfalo craneano. Las soluciones salinas tamponadas son las recomendadas en pacientes que van a ser sometidos a cirugía mayor o aquellos con quemaduras. La seguridad y eficacia de los coloides semi-sintéticos no ha quedado establecida en ninguna población. El hidroxietil starch está contraindicado en pacientes con sepsis severa. El hidroxietil starch está contraindicado en pacientes con alto riesgo de desarrollar injuria renal aguda. No se establecido aún en ninguna población la seguridad y eficacia de los cristaloides hipertónicos. 5. Cuando se cuente con la capacidad de cuantificar el Volumen Sistólico o GC, se debería corroborar con el incremento de su valor tras un reto de fluidos la presunción sobre la capacidad de respuesta a la fluido terapia del paciente crítico. También se puede recurrir a la cuantificación de este incremento, cuando los Parámetros Predictores de Respuesta a Fluidos no se correlacionen con claridad con el cuadro clínico del paciente. 6. Los cristaloides balanceados serían los fluidos más adecuados en la fluido terapia inicial del paciente crítico sobre la solución salina normal por su menor incidencia de acidosis metabólica, hipernatremia, y falla renal aguda. En caso de alcalosis o hiponatremia se preferiría el suero fisiológico normal. 7. La Albúmina estaría indicada complementariamente a los cristaloides en los pacientes con shock séptico y con albúmina menor a 3 g/dL. 8. Debería evitarse el uso del HES a la luz de la evidencia actual. 32 Intensivismo Intensivismo 33
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