Administración de fluidos en el paciente grave

Iván Moyano Alfonso, Alejandro González Alvarez, Julio Antonio Fernández Hernández

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Resumen

Introducción: la administración de fluidos constituye uno de los pilares fundamentales en el tratamiento de los pacientes graves; solo 50 % responden a este procedimiento y existe incoherencia entre variables macro y microhemodinámicas, lo cual hace más complejo su seguimiento. Las investigaciones actuales se centran en múltiples variables de monitoreo y diversas estrategias para la administración de fluidos en el paciente grave.

Objetivo: actualizar las evidencias sobre la administración de fluidos en el paciente grave.

Método: se revisaron los estudios publicados en las bases de datos PubMed, SciELO Cuba, Cumed y en el buscador Google Académico. Se seleccionaron los trabajos publicados en los últimos cinco años, en idiomas inglés y español.

Desarrollo: se presentan evidencias relacionadas con las variables de monitoreo para la administración de fluidos, y estrategias para su mantenimiento. Al respecto, los autores exponen sus consideraciones críticas.

Conclusiones: existe consenso en que la administración inicial de fluidos en pacientes en choque debe ser precoz y agresiva para restituir la volemia. La administración de fluidos necesita variables de monitoreo para definir con eficacia el paciente que se beneficia con su empleo, teniendo en cuenta que los signos del examen físico, las variables fisiológicas más comunes, y el estudio radiográfico son poco efectivos para guiar su aporte. A pesar de las evidencias de que la sobrecarga de fluidos empeora el pronóstico del paciente, aún no hay consenso en cuanto al mantenimiento de volumen en enfermos graves, por lo cual se requieren nuevos estudios que aborden este tema.

Referencias

Sumeet R, Laurence W, Young P. Crystalloid fluid therapy. Crit Care [Internet]. 2016 [citado 12 Feb 2018];20:59 [aprox. 9 p.] Disponible en: https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1217-5

Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Annals of Intensive Care [Internet]. 2011 [citado 12 Feb 2018];1:1[aprox. 9 p.] Disponible en: http://www.annalsofintensivecare.com/content/1/1/1

Monnet X, Teboul JL. Assessment of volume responsiveness during mechanical ventilation: recent advances. Crit Care. 2013 [citado 12 Feb 2018];17(2):217. Disponible en: https://healthmanagement.org/c/icu/issuearticle/fluid-responsiveness-new-advances

Marik PE, FCCM, FCCP. Hemodynamic parameters to guide fluid therapy. Transf Med [Internet]. 2010 [citado 12 Feb 2018];11(3):102-112. Disponible en: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1778-428X.2010.01133.x

de Oliveira OH, Freitas FG, Ladeira RT, Fischer CH, Bafi AT, Azevedo LC, et al. Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients. J Crit Care [Internet]. 2016 [citado 12 Feb 2018];34:46–49. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/27288609

Diaztagle Fernández JJ, Cruz Martínez LE, Caicedo Ruiz JD. La prueba de líquidos en sepsis severa y choque séptico: una mirada desde la fisiología. Acta Colomb Cuid Intensivo [Internet]. 2015 [citado 12 Feb 2018];15(3):204-214. Disponible en: https://www.sciencedirect.com/science/article/pii/S0122726215000221

Yunfan W, Shusheng Z, Zhihua Z, Bao L. A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness. Crit Care [Internet]. 2014 [citado 12 Feb 2018];18:R108. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075154

Hernández Sómerson MA, Bernal Ramirez O, Jiménez Palomino JC, Rodriguez Urueña S, Jurado Zambrano JR, Montoya Agudelo F. Terapia temprana dirigida por metas en sepsis: ¿es momento para un nuevo algoritmo? Acta Colomb Cuid Intensivo [Internet]. 2016 [citado 12 Feb 2018];16(4):283-289. Disponible en: http://dx.doi.org/10.1016/j.acci.2016.05.003

Zochios V, Wilkinson J. Assessment of intravascular fluid status and fluid responsiveness during mechanical ventilation in surgical and intensive care patients. Int Care Society [Internet]. 2011 [citado 12 Feb 2018];12(4):295-300. Disponible en: http://journals.sagepub.com/doi/pdf/10.1177/175114371101200410

ARISE, ANZICS Clinical Trials Group. Goal-Directed Resuscitation for Patients with Early Septic Shock. N Engl J Med [Internet]. 2014 [citado 12 Feb 2018];371:1496-1506. Disponible en: http://www.nejm.org/doi/full/10.1056/NEJMoa1404380

ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med [Internet]. 2014 [citado 12 Feb 2018];370:1683-93. Disponible en: http://www.nejm.org/doi/full/10.1056/NEJMoa1401602

Mouncey PR, Osborn TM, Power S, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of early, goal directed resuscitation for septic shock. N Engl J Med [Internet]. 2015 [citado 12 Feb 2018];372:1301-1311. Disponible en: http://www.nejm.org/doi/full/10.1056/NEJMoa1500896

Maitland K, George EC, Evans JA, Kiguli S, Olupot Olupot P, Akech SO, et al. Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial. BMC Medicine [Internet]. 2013 [citado 12 Feb 2018];11:68. Disponible en: http://www.biomedcentral.com/1741-7015/11/68

Hanson J, Lam SWK, Shamsul A, Pattnaik R, Mahanta KC, Uddin Hasan M, et al. The reliability of the physical examination to guide fluid therapy in adults with severe falciparum malaria: an observational study. Mal Journal [Internet]. 2013 [citado 12 Feb 2018];12:348. Disponible en: http://www.malariajournal.com/content/12/1/348

Soliman RA, Samir S, El Naggar A, El Dehely K. Stroke volume variation compared with pulse pressure variation and cardiac index changes for prediction of fluid responsiveness in mechanically ventilated patients. Egypt J Crit Care Med [Internet]. 2015 [citado 12 Feb 2018];3(1):9-16. Disponible en: http://dx.doi.org/10.1016/j.ejccm.2015.02.002

Hasanin A. Fluid responsiveness in acute circulatory failure. J Intensive Care [Internet]. 2015 [citado 12 Feb 2018];3:50. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/26594361

Maas J. Mean systemic filling pressure: from Guyton to the ICU. [Internet]. Leiden University; 2013. [citado 12 Feb 2018] Disponible en: https://openaccess.leidenuniv.nl/bitstream/handle/1887/20407/Thesis%20book.pdf?sequence=3

Berlin DA, Bakker J. Starling curves and central venous pressure. Crit Care [Internet]. 2015 [citado 12 Feb 2018];19(1):55. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329649

Grassi P, Lo Nigro L, Battaglia K, Barone M, Testa F, Berlot G. Pulse pressure variation as a predictor of fluid responsiveness in mechanically ventilated patients with spontaneous breathing activity: a pragmatic observational study. HSR Proc Intensive Care Cardiovasc Anesth [Internet]. 2013 [citado 12 Feb 2018];5(2):98-109. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722341

Sasai T, Tokioka H, Fukushima T, Mikane T, Oku S, Iwasaki E, et al. Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation in patients with septic shock. J Int Care [Internet]. 2014 [citado 12 Feb 2018];2:58. Disponible en: http://www.jintensivecare.com/content/2/1/58

Pinsky MR. Functional hemodynamic monitoring. Crit Care Clin [Internet]. 2015 [citado 12 Feb 2018];31(1):89-111. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/25435480

Lakhal K, Ehrmann S, Runge I, Benzekri Lefe D, Legras A, Dequin PF, et al. Central venous pressure measurements improve the accuracy of leg raising induced change in pulse pressure to predict fluid responsiveness. Int Care Med [Internet]. 2010 [citado 12 Feb 2018];36(6):940–948. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/20111858

Perel A. The physiological basis of arterial pressure variation during positive pressure ventilation. Reanimation [Internet]. 2005 [citado 12 Feb 2018];14:162–171. Disponible en: https://www.srlf.org/wp-content/uploads/2015/11/0505-Reanimation-Vol14-N3-p162_171.pdf

Cannesson M, Aboy M, Hofer CK, Rehman M. Pulse pressure variation: where are we today?. J Clin Monit Comput [Internet]. 2011 [citado 12 Feb 2018];25(1):45-56. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/20390324

Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care [Internet]. 2010 [citado 12 Feb 2018];14:R118. Disponible en: http://ccforum.com/content/14/3/R118

Biais M, Ehrmann S, Mari A, Conte B, Mahjoub Y, Desebbe O, et al. Clinical relevance of pulse pressure variations for predicting fluid responsiveness in mechanically ventilated intensive care unit patients: the grey zone approach. Crit Care [Internet]. 2014 [citado 12 Feb 2018];18:587. Disponible en: http://ccforum.com/content/18/6/587

Vallee F, Richard JC, Mari A, Gallas T, Arsac E, Verlaan PS, et al. Pulse pressure variations adjusted by alveolar driving pressure to assess fluid responsiveness. Int Care Med [Internet]. 2009 [citado 12 Feb 2018];35(6):1004–1010. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/19347330

Freitas FG, Bafi AT, Nascente AP, Assuncao M, Mazza B, Azevedo LC, et al. Predictive value of pulse pressure variation for fluid responsiveness in septic patients using lung-protective ventilation strategies. Br J Anaesth [Internet]. 2013 [citado 12 Feb 2018];110(3):402-408. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/23161359

Li C, Lin FQ, Fu SK, Chen GQ, Yang XH, Zhu CY, et al. Stroke volume variation for prediction of fluid responsiveness in patients undergoing gastrointestinal surgery. Int J Med Sci [Internet]. 2013 [citado 12 Feb 2018];10(2):148-155. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/23329886

Messina A, Colombo D, Cammarota G, De Lucia M, Cecconi M, Antonelli M, et al. Patient ventilator asynchrony affects pulse pressure variation prediction of fluid responsiveness. J Crit Care [Internet]. 2015 [citado 12 Feb 2018];30(5):1067–1071. Disponible en: http://dx.doi.org/10.1016/j.jcrc.2015.06.010

Lee JY, Park HY, Jung WS, Jo YY, Kwak HJ. Comparative study of pressure and volume controlled ventilation on stroke volume variation as a predictor of fluid responsiveness in patients undergoing major abdominal surgery. J Crit Care [Internet]. 2012 [citado 12 Feb 2018];27(5):9–14. Disponible en: http://dx.doi.org/10.1016/j.jcrc.2011.11.012

Feissel M, Teboul JL, Merlani P, Badie J, Faller JP, Bendjelid K. Plethysmographic dynamic indices predict fluid responsiveness in septic ventilated patients. Int Care Med [Internet]. 2007 [citado 12 Feb 2018];33(6):993–999. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/17393139

Technical Bulletin. Pleth Variability Index: A Dynamic Measurement to Help Assess Physiology and Fluid Responsiveness. Masimo international. 2015:[aprox. 7 p.] Disponible en: http://anesthesiology.queensu.ca/assets/LAB4583B_Technical_Bulletin_Pleth_Variability_Index.pdf

Monnet X, Guerin L, Jozwiak M, Bataille A, Julien F, Richard C, et al. Pleth variability index is a weak predictor of fluid responsiveness in patients receiving norepinephrine. Br J Anaesth [Internet]. 2013 [citado 12 Feb 2018];110(2):207–213. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/23103777

Cavallaro F, Sandroni C, Marano C, La Torre G, Mannocci A, De Waure CH, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Int Care Med [Internet]. 2010 [citado 12 Feb 2018];36(9):1475-1483. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/20502865

Jabot J, Teboul JL, Richard C, Monnet X. Passive leg raising for predicting fluid responsiveness: importance of the postural change. Int Care Med [Internet]. 2009 [citado 12 Feb 2018];35(1):85–90. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/18795254

Lafanechère A, Pène F, Goulenok C, Delahaye A, Mallet V, Choukroun G, et al. Changes in aortic blood flow induced by passive leg raising predict fluid responsiveness in critically ill patients. Crit Care [Internet]. 2006 [citado 12 Feb 2018];10:R132. Disponible en: http://ccforum.com/content/10/5/R132

Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement and passive leg raising predict volume responsiveness in medical ICU patients: an observational cohort study. Crit Care [Internet]. 2009 [citado 12 Feb 2018];13:R111. Disponible en: http://ccforum.com/content/13/4/R111

Monnet X, Bataille A, Magalhaes E, Barrois J, Le Corre M, Gosset C, et al. End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test. Int Care Med [Internet]. 2013 [citado 12 Feb 2018];39(1):93-100. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/22990869

Monge García MI, Gil Cano A, Gracia Romero M, Monterroso Pintado R, Pérez Madueño V, Díaz Monrovéet JC. Non-invasive assessment of fluid responsiveness by changes in partial end-tidal CO2 pressure during a passive leg-raising maneuver. An Intensive Care [Internet]. 2012 [citado 12 Feb 2018];2:9. Disponible en: http://www.annalsofintensivecare.com/content/2/1/9

Zang ZD, Yan J, Xu HY, Liang FM, Yang T, Wang DP, et al. The value of changes in end-tidal carbon dioxide pressure induced by passive leg raising test in predicting fluid responsiveness in mechanically ventilated patients with septic shock. Zhouqhua Nei Ke Za Zhi [Internet]. 2013 [citado 12 Feb 2018];52(8):646-650. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/24199878

Boulain T, Garot D, Vignon P, Lascarrou JB, Desachy A, Botoc V, et al. Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients: a prospective multicenter study. Cri Care [Internet]. 2014 [citado 12 Feb 2018];18:609. Disponible en: http://ccforum.com/content/18/6/609

Meehan PA. Venous oximetry: indications and applications. Spring 2012. Disponible en: https://www.yumpu.com/en/document/view/38944045/venous-oximetry-indications-and-applications

Walley KR. Use of central venous oxygen saturation to guide therapy. Am J Respir Crit Care Med [Internet]. 2011 [citado 12 Feb 2018];184(5):514–520. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/21177882

Perz S, Uhlig T, Kohl M, Bredle DL, Reinhart K, Bauer M, et al. Low and ‘‘supranormal’’ central venous oxygen saturation and markers of tissue hypoxia in cardiac surgery patients: a prospective observational study. Int Care Med [Internet]. 2011 [citado 12 Feb 2018];37(1):52–59. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/20689932

Mikor A, Trásy D, Németh MF, Osztroluczki A, Kocsi Z, Kovács I, et al. Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial. BMC Anesthesiology [Internet]. 2015 [citado 12 Feb 2018];15:82. Disponible en: http://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-015-0064-2

Bjerregaard LS, Moller Sorensen H, Lindskov K, Ravn J, Nilsson JC. Using clinical parameters to guide fluid therapy in high risk thoracic surgery. A retrospective, observational study. BMC Anesthesiology [Internet]. 2015 [citado 12 Feb 2018];15:91. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464224

Vallet B, Robin E, Lebuffe G. Venous oxygen saturation as a physiologic transfusion trigger. Crit Care [Internet]. 2010 [citado 12 Feb 2018];14:213. Disponible en: http://ccforum.com/content/14/2/213

Bustos R, Padilla O. El tiempo de llene capilar prolongado es predictor de una saturación venosa central de oxígeno disminuida. Rev Chil Pediatr [Internet]. 2014 [citado 12 Feb 2018];85(5):539-545. Disponible en: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0370-41062014000500003

Textoris J, Fouché L, Wiramus S, Antonini F, Tho S, Martin C, et al. High central venous oxygen saturation in the latter stages of septic shock is associated with increased mortality. Crit Care [Internet]. 2011 [citado 12 Feb 2018];15:R176. Disponible en: http://ccforum.com/content/15/4/R176

Lichtenstein D, Karakitsos D. Integrating lung ultrasound in the hemodynamic evaluation of acute circulatory failure (the fluid administration limited by lung sonography protocol). J Crit Care [Internet]. 2012 [citado 12 Feb 2018];27(5):11–19. Disponible en: http://dx.doi.org/10.1016/j.jcrc.2012.03.004

Marik PE, Lemson J. Fluid responsiveness: an evolution of our understanding. Br J Anaesth [Internet]. 2014 [citado 12 Feb 2018];112(4):617-620. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/24535603

Barmparas G, Ko A, Harada MY, Zaw AA, Murry JS, Smith EJT, et al. Decreasing maintenance fluids in normotensive trauma patients may reduce intensive care unit stay and ventilator days. J Crit Care [Internet]. 2016 [citado 12 Feb 2018];31(1):201–205. Disponible en: http://dx.doi.org/10.1016/j.jcrc.2015.09.030

Elofson KA, Eiferman DS, Porter K, Murphy CV. Impact of late fluid balance on clinical outcomes in the critically ill surgical and trauma population. J Crit Care [Internet]. 2015 [citado 12 Feb 2018];30(6):1338–1343. Disponible en: http://dx.doi.org/10.1016/j.jcrc.2015.07.009

Winther Voldby A, Brandstrup B. Fluid therapy in the perioperative setting a clinical review. J Int Care [Internet]. 2016 [citado 12 Feb 2018];4:27. Disponible en: https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-016-0154-3

Futier E, Constantin JM, Petit A, Chanques G, Kwiatkowski F, Flamein R, et al. Conservative vs. restrictive individualized goal directed fluid replacement strategy in major abdominal surgery: A prospective randomized trial. Arch Surg [Internet]. 2010 [citado 12 Feb 2018];145(12):1193-1200. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/21173294