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Campaaparalasupervivenciadelasepsis|16MAY17

Guainternacionalparaelmanejodelasepsisyelshock
sptico
Actualizacindelasrecomendacionesparaelmanejodelasepsisyshockspticodela"Campaapara
laSupervivenciadelaSepsis
Autor:AndrewRhodes,LauraE.Evans,WaleedAlhazzani,Mitchellyotros.CareMed201745:Nmero3.Pag.486552

Pgina1

IntraMed
Gua internacional para el manejo de la sepsis y el shock sptico Share

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Introduccin

Lasepsisesunadisfuncinorgnicapotencialmentemortalcausadaporunadesregulacindelarespuestadel
huspedalainfeccin.Lasepsisyelshockspticosonproblemasdesaludimportantesqueafectanamillonesde
personascadaao,matandoaunodecadacuatro(yamenudoams).Igualqueconelpolitraumatismo,elinfarto
agudodemiocardiooelaccidentecerebrovascular,laidentificacinyelmanejotempranosenlasprimerashoras
posterioresalaaparicindelasepsis,mejoranlosresultados.Sehacenotarqueestasrecomendacionesnopueden
reemplazarlacapacidaddetomadedecisionesdelclnicocuandosepresentancomounconjuntonicodevariables
clnicasencadapaciente.Estaspautassonapropiadasparaelpacientespticohospitalizado.

ElComitparaelconsenso,compuestopor55expertosinternacionalesy25organizacionesinternacionales
proporcion93declaracionessobreelmanejotempranoylareanimacindelospacientesconsepsisoshocksptico,
todasconelmismoniveldeevidencia.

RecomendacionesdelConsenso

A.ResucitacinInicial

1.Comenzarinmediatamenteeltratamientoylareanimacindelasepsisyelshockspticoyaqueson
emergenciasmdicas.

2.Enlareanimacindelahipoperfusininducidaporsepsisserecomiendaadministraralmenos30ml/kgde
lquidoscristaloidesIVenlasprimeras3horas.

3.Despusdelareanimacininicialmedianteelaportelquido,lacontinuacindelaadministracindelquidos
adicionalesdebeguiarseporfrecuentesreevaluacionesdelestadohemodinmico.

Nota:Lareevaluacindebeincluirunexamenylaevaluacindelasvariablesfisiolgicasdisponibles:(frecuenciacardaca,presinarterial,saturacin
arterialdeoxgeno,temperatura,diuresisyotros,ascomootrosmonitoreosnoinvasivosoinvasivos,segnladisponibilidad.

4.Sielexamenclniconoconduceaundiagnstico,serecomiendamayorevaluacinhemodinmica(porej.,
evaluacindelafuncincardaca)paradeterminareltipodeshock.

5.Parapredecirlacapacidadderespuestaalaportelquidosesugiereutilizarvariablesdinmicasenvezde
variablesestticas,siemprequeestndisponibles.

6.Serecomiendaunapresinarterialmediainicialde65mmHgenpacientesconshockspticoquerequieren
vasopresores.

7.Guiarlareanimacinparanormalizarellactatoenpacientesconniveleselevadosdelactatocomomarcador
dehipoperfusintisular.

Justificacin.
Lareanimacineficaztempranaconaportelquidoescrucialparalaestabilizacindelahipoperfusintisularinducida
porlasepsisoelshock.Lahipoperfusininducidaporsepsispuedemanifestarseporladisfuncinorgnicaaguday/o
ladisminucindelapresinarterialyelaumentodellactatosrico.Lasversionespreviasdelasguashanrecomendado
unareanimacincuantitativaprotocolizada,tambinconocidacomoterapiatempranadirigidaametas",entreellasla Page 1 / 41
porlasepsisoelshock.Lahipoperfusininducidaporsepsispuedemanifestarseporladisfuncinorgnicaaguday/o
ladisminucindelapresinarterialyelaumentodellactatosrico.Lasversionespreviasdelasguashanrecomendado
unareanimacincuantitativaprotocolizada,tambinconocidacomoterapiatempranadirigidaametas",entreellasla
presinvenosacentral(PVC)ylasaturacindeoxgenovenosocentral(So2vc).

Recientemente,esteenfoquehasidocuestionadoluegodenohabersedemostradounareduccindelamortalidaden
estudiosimportantesperonosehalldaoasociadoalasestrategiasintervencionistas,as,elusodelasmetas
anterioressiguesiendoseguroypuedeserconsiderado.Cabedestacarquelosensayosmsrecientesincluyeron
pacientesmenosgraves(menoresnivelesdelactato,ScvO2igualosuperioralvalorobjetivoalingreso,ymenor
mortalidadenelgrupodecontrol).Aunquelaevidenciaactualnogarantizalarecomendacindeesteprotocolo,ala
cabeceradelenfermolosmdicossiguennecesitandoorientacinsobrecmoactuarconelgrupodepacientescon
mortalidadymorbilidadsignificativas.

Elconsensorecomienda,porlotanto,queestospacientesseanconsideradosenemergenciamdicayrequierenuna
evaluacinytratamientourgentes.Comopartedesto,serecomiendainiciarlquidodereanimacin(30ml/kgde
cristaloide)dentrodelasprimeras3horas.Estevolumenfijodelquidopermiteiniciarlareanimacinyobtener
informacinmsespecficasobrelospacientesmientrasseesperanlasmedicionesmsprecisasdelestado
hemodinmico.Aunqueespocalaliteraturaqueincluyedatospararespaldarestevolumendelquido,estudiosrecientes
handescritostocomounaprcticahabitualenlosestadiosdereanimacin,ylaevidenciaobservacionalapoyanesta
prctica.Muchospacientesnecesitarnmsde30ml/kgdepesodelquido,yparaestegrupoelconsensoaconseja
basarseenlasmedicioneshemodinmicasfuncionales.

Unodelosprincipiosmsimportanteseneltratamientodeestospacientescomplejoseslanecesidaddeuna
evaluacininicialylareevaluacincontinuadelarespuestaaltratamiento,comenzandoconelexamenylaevaluacin
delasvariablesfisiolgicasdisponibles,quepuedendescribirelestadoclnicodelpaciente.Yanosejustificaelusode
laPVCsolaparaguiarlareanimacinconlquidoyaquelacapacidaddepredecirunarespuestaalainfusindelquido
cuandolaPVCestdentrodeunintervalorelativamentenormal(812mmHg)eslimitada.Lomismoocurreconotras
medidasestticasdelaspresionesovolmenescardacosderechosoizquierdos.

Paramejorarelmanejodeloslquidossehanpropuestomedidasdinmicasquepermitenestablecersiunpaciente
requierelquidoadicionallasmismashandemostradoprecisindiagnsticaparapredecirculessernlospacientes
querespondernaunmayoraportedelquidosatravsdelaumentodelvolumensistlico.Estastcnicasabarcanla
elevacinpasivadelaspiernas,losdesafosdelquidosconlasmedicionesdelvolumensistlicoolasvariacionesdela
presinsistlica,lapresindepulsooelvolumensistlicoparaloscambiosenlapresinintratorcicainducidosporla
ventilacinmecnica.Sehademostradoqueelusodelavariacindelapresindelpulsoparapredecirlarespuestaal
lquidoenpacientesconsepsisoshockspticotieneunasensibilidadde0,72yunaespecificidadde0,91.

Lapresinarterialmediaeslapresinmotoradelaperfusintisular.Mientraslaperfusinderganoscrticos(cerebro,
riones)estprotegidadelahipotensinsistmicaporlaautorregulacindelaperfusinregional,pordebajodelun
umbraldelapresinarterialmedia(PAM)laperfusintisularsetornalinealmentedependientedelapresinarterial.

Ellactatosriconoesunamedidadirectadelaperfusintisular.Elaumentodelniveldelactatosricopuede
representarhipoxiatisular,gliclisisaerbicaaceleradaimpulsadaporunexcesodeestimulacinandrognicauotras
causas(porej.,insuficienciaheptica).Independientementedelorigen,elaumentodelosnivelesdelactatoseasocia
conpeoresresultados.Debidoaqueellactatoesunanlisisdelaboratorioestndarcontcnicasprescritasparasu
medicin,puedeservircomounsustitutomsobjetivoparalaperfusintisularencomparacinconelexamenfsicoola
diuresis.Sehacomprobadoqueenlasreanimacionesdepacientesconshockspticobasadasenelniveldelactato,la
mortalidadseredujosignificativamenteencomparacinconlareanimacinsinmonitoreodellactato.

B.Cribadodelasepsisymejoramientodelrendimiento

1.Serecomiendaqueloshospitalesysistemashospitalariostenganunprogramaparaelmejoramientodel
rendimientodesepsis,incluyendoladeteccindelasepsisenlaenfermedadagudaenpacientesdealtoriesgo.

Justificacin:Losesfuerzosparamejorarelrendimientoenlasepsisseasocianconmejoresresultados.Estos
programasdeberanestarrepresentadospormltiplesprofesionalesylaintervencinensudesarrollodelaspartes
interesadasdetodaslasdisciplinas(mdicos,enfermeras,afiliadosprestadores,farmacuticos,terapeutas
respiratorios,dietistas,administradores).Losprogramasdebenincluireldesarrolloeimplementacindeprotocolos,
mtricasespecficasaevaluar,recopilacindedatosyretroalimentacincontinua,conelfindefacilitarelmejoramiento
continuodelrendimiento.

Ademsdelaeducacincontinuatradicional,puedenservaliososelusodeguaslaprcticaclnica.Puedentenercomo
objetivoelreconocimientoprecozdelasepsismedianteelcribadoyunmejormanejodelospacientesunavez
identificadoscomospticos.Comolafaltadereconocimientodelasepsisimpideeltratamientooportuno,elcribadode
lasepsispermiteeltratamientoprecozyunadisminucindelamortalidad.Dentrodeestosprogramas,la
implementacindeun"paquete"bsicoderecomendacioneshasidounafundamental.Untemaobjetivocomnalos
diversosprogramasesmejorarelcumplimientodelospaquetesyaqueseasociaconunaumentosignificativode
reduccindelamortalidad.
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C.Diagnstico
diversosprogramasesmejorarelcumplimientodelospaquetesyaqueseasociaconunaumentosignificativode
reduccindelamortalidad.

C.Diagnstico

1.Enlospacientesconsospechadesepsisoshockspticoserecomiendarealizarcultivosmicrobiolgicos
(incluyendoelhemocultivo)antesdecomenzarlaterapiaantimicrobiana,siesqueestaeleccinnoprovocaun
retrasoeneliniciodelosantimicrobianos.

Observaciones:loscultivosmicrobiolgicosderutinaapropiadossiempredebenincluiralmenos2hemocultivos(para
aerobiosyanaerobios).

Justificacin:Minutosuhorasdespusdelaprimeradosisdeunantimicrobianoapropiadopuedeproducirsela
esterilizacindeloscultivos.Laobtencindecultivosantesdelaadministracindeantimicrobianosaumenta
significativamentesurendimiento,haciendomsprobablelaidentificacindeunpatgeno.Elaislamientode1
organismoinfectantepermiteajustarlaprimeraterapiaantimicrobianaenelmomentodelaidentificacin,yluego,un
nuevoajusteunavezconocidaslassensibilidades.

Lareduccindelaterapiaantimicrobianaesunpilardelosprogramasparalaadministracindeantibiticosyse
asociaconmenosresistenciademicroorganismos,efectossecundariosycostos.Laobtencindecultivosantesdela
terapiaantimicrobianaseasociaconmejoresresultadosysupervivencia,peroeldeseodeobtenercultivospreviosal
tratamientoantimicrobianodebeequilibrarseconelriesgodemortalidadoderetrasoeneltratamientoclavepara
pacientescrticosconsospechadesepsisoshockspticoqueestnenriesgosignificativodemuerte.

Serecomiendaobtenerhemocultivosantesdeiniciarlaterapiaantimicrobiana,siemprequesepuedahacercon
rapidez,delocontrario,larelacinriesgo/beneficioseinclinahacialaadministracinrpidadeantimicrobianos.Lo
mismocabecuandosedecideobtenercultivosdemltiplessitiosconsideradosfuentespotencialesdeinfeccin.En
general,noseincluyenmuestrasquerequieranunprocedimientoinvasivo.Losautoresdesaconsejanladecisinde
"pancultivar"todoslossitiospotencialesdeinfeccin(amenosqueelorigendelasepsisnoseaclnicamenteevidente),
yaquesefavoreceelusoinapropiadodeantimicrobianos.

Silahistoriaoelexamenclnicoindicanclaramenteunsitioanatmicoinfectadoespecfico,esinnecesariohacer
cultivosdeotrossitios(apartedelhemocultivo).Porejemplo,seconsideraqueunaesperade45minutosmientrasse
obtienenloscultivosnoimplicaunretrasoimportanteenlaterapiaantimicrobiana.Antesdeiniciarcualquiertratamiento
antimicrobianonuevoserecomiendan2seriesdehemocultivos(aerbicayanaerbica).Nosehademostradoqueel
rendimientodeloscultivosmejoresilamuestrasetomadurantelospicosdetemperatura.

Enlospacientessinsospechadeinfeccinasociadaalcatter,yenquienessesospechainfeccinclnicaenotrositio,
porlomenosunodeloshemocultivo(delos2omsrequeridos)serobtenidoperifricamente.Sinembargo,nose
puedenhacerrecomendacionesacercadecuntoshemocultivosserequieren.Lasopcionesincluyen:a)todoslos
cultivosseobtienenperifricamenteporvenopuncinb)seobtienenmuestrasparacultivoatravsdecadadispositivo
intravascularperonoatravsdelosmltipleslmenesdeunmismocatterintravascular,o,c)lasmuestrasseextraen
delosmltipleslmenesdeundispositivointravascular.

D.TerapiaAntimicrobiana

1.LaadministracindeantimicrobianosIVdebehacersetanprontocomoseaposibledespusdel
reconocimientodelasepsisyelshocksptico,dentrodelaprimerahora.

Justificacin:Larapidezdelaadministracindeantimicrobianosapropiadosesfundamentalparaobtenerunefecto
beneficioso.Enpresenciadesepsisoshocksptico,cadahoraderetrasoseasociaconunaumentodelamortalidad.
SibienlosdatosdisponiblesparaobtenerresultadosptimossugierenadministrarlosantimicrobianosapropiadosIVlo
antesposibleluegodelreconocimientodelasepsisodelshocksptico,unobjetivomnimorazonablepararetrasarsu
iniciacines1hora,aunquedebidoaconsideracionesprcticasnotodosloscentrosestnencondicionesdecumplirlo.

Laadministracinprecozdeantimicrobianosapropiadosenlainstitucincomienzaconunaevaluacindelascausasde
losretrasos,losquepuedenincluirunafrecuenciainaceptablementeelevadadefallasparasospecharlasepsisoel
shockspticoyeliniciodeuntratamientoantimicrobianoempricoinapropiado.Porotraparte,puedehaberunafaltade
reconocimientoolasubestimacindelosfactoresadministrativosologsticos(amenudofcilesderemediar)que
influyenenelretraso.

Lassolucionesposiblesparalosretrasosenlainiciacindelosantimicrobianosson:elusoderdenesestablecidaso
queincluyenunelementodetiempomnimoparaeliniciodelosantimicrobianos,dirigidoalosretrasosenlaobtencin
deloshemocultivosyloscultivosdesitioshastalaadministracindelosantimicrobianosylasecuenciacinptimade
losantimicrobianos,outilizarlaadministracinsimultneadeantimicrobianosclaveascomomejorarlasdeficiencias
delacadenadesuministro.Mejorarlacomunicacinconlosmdicos,lafarmaciaylaenfermeratambinpuedeser
altamentebeneficioso.

Silosagentesantimicrobianosnopuedensermezcladosyentregadosrpidamenteporlafarmacia,sedebeestablecer
unsuministrodemedicamentospremezcladosparasituacionesurgentes,unaestrategiaapropiadaparaaseguraruna
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administracinrpida.Muchosantimicrobianosnopermanecernestablessisepremezclanensolucin,locualdebe
Silosagentesantimicrobianosnopuedensermezcladosyentregadosrpidamenteporlafarmacia,sedebeestablecer
unsuministrodemedicamentospremezcladosparasituacionesurgentes,unaestrategiaapropiadaparaaseguraruna
administracinrpida.Muchosantimicrobianosnopermanecernestablessisepremezclanensolucin,locualdebe
sertenidoencuentaenlasinstitucionesqueutilizansolucionespremezcladasparaeltratamientoantimicrobianorpido.
Alelegirelrgimenantimicrobiano,sedebeconsiderarquealgunosagenteslactmicostienenlaventajadepoderser
administradosconseguridadenbolooinfusinrpida,mientrasqueotrosrequierenunainfusinmslenta.Sielacceso
vasculareslimitadoyhayqueadministrarmuchosfrmacos,aquellosquepuedenseradministradosenbolooinfusin
rpidapuedenofrecerventajas.

Mientrasseestableceelaccesovascularyseiniciaeltratamientointensivo,lareanimacinconlquidoylainfusinIV
rpidadeantimicrobianossonmuyimportantes.Estopuederequeriraccesosvascularesadicionales,comoelacceso
intraseo.Intramuscular(haypreparacionesaprobadasparavarioslactmicosdeprimeralnea),aunqueestaltima
solodeberaconsiderarsesinoesposibleestablecerunaccesovascular.

2.Serecomiendalaterapiaempricadeamplioespectro(parabacterias,hongosyvirus)con1oms
antimicrobianosparapacientesconsepsisoshocksptico.

3.Realizarlaterapiaantimicrobianaempricaunavezquesehanidentificadolospatgenosysuysensibilidad,
y/ounamejoraclnicaadecuada.

Justificacin:
Unadelasfacetasmsimportantesdeunmanejoeficazeseliniciodelaterapiaantimicrobianaapropiada(esdecir,
conactividadcontraelolospatgenoscausantes)paralasinfeccionespotencialmentemortalesquecausansepsisy
shocksptico.Elfracasoeniniciaruntratamientoempricoapropiadoenpacientesconsepsisyshockspticose
asociaconungranaumentodelamorbilidadymortalidadydelaprobabilidaddeprogresindelainfeccin
bacterimicagramnegativaenelshocksptico.Enconsecuencia,laseleccininicialdeltratamientoantimicrobiano
debesersuficientementeampliaparacubrirlospatgenosprobables,teniendoencuentatodoslosfactores
relacionadosconelpaciente(suprocedencia:comunidad,institucindecuidadocrnico,hospitaldeagudos.),la
institucin,laepidemiologalaprevalencialocaldelospatgenosysuspatronesdesensibilidad,tantoenlacomunidad
comoenelhospital.Tambinhayqueconsiderarlaspotencialesintoleranciasylatoxicidaddelosmedicamentos.

Histricamente,alosfinesdeseleccionareltratamientoantimicrobiano,lospacientesgravementeenfermosconuna
infeccinseveranohansidoconsideradoscomounsubgruponicocomparablealdelospacientesneutropnicos,No
obstante,lospacientescrticosyconshocksptico,aligualquelospacientesneutropnicos,secaracterizanpor
distintasdiferenciasconelpacienteinfectadotpico,lasqueImpactanenlaestrategiaptimadelmanejo
antimicrobiano.Entreestasdiferenciaspredominanlapredisposicinalainfeccinconorganismosresistentesyun
marcadoaumentodelafrecuenciademuerteyotrosresultadosadversossinoseiniciaunaterapiaantimicrobiana
efectivaconrapidez.

Laseleccindeunrgimenantimicrobianoempricoptimoparalasepticemiayelshockspticoesunodelos
determinantesdelresultado.Lasupervivenciapuededisminuirhasta5vecesenlospacientesconshocksptico
tratadosconunrgimenempricoquenocubrealpatgenoinfectante.Debidoalaelevadamortalidadasociadaauna
terapiainicialinapropiada,losregmenesempricosdebencontemplarunaampliainclusinbacteriana.Sinembargo,
estosregmenesenpacientesconsepticemiayshockspticoescomplejanopuedenreducirseaunasimplelista.Para
laterapiaempricaesnecesarioevaluarvariosfactores:

a)Elsitioanatmicodelainfeccinconrespectoalperfildelpatgenotpicoylaspropiedadesdecadaantimicrobiano
parapenetrarenesesitio.

b)Lospatgenosprevalentesdentrodelacomunidad,hospitalyguardiahospitalaria.

c)Lospatronesderesistenciadelospatgenosprevalentesylapresenciadedefectosinmunolgicosespecficos
(neutropenia,esplenectoma,infeccinporelVIHmalcontroladaydefectosadquiridosocongnitosdela
inmunoglobulina,complementoofuncinoproduccinleucocitaria.

e)Laedadylascomorbilidades,incluyendoenfermedadescrnicas(porej.,diabetes)ydisfuncinorgnicacrnica(por
ej.,insuficienciahepticaorenal),presenciadedispositivosinvasivos(porej.,cattervenosocentralourinario),que
comprometenladefensaalainfeccin.

Porparte,elclnicodebeevaluarlosfactoresderiesgodeinfeccinporpatgenosmultirresistentesincluyendola
hospitalizacinprolongada/estanciaenserviciodecuidadoscrnicos,usorecientedeantimicrobianos,hospitalizacin
previaycolonizacinpreviaoinfeccinresistenteamltiplesfrmacos.Laaparicindeunaenfermedadmsgrave(por
ej.,shocksptico)puedeestarintrnsecamenteasociadaaunamayorprobabilidaddeaislamientodemicroorganismos
resistentesdebidoalaseleccinderivadadelafaltaderespuestaalosantimicrobianosanteriores.

Dadalaampliagamadevariablesquedebeserevaluada,noesposiblerecomendarunrgimenespecficoparala
sepsisyelshocksptico.Sinembargo,sepuedenhacersugerenciasgeneralespueslagranmayoradeesos
pacientestiene1formasdeinmunodepresinyelrgimenempricodebesersuficientementeamplioparacubrirala
mayoradelospatgenosaisladosenlasinfeccionesasociadasalaatencindelasalud..Porsupuesto,elrgimen
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especficopuedeydebesermodificadosegnelsitioanatmicodelainfeccin,siesevidente,yporelconocimientode
sepsisyelshocksptico.Sinembargo,sepuedenhacersugerenciasgeneralespueslagranmayoradeesos
pacientestiene1formasdeinmunodepresinyelrgimenempricodebesersuficientementeamplioparacubrirala
mayoradelospatgenosaisladosenlasinfeccionesasociadasalaatencindelasalud..Porsupuesto,elrgimen
especficopuedeydebesermodificadosegnelsitioanatmicodelainfeccin,siesevidente,yporelconocimientode
lafloramicrobiolgicalocal.

Amenudoserequierelaterapiamultifarmacolgicaparaasegurarunamplioespectrodecoberturaempricainicial.Los
mdicosdebentenerencuentaelriesgoderesistenciadelosbacilosgramnegativosaloslactmicosy
carbapenemesdeamplioespectroqueexistenenalgunascomunidadesyentornossanitarios.Serecomiendaagregar
unagentesuplementarioparagramnegativosalrgimenempricoaplicadoapacientesspticosgravementeenfermos
conriesgoelevadodeinfeccinporpatgenosmultirresistentes(porej.,Pseudomonas,Acinetobacter,etc.).

Aunquelarestriccindelosantimicrobianosesunaestrategiaimportanteparareducirtantoeldesarrollodepatgenos
resistentescomoloscostos,noesunaestrategiaapropiadaenlaterapiainicialdelapoblacindepacientescon
probableinfeccindemicroorganismosresistentesopococomunes.Lospacientesconsepsisoshockspticosuelen
recibirterapiaempricadeamplioespectrohastaqueelorganismocausalysusensibilidadantimicrobianaquedan
definidos.

Enesemomento,sedebeneliminarlosantimicrobianosinnecesariosyreemplazarloslosagentesdeamplioespectro
poragentesmsespecficos.Sinembargo,esapropiadoachicarelespectroempricodelacoberturasobrelabasede
labuenarespuestaclnica,inclusosiloscultivossonnegativos.Enlasinfeccionesmsgraves,unavezidentificadoel
patgenosedebeeliminarelagenteefectivodeespectromsestrecho.Dadoslosriesgossocialeseindividuales
adversosdecontinuarconunaterapiaantimicrobianainnecesaria,serecomiendareducirlosantimicrobianos,sobrela
basedelamejoraclnica,inclusosiloscultivossonnegativos.Enausenciadeinfeccin,losantimicrobianosdeben
suspenderserpidamenteparaminimizarlaprobabilidaddequeelpacienteseinfecteconunpatgenoresistenteo
desarrolleunefectoadversorelacionadoconelfrmaco.Porlotanto,ladecisindecontinuar,restringirosuspenderlos
antimicrobianosdependedelcriterioylainformacinclnicos.

4.Noserecomiendalaprofilaxissostenidaconantimicrobianossistmicosenlospacientesconestados
inflamatoriosgravesdeorigennoinfeccioso(porej.,pancreatitisgrave,quemaduras).

Justificacin:Unarespuestainflamatoriasistmicasininfeccinnorequieretratamientoantimicrobiano(porej.,
pancreatitisgrave,quemadurasextensas).Elobjetivoesminimizarlaprobabilidaddequeelpacienteseinfecteconun
patgenoresistentealosantimicrobianosodesarrolleefectosadversosalfrmaco.Aunqueantesseusabalaprofilaxis
conantimicrobianossistmicosparalapancreatitisnecrotizantegraveolasquemadurasgraves,estudiosactualesla
handesestimado,perotodavaesunconceptocuestionado.Porotraparte,enlospacientesconunestadoinflamatorio
severodeorigennoinfeccioso,silasospechadesepsisesmuyfuerteoexisteshocksptico,estindicadalaterapia
antimicrobiana.

5.Serecomiendaoptimizarladosificacindelosantimicrobianossegnsufarmacocintica/farmacodinmicay
laspropiedadesespecficasdelosfrmacos.

Justificacin:Laoptimizacinprecozdelafarmacocinticaantimicrobianapuedemejorarlosresultados.Aldeterminar
lasdosisptimasparalospacientescrticosconsepsisyshockspticosedebenhacervariasconsideraciones,yaque
presentandiferenciasconlospacientesinfectadostpicos.Estoafectalaestrategiadelmanejoantimicrobianoptimo.
Estasdiferenciasincluyenunamayorfrecuenciadeladisfuncinhepticayrenal,laelevadaprevalenciadedisfuncin
inmunolgicanoreconocidaylapredisposicinalainfeccinconorganismosresistentes.Quizslomsimportantecon
respectoaladosificacinantimicrobianaempricainicialeslamayordistribucindelamayoradelosantimicrobianos
debidoalarpidaexpansindelvolumenextracelular,comoconsecuenciadelareanimacinintensivaconlquidos.
Estohacequeenesospacienteslosnivelesdediversosantimicrobianosseansubptimos.

Laplanificacintempranadeladosificacindelosantimicrobianosapropiadosesfundamentalparamejorarlos
resultadosenlamortalidadyefectosadversos,cuandonoseiniciaprecozmenteunaterapiaeficaz.Laterapia
antimicrobianasiempredebeiniciarseconuntratamientocompleto,condosisdecargaenelmximoniveldecada
agenteutilizado.Alrespecto,diferentesantimicrobianostienendiferentesconcentracionesrequeridasparaobtenerel
mejorresultado.Losmsutilizadossonlosaminoglucsidos,lavancomicinayloslactmicos.Porelmomento,existen
dificultadesparadosificarlosantimicrobianossobrelabasedesufarmacocintica.

6.Sesugierelaterapiacombinadaemprica(usandoalmenos2antibiticosdediferentesclases)paralos
patgenosbacterianosmsprobablesinvolucradosenelshocksptico.

7.Sesugierenoutilizarrutinariamentelaterapiacombinadaparaeltratamientoencursodelamayoradeotras
infeccionesgraves,incluyendolabacteriemiaylasepsissinshock.

Observaciones:Estonoexcluyeelusodelaterapiaconmltiplesfrmacosparaampliarlaactividadantimicrobiana.

8.Noserecomiendalaterapiacombinadaparaeltratamientorutinariodelasepsisneutropnica/bacterimica.

Observaciones:Estonoexcluyeelusodelaterapiademltiplesfrmacosparaampliarlaactividadantimicrobiana.
Page 5 / 41
Observaciones:Estonoexcluyeelusodelaterapiademltiplesfrmacosparaampliarlaactividadantimicrobiana.

9.Silaterapiacombinadaseutilizainicialmenteparaelshocksptico,serecomiendadisminuirlasdosise
interrumpirlaterapiacombinadaenlosprimerosdas,enrespuestaalamejoraclnicay/olaevidenciade
resolucindelainfeccin.Estoseaplicatantoalaslaterapiascombinadasdirigidascomoalasempricas(para
lasinfeccionesconcultivosnegativos).

Justificacin:Dadalacrecientefrecuenciadepatgenosresistentesalosagentesantimicrobianosenmuchaspartes
delmundo,amenudoserequiereelusoinicialdeterapiaconmltiplesfrmacosoterapiacombinada(usualmenteun
lactmicoconfluoroquinolonaaminoglucsidoounmacrlido)paraunsolopatgenoesperandoqueseasensiblealos
antibiticoselegidos,particularmenteconelfindeacelerarlaeliminacindelpatgeno.Eltrminoterapiacombinada
noseutilizacuandoelpropsitodelaestrategiademltiplesfrmacosconsisteenampliarestrictamentelagamade
frmacosantimicrobianos(porej.,aadirlavancomicinaalaceftazidima,oelmetronidazolaunaminoglucsidoo,una
equinocandinaaunlactmico).

Sehademostradoquelaterapiacombinadaconsiguemayorsupervivenciaenpacientesspticosgravementeenfermos
conunriesgoelevadodemuerte,particularmenteenaquellosconshocksptico.Sinembargo,sehacomprobadoun
aumentodelriesgodemortalidadconlaterapiacombinadaenpacientesdebajoriesgosinshock.Alaesperadel
desarrollodetcnicasparaladeteccinrpidadepatgenos,porelmomentonosepuededetectarelpatgeno
infractoralacabeceradelpaciente.

Porlotanto,laterapiadecombinacinespecficaparapatgenosidentificadosespecficosestilsolosisecontempla
unaterapiacombinadadirigidamsprolongada.Asimismo,conrespectoalospatgenosmultirresistentes,sehan
obtenidoresultadosvariablesdependiendodelpatgenoydelcontextoclnico.Apesardelaspruebasquesugierenel
beneficiodelaterapiacombinadaenelshocksptico,esteenfoquenohademostradosereficazparaeltratamiento
continuodelamayoradeotrasinfeccionesgraves,comolabacteriemiaylasepsissinshock.

Ladisminucintempranadelaterapiaantimicrobianaenelcontextodelaterapiacombinadadescritaaqunohasido
estudiada.Sinembargo,estudiosdeobservacinhandemostradoqueenelshockdisminucintempranadelaterapia
demltiplesfrmacosseasociaconresultadosclnicosequivalentesosuperioresenlasepsisyelshocksptico.A
pesardeesto,almenosunestudiohahalladomayorfrecuenciadesuperinfeccinyestanciamsprolongadaenlaUCI.
Aunquehaygranconsensosobrelanecesidaddeunaprontadesescaladadelaterapiacombinada,nolohaysobrelos
criteriosprecisosparahacerla.Losconceptosdelosmiembrosdelpanelparaladesescaladason:a)progresoclnico
(resolucindelshock,disminucindelrequerimientodevasopresores,etc)b)resolucindelainfeccinsegnlos
biomarcadores(especialmentelaprocalcitonina)y,c)duracinrelativamentefijadelaterapiacombinada.

10.Laduracinadecuadasugeridaparaeltratamientoantimicrobianoes7a10dasparalasinfeccionesms
gravesasociadasalasepsisyelshocksptico.

11.Loscursosmsprolongadossonapropiadosparalospacientesconunarespuestaclnicalenta,sinfocos
deinfeccinbacterimicaconS.aureus,algunoshongos,virusodeficienciasinmunolgicascomola
neutropenia.

12Loscursosteraputicosmscortossonapropiados,particularmenteparaaquellospacientescon
resolucinclnicarpidadespusdeuncontroleficazdelafuenteintrabdominalourinariadelasepsis,y
aquellosconpielonefritissincomplicacionesanatmicas.

13.Serecomiendalaevaluacindiariaparaladesescaladadeltratamientoantimicrobianoenpacientescon
sepsisyshocksptico.

Justificacin.Laadministracininnecesariamenteprolongadadeantimicrobianosesperjudicialparalasociedady
paraelpacienteindividual.Paralasociedad,elusoexcesivodeantimicrobianosimpulsaeldesarrolloyladiseminacin
demicroorganismosresistentesalosantimicrobianos.Lasguasactualesrecomiendanuncursode7dasdeterapia
paralaneumonanosocomial(tantonosocomialcomolaasociadaalventilador.

Lasinfeccionesgravespuedensertratadasconcursosmscortos,siexistelanecesidadysepuedecontrolar
exitosamenteelorigendelainfeccin,comosucedeensituacionesenlasquehayunarespuestaclnicalentaofocosde
infeccinincontrolables.Laevaluacindeladuracindelaterapiaenenfermoscrticosdebeconsiderarlosfactoresdel
husped,particularmenteelestadoinmunolgico,ydelpatgenoinfeccioso.

Lasdecisionesdereducirodetenerlaterapiaantimicrobianadebenhacerseenltimainstanciasobrelabasedeun
criterioclnicoslido.Porotraparte,existeunatendencianaturalaquerercontinuarunaterapiaqueamenudoseve
comobenigna,duranteuntiemposuficiente,paraestarsegurosdelacura.Sinembargo,losantimicrobianosnosonuna
terapiaenteramentebenigna.Enlospacientesdebajoriesgo,losefectosadversospuedencontrarrestarcualquier
beneficio.Teniendoencuentaeldaopotencialasociadoalaprolongacininnecesariadeltratamientoantimicrobiano,
paraladesescaladadelaterapiaantimicrobianaenpacientesconsepsisyshockspticoserecomiendalaevaluacin
diaria.
Page 6 / 41
beneficio.Teniendoencuentaeldaopotencialasociadoalaprolongacininnecesariadeltratamientoantimicrobiano,
paraladesescaladadelaterapiaantimicrobianaenpacientesconsepsisyshockspticoserecomiendalaevaluacin
diaria.

14.Lamedicindelosnivelesdeprocalcitoninapuedeserusadaparaapoyarlareduccindeladuracindelos
antimicrobianosenlospacientesconsepsis

15.Losnivelesdeprocalcitoninapuedenutilizarseparaapoyarlainterrupcindelosantibiticosempricosen
pacientesqueinicialmenteparecantenersepsis,peroqueposteriormentetienenevidenciaclnicalimitadade
infeccin

Justificacin:ElusodebiomarcadorescomoelgalactomananoyelDglucanoparalaevaluacindelaspergilus
invasivo(yunagamadepatgenosfngicos)hasidobienaceptado.Tambinlamedicindelaprocalcitoninasricase
utilizaparaayudaraldiagnsticodeinfeccinagudaydefinirladuracindelosantimicrobianos.Sibienexisten
algoritmos,noestclarosialgunodeellosproporcionaventajaclnicasobreotro.

E.Controldelorigendelainfeccin

1.Enlospacientesconsepsisoshocksptico,serecomiendarealizarundiagnsticoanatmicodelainfeccin
paraelcontroldelafuenteemergenteoparaprocederasuexclusinlomsrpidoposible,yhacerla
intervencinrequeridaparaelcontroldelafuenteenelmomentodelaintervencinmdicayquesea
logsticamenteposibledespusdeldiagnstico.

2.Serecomiendalaeliminacinrpidadelosdispositivosdeaccesointravasculardespusdehaberse
establecidootrosaccesosvasculares,yaquesonunaposiblefuentedesepsisoshocksptico.

Justificacin:Losprincipiosparaelcontroldelasfuentesdeinfeccinenlasepsisyelshockspticosoneldiagnstico
rpidodelsitiodelainfeccinydeterminarsielmismoessusceptibledelasmedidasdecontrolinsitu(especficamente
eldrenajedeunabsceso,eldesbridamientodetejidonecrticoinfectado,laeliminacindeundispositivo
potencialmenteinfectadoyelcontroldefinitivodeunafuentedecontaminacinmicrobianacontinua).Losfocosde
infeccinquepuedencontrolarsefcilmentemedianteeltratamientoson:abscesosintraabdominales,perforacin
gastrointestinal,isquemiaovlvulointestinal,colangitis,colecistitis,pielonefritisasociadaaobstruccinoabsceso,
Infeccinnecrotizantedelostejidosblandos,otrainfeccinprofunda(porej.,empiemaoartritis)einfeccionesdel
dispositivoimplantado.

F.Terapiadefluidos

1.Serecomiendahacerunasobrecargalquidadurantelacontinuacindelaadministracin,tantotiempocomo
losfactoreshemodinmicossiganmejorando.

2.Serecomiendanloscristaloidesyaquesonloslquidosdeeleccinparalareanimacinyelsubsiguiente
reemplazodelvolumenintravascularenpacientesconsepsisyshocksptico.

3.Paralareanimacinconfluidosdelospacientesconsepsisoshockspticosesugiereusarcristaloides
balanceadososolucinsalina.

4.Paralareanimacininicialyelposteriorreemplazodelvolumenintravascularenpacientesconsepsisy
shocksptico,sesugiereagregaralbminasiesqueserequierencantidadesimportantesdecristaloides.

5.Noserecomiendaelusodealmidonesdehidroxietiloparaelreemplazodelvolumenintravascularen
pacientesconsepsisoshocksptico.

6.Paralareanimacindepacientesconsepsisoshockspticoserecomiendausarcristaloidesenvezde
gelatinas.

Justificacin:Enlaterapiamoderna,elusodelquidosintravenososesfundamentalparalareanimacin.Sinembargo,
existepocaevidenciaqueapoyesuprcticaysenecesitainvestigacinurgente,perolosautoresrecomiendanalinicio
urgentedelainfusindelquidosseguidadeunainfusinmscautelosaunavezqueelpacientesehaestabilizo.Hay
ciertaevidenciadequeelbalancedelquidospositivodurantelaestanciaenlaUCIesperjudicialporloquelos
panelistasnorecomiendanadministrarlquidosmsalldelareanimacinsintenerciertacertezadequeelpaciente
respondersatisfactoriamente.

Laausenciadeunbeneficioclarotraslaadministracindesolucionescoloidalescomparadasconloscristaloidesenlos
subgruposdesepsis,juntoconelelevadocostodelaalbmina,apoyanunafirmerecomendacinparaelusode
cristaloidesenlareanimacininicialdelospacientesconsepsisyshocksptico.

G.Medicamentosvasoactivos

1.Serecomiendalanorepinefrinacomovasopresordeprimeraeleccin.
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1.Serecomiendalanorepinefrinacomovasopresordeprimeraeleccin.

2.Sesugiereagregarvasopresina(hasta0,03U/min)oepinefrinaenlugardenorepinefrinaconlaintencinde
elevarlaPAMalvalorobjetivo,oagregandovasopresina(hasta0,03U/min)paradisminuirladosisde
norepinefrina.

3.Sesugiereusardopaminacomovasopresoralternativoalanorepinefrinasolamenteenpacientesaltamente
seleccionados(porej.,conbajoriesgodetaquiarritmiasybradicardiaabsolutaorelativa).

4.Nousardosisbajasdedopaminaparalaproteccinrenal.

5.Usardobutaminaenpacientesquemuestranevidenciadehipoperfusinpersistenteapesardeunaaporte
adecuadodelquidoyelusodeagentesvasopresores.

Observaciones:Siseinicianvasopresores,ladosisdebesertituladaaunpuntofinalquereflejelaperfusin,yreducir
osuspenderelagentesilahipotensinolaarritmiaempeoran.

Justificacin:LanoradrenalinaaumentalaPAMdebidoasuefectovasoconstrictorconpococambioenlafrecuencia
cardacaymenosaumentodelvolumensistlicocomparadaconladopamina.LadopaminaaumentalaPAMyelgasto
cardaco,principalmentedebidoalaumentodelvolumensistlicoylafrecuenciacardiaca.Lanoradrenalinaesms
potentequeladopaminaypuedesermseficazpararevertirlahipotensinenlospacientesconshocksptico.Puede
serparticularmentetilenlospacientesconalteracindelafuncinsistlica,perocausamstaquicardiaypuedeser
msarritmognicaquelanorepinefrina.Tambinpuedeinfluirenlarespuestaendocrinaatravsdelejehipotalmico
hipofisarioytenerefectosinmunosupresores.Sinembargo,unarevisinymetanlisisrecientesnorespaldaneluso
rutinariodeladopaminaenelmanejodelshocksptico.

Estudiosensereshumanosyanimalessugierenquelainfusindeepinefrinapuedetenerefectosdeletreosenla
circulacinesplcnicayproducirhiperlactatemia.Sinembargo,losensayosclnicosnomuestranempeoramientodelos
resultadosclnicos.Nosehallunadiferenciasignificativaenlamortalidadconelusodenorepinefrinayepinefrina.Esta
ltimapuedeaumentarlaproduccindelactatoaerbicoporlaestimulacindelosreceptores2adrenrgicosdel
msculoesquelticoeimpedirquelosnivelesdelactatoseanutilizadosparaguiarlareanimacin.Sehaobservadoque
enelshocksptico,losnivelesdevasopresinasoninferioresaloprevistoenelestadodeshock.Lasdosisbajasdela
vasopresinapuedensereficacesparaelevarlapresindelospacientesrefractariosaotrosvasopresoresypuede
brindarbeneficiosfisiolgicospotenciales.

6.Sesugierecolocaruncatterarterialatodoslospacientesquerequierenvasopresores,tanprontocomosea
posible.

Justificacin.Enlosestadosdeshockesincorrectoestimarlapresinarterialconmanguito,especialmentesiel
sistemademedicinesautomatizado.Elusodeuncatterarterialproporcionaunamedicinreproducibledelapresin
arterialytambinpermiteunanlisislatidoalatido,demodoquelasdecisionesteraputicaspuedanbasarseenuna
respuestainmediataytenerunainformacinreproducibledelapresinarterial.Lainsercindecatteresenlaarteria
radialgeneralmenteessegura.

Sehacomprobadounaincidenciadeisquemiadelaextremidadyhemorragiaen<1%,siendoelhematomala
complicacinlocalmsfrecuente(14%).Lastasasdecomplicacinpuedensermsbajassisecolocabajolagua
ecogrfica.Sehacomprobadounmayorriesgodeinfeccionescuandoelcatteresinsertadoenlaarteriafemoralyno
enlaarteriaradial,ylaincidenciaagrupadaglobaldeinfeccindeltorrentesanguneofuede3,4/1.000catteres.

H.Corticosteroides

1.SesugierenoutilizarhidrocortisonaIVparaeltratamientodelospacientesenshockspticosila
reanimacinadecuadaconlquidoyvasopresoreslograrestaurarlaestabilidadhemodinmica.Encaso
contrario,sesugiereadministrar200mg/dadehidrocortisonaIV.

Justificacin:Larespuestadelospacientesconshockspticoalaterapiavasopresorapareceserunfactorimportante
alahoradeelegiralospacientesparasertratadosopcionalmenteconhidrocortisona.Unestudioaleatorizadoy
controladomulticntricofrancs(depacientesconinsuficienciasuprarrenalrelativa)yotros2estudiospequeosde
pacientesenshockspticoquenorespondanalosvasopresores(presinarterialsistlica<90mmHgapesardela
reanimacinconlquidosyvasopresoresdurantemsde1hora)comprobaronunainversinsignificativadeshockyuna
reduccindelamortalidadenpacientesconinsuficienciasuprarrenalrelativa.Porelcontrario,ungranestudioeuropeo
multicntrico(CORTICUS)queincluypacientesconpresinarterialsistlica<90mmHgapesardelaadecuada
sustitucindelquidosolanecesidaddevasopresoreshallunriesgomsbajodemuertequeelensayofrancsyno
mostrbeneficiosobrelamortalidadconlaterapiaesteroidea.

1.Serecomiendatransfundirglbulosrojoscuandolahemoglobinasea<7,0g/dlenlosadultos,enausencia
decircunstanciasextenuantes,comolaisquemiamiocrdica,lahipoxemiaseveraolahemorragiaaguda.

Justificacin:.Dosensayosclnicosdepacientesspticosevaluaronlosumbralesparalatransfusinsangunea.En
ambos,elumbraldetransfusinparalospacientesconshockspticodespusdesuadmisinenlaUCIfuebastante Page 8 / 41
Justificacin:.Dosensayosclnicosdepacientesspticosevaluaronlosumbralesparalatransfusinsangunea.En
ambos,elumbraldetransfusinparalospacientesconshockspticodespusdesuadmisinenlaUCIfuebastante
similar.Luegodecomprobarqueelusodediferentesumbralesdehemoglobinaresultabaenpocasdiferenciasen
cuantoalamortalidadalos60y90das,loseventosisqumicosyelusodesoportevital,lospanelistasconcluyeron
que,conbastantecerteza,sepuedeelegirunumbraldehemoglobinamsbajo.

2.Serecomiendaindicareritropoyetinaparaeltratamientodelaanemiaasociadaalasepsis.

Justificacin.Nohayinformacinespecficasobreelusodeeritropoyetinaenpacientesspticos.Losensayosclnicos
enpacientescrticamenteenfermosmuestranquesuadministracinseacompaadeunadisminucindelrequerimiento
detransfusindeglbulosrojossinefectossobrelamortalidad.Noesdeesperarqueelefectodelaeritropoyetinaenla
sepsisyelshockspticoseamsbeneficiosoqueenotrascondicionescrticas.Enenfermoscrticos,suadministracin
puedeirasociadaaunamayorincidenciadeeventostrombticos.Lospacientesconsepsisyshockspticopueden
tenercondicionescoexistentesquenecesitenlaadministracindeeritropoyetinaoagentessimilares.

3.Sesugierenoutilizarplasmafrescocongeladoparacorregirlasanomalasdelacoagulacinenausenciade
sangradooprevioaprocedimientosinvasivos

Justificacin:Noexistenestudiosaleatorizadosycontroladosrelacionadosconlatransfusinprofilcticadeplasma
frescocongeladoenpacientesspticosocrticamenteenfermos,concoagulpatas.Lasrecomendacionesactualesse
basanenlaopinindeexpertossobrelatransfusindeplasmafrescocongeladocuandoexisteunadeficienciadela
coagulacindocumentadaylapresenciadesangradoactivooprevioalarealizacindeprocedimientosquirrgicoso
invasivos.Porotraparte,latransfusindeplasmafrescocongeladonocorrigeeltiempodeprotrombinaenpacientesno
hemorrgicosoconanomalasleves.Ningnestudiosugierequelacorreccindemsanomalasdelacoagulacin
gravesbeneficiealospacientesquenosangran.

4.Sesugierelatransfusinprofilcticadeplaquetascuandolosrecuentosson<10.000/mm3,enausenciade
sangradoysison<20.000/mm3sielpacientetieneunriesgosignificativodehemorragia.Paraelsangrado
activo,lacirugaounprocedimientoinvasivoserecomiendanumbralesmselevados(50.000/mm3).

Justificacin.Noexistenensayosaleatorizadosycontroladosdetransfusinprofilcticadeplaquetasenpacientes
spticosocrticamenteenfermos.Lasrecomendacionesylasguasactualessebasanenensayosclnicosde
transfusinplaquetariaprofilcticaenpacientescontrombocitopeniainducidaporlateraputica(usualmenteleucemiay
trasplantedeclulasmadre).Probablemente,enlasepsislatrombocitopeniasedebaaunafisiopatologadiferentede
laproduccindeplaquetasyalaumentodelconsumodeplaquetas.Losfactoresquepuedenaumentarelriesgode
sangradoeindicanlanecesidaddeunamayorcantidaddeplaquetasestnlospacientesconsepsis.

J.Immunoglobulinas

1.Sesugierenousarinmunoglobulinas(Ig)IVenlospacientesconsepsisoshocksptico.

Justificacin.Nohaynuevosestudiosqueorientenestarecomendacin.Unestudioimportantenohallbeneficioscon
laIgIV.ElmetaanlisisCochranemsrecientenohalldiferenciasentrelasIgIVpoliclonalesestndarylaIgpoliclonal
enriquecidaenIgM.Tampocorevelbeneficioenlasupervivencia.

K. Purificacinsangunea

1.Lospanelistasnohacenningunarecomendacinconrespectoalusodetcnicasdepurificacindela
sangre.

Justificacin:Lapurificacindelasangreincluyevariastcnicas,comolahemofiltracindealtovolumenyla
hemoadsorcin(hemoperfusin),enlasquelossorbentes,removiendolasendotoxinasylascitocinas,seponenen
contactoconlasangreelintercambioolafiltracinplasmtica,atravsdeloscualesseseparaelplasmadelasangre
entera,removidoyreemplazadoporsolucinsalina,albminaoplasmafrescocongeladoy,elsistemahbrido:que
combinalaadsorcinconlafiltracindelplasma,utilizandounaresinaqueeliminalascitocinas.

L.Anticoagulantes

1.Noserecomiendaelusodeantitrombinaparaeltratamientodelasepsisyelshocksptico.

Justificacin:Laantitrombinaeselanticoagulantemsabundantequecirculaenplasma.Ladisminucindesu
actividadplasmticaaliniciodelasepsissecorrelacionaconlacoagulacinintravasculardiseminadayelresultado
letal.Sinembargo,algunosestudiosdeantitrombinaparapacientescrticamenteenfermosnodemostraronningn
efectobeneficiososobrelamortalidad.Laantitrombinaseasociconmayorriesgodesangrado.Todavafaltanotros
datospararecomendaresteagente.

2.Nosehaceningunarecomendacinconrespectoalusodetrombomodulinaoheparinaparaeltratamiento
delasepsisoelshocksptico.
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2.Nosehaceningunarecomendacinconrespectoalusodetrombomodulinaoheparinaparaeltratamiento
delasepsisoelshocksptico.

Justificacin:Lamayoradelosestudiosaleatorizadosycontroladosdetrombomodulinasolublerecombinantehan
estadodirigidosalasepsisasociadaalacoagulacinintravasculardiseminada,yunarevisinsugiriunefecto
beneficiososobrelasupervivenciasinunaumentodelriesgodesangradoperopaneltodavanosehaexpedidoal
respecto.Sehacomprobadobeneficiopotencialenlasupervivenciaconelusodeheparinaenpacientesconsepsis,sin
unaumentodesangradomayor.Sinembargo,laheparinanopuederecomendarsehastaqueserealicennuevos
estudios.

LaprotenaCactivadarecombinanteantesrecomendadanoeseficazparalospacientesadultosconshockspticoy
fueretiradodelmercado.

M.Ventilacinmecnica

1.Serecomiendausarunvolumendemareaobjetivode6ml/kgenvezde12ml/kgparalospacientesadultos
consndromededificultadrespiratoriaaguda(SDRA)inducidaporsepsis.

2.EnlospacientesadultosconSDRAseveroinducidoporsepsisserecomiendausarpresionesmeseta
objetivoenellmitesuperior(30cmH2O)envezdepresionesmesetamselevadas.

Justificacin.Estarecomendacinessimilaralasdelasguasanteriores.Variosensayosaleatorizadosmulticntricos
enpacientesconSDRAestablecidoqueevaluaronlosefectosdelimitarlapresininspiratoriamoderandoelvolumen
corrientemostraronresultadosdiferentes.Variosmetaanlisissugierenunadisminucindelamortalidadenlos
pacientesenlosqueseusaronpresionesyvolmeneslimitadas.

3.SesugiereusarunaPEEPmselevadaquebajaenlospacientesadultosconSDRAmoderadoasevero
inducidoporsepsis

Justificacin:EnelSDRA,elaumentodelaPEEPpuedeabrirunidadespulmonaresqueparticiparnenelintercambio
gaseoso.SilaPEEPesaplicadaatravsdeuntuboendotraquealounamscarafacial,dichaaperturapuede
aumentarlaPaO2,loqueenalgunosestudiosseasociconmenormortalidad,corroboradoporotros2ensayosenlos
quelaPEEPseacompadeunaumentodelcocientePaO2/FiO2.Unanlisisdecasitodoslosensayosaleatorizados
deventilacinpulmonarprotectoracomprobunbeneficiosilapresinaumentabaalelevarlasPEEP,loque
presumiblementeindicaunaumentodelacompliancepulmonaralabrirmsunidadespulmonares.

4.SesugiereelusodemaniobrasdereclutamientoenpacientesadultosconSDRAseveroinducidoporsepsis

Justificacin.ExistenmuchasestrategiasparatratarlahipoxemiarefractariaenpacientesconSDRAsevero.Elevando
transitoriamentelapresintranspulmonarsepuedefacilitarlaaperturadealvolos,perotambinpodradistender
demasiadolasunidadespulmonaresaireadasprovocandolesionespulmonaresinducidasporelventiladore
hipotensintransitoria.Laaplicacindepresinpositivacontinuaenlasvasrespiratorias(CPAP)mejorala
supervivenciayreducelaaparicindehipoxiaseveraquerequiereterapiaderescateenpacientesconSDRA.Aunque
losefectosdelasmaniobrasdereclutamientomejoraninicialmentelaoxigenacin,puedesertransitorio.Lospacientes
conhipoxemiagravepuedenbeneficiarsedelasmaniobrasdereclutamientoconPEEPmselevada,perohaypoca
evidenciaqueapoyesuusorutinarioparatodoslospacientesconSDRA.Siaparecedeteriorodelasvariablesclnicas,
lasmaniobrasdereclutamientodebenserinterrumpidas.

5.SerecomiendaelusodeldecbitopronosobreeldecbitosupinoenlospacientesconSDRAinducidopor
sepsisyuncocientePaO2/FiO2<150.

Justificacin:EnlospacientesconSDRAycocientePaO2/FiO2<150,elusodeldecbitopronocomparadoconel
decbitosupinoenlasprimeras36horasdeintubacin,mantenidodurantemsde16horas,seasociconmayor
supervivenciaymejoroxigenacinycompliancepulmonar.Sibieneldecbitopronopuedeasociarsecona
complicacionespotencialmentemortalescomolaeliminacinaccidentaldeltuboendotraqueal,nosehallevidenciaen
elanlisiscombinado.Perosseasociconlcerasporpresinmientrasquealgunospacientestienencontraindicada
esaposicin.Enlospacientesconhipoxiarefractaria,lasterapiasderescatealternativassonlaventilacincon
liberacindepresindelavaareaylaoxigenacinconmembranaextracorprea.

6.Serecomiendanoutilizarventilacinoscilantedealtafrecuencia(VOAF)enlospacientesadultosconSDRA
inducidoporsepsis.

Justificacin:ElpapeldelaVOAFcomotcnicaderescateparaelSDRArefractarioannoestclaroperose
recomiendanoutilizarlaenelSDRAmoderadoaseverodadalafaltadebeneficiodemostradoyeldaopotencial.

7.Elpanelnohaceningunarecomendacinconrespectodelusodeventilacinnoinvasiva(VNI)paralos
pacientesconSDRAinducidoporsepsis.

Justificacin:LaVNIpuedetenerbeneficiostericosenpacientesconinsuficienciarespiratoriainducidapor
sepsismejorcapacidadparacomunicarse,menornecesidaddesedacineintubacin.Sinembargo,puedeimpedirel
Page 10 / 41
Justificacin:LaVNIpuedetenerbeneficiostericosenpacientesconinsuficienciarespiratoriainducidapor
sepsismejorcapacidadparacomunicarse,menornecesidaddesedacineintubacin.Sinembargo,puedeimpedirel
usodeunvolumendemareabajooalcanzarnivelesadecuadosdePEEP,dosestrategiasdeventilacinquehan
mostradobeneficiosinclusoenelSDRA.Adiferenciadeotrasindicaciones(porej.,edemapulmonarcardiognico,
exacerbacindelaenfermedadpulmonarobstructivacrnica)querequierenunusobrevedelaNIV,elSDRAsuele
tardardasosemanasenmejoraryelusoprolongadodelaNVIpuedeprovocarcomplicacionescomolesiones
cutneasfaciales,ingestanutricionalinadecuadayfaltadereposodelosmsculosrespiratorios.

8.Sesugiereelusodebloqueantesneuromuscularesdurante48horasenpacientesadultosconSDRA
inducidoporsepsisyuncocientePaO2/FiO2<150mmHg.

Justificacin:LaindicacinmscomnparaelusodebloqueantesneuromuscularesenlaUCIesfacilitarlaventilacin
mecnica.Estosagentespuedenmejorarlacompliancedelaparedtorcica,prevenirladisincronarespiratoriay
reducirlaspresionespicodelasvasrespiratorias.Laparlisismusculartambinpuedereducirelconsumodeoxgeno
disminuyendoeltrabajorespiratorioyelflujosanguneodelosmsculosrespiratorios.

9.SerecomiendaunaestrategiadelquidosconservadoraparalospacientesconSDRAinducidoporsepsissin
evidenciadehipoperfusintisular.

Justificacin:losmecanismosparaeldesarrollodeedemaenpacientesconSDRAson:aumentodelapermeabilidad
capilarydelapresinhidrostticaydisminucindelapresinonctica.Pequeosestudiosprospectivosenpacientes
conenfermedadcrticaySDRAhanmostradoquelapocagananciadepesoseasociaconmejoroxigenacinymenos
dasdeventilacinmecnica.Unaestrategiadelquidosconservadoraparaminimizarlainfusindelquidosyla
gananciadepesoenpacientesconSDRA,segnelniveldelaPVColapresinenlaarteriapulmonarmediantecatter
(presindeenclavamientopulmonar),juntoconlasvariablesclnicascomoguasteraputicacondujeronamenosdas
deventilacinydeinternacinenlaUCI,sinalterarlaincidenciadeinsuficienciarenalolastasasdemortalidad.Esta
estrategiasolofueutilizadaenpacientesconSDRAestablecido,algunosdeloscualessufrieronshockdurantesu
estanciaenlaUCI,ylosintentosactivosparareducirelvolumendelquidoserealizaronsolofueradelosperodosde
shock.

10.Serecomiendanousaragonistas2paraeltratamientodelospacientesconSDRAinducidoporsepsissin
broncoespasmo.

Justificacin:LospacientesconSDRAinducidoporsepsisamenudodesarrollanunaumentodelapermeabilidad
vascularLosdatospreclnicossugierenquelosagonistasadrenrgicospuedenacelerarlareabsorcindeledema
alveolar.

11.SerecomiendanousarrutinariamenteelcatterarterialpulmonarparalospacientesconSDRAinducido
porsepsis.

Justificacin:estarecomendacinnohasufridocambios.Aunquelainsercindeuncatterenlaarteriapulmonar
(CAP)puedeproporcionarinformacintilsobreelestadodelvolumenylafuncincardacos,estosbeneficiospueden
verseconfundidospor:diferenciasenlainterpretacindelosresultadosfaltadecorrelacinentrelaspresionesde
enclavamientoarterialpulmonarylarespuestaclnicay,faltademostradademejoresresultadosconelusodelCAP.

Noobstante,silasdecisionesdelmanejodependendelainformacinobtenidanicamentemedianteelCAP
(atendiendoalosrecursosdisponibles),pacientesspticosseleccionadospuedensercandidatosalainsercinde
dichocatter.

12.Enlospacientesadultosconinsuficienciarespiratoriainducidaporsepsis,sinSDRA,sesugiereutilizar
volmenesdemareabajosynoaltos.

Justificacin:Sehacomprobadoqueunaventilacindebajovolumendemareaotidal(46ml/kg)esbeneficiosopara
lospacientesconSDRAestablecido,limitandolalesinpulmonarinducidaporelventilador.Sinembargo,elefectodela
ventilacinlimitadaporvolumenypresinesmenosclaroenlospacientesconsepsisquenotienenSDRA.

Apesardelosproblemasmetodolgicosydecalidaddelosestudiosrealizados,quemuestrandisparidadenlos
resultados,lospanelistasconsideranquelosbeneficiosdelaventilacindevolumentidalbajoenlospacientessin
SDRAsuperancualquierdaopotencial.

13.Serecomiendaquelospacientesconsepsisventiladosmecnicamentepermanezcanconlacabeceradela
camaelevadaentre30y45paralimitarelriesgodeaspiracinyprevenirlaneumonaasociadaalventilador
(NAV).

Justificacin:SehademostradoquelaposicinsemidecbitodisminuyelaincidenciadeNAV.Unestudiocomprob
queelriesgodeNAVaumentaporelusodelaalimentacinenteralel50%delospacientesalimentadosporvaenteral
enposicinsupinadesarrollNAV,comparadosconel9%delosalimentadosenposicinsemidecbito.Sinembargo,
quedandudassobreelcumplimientoestrictodelaelevacindellecho.Cuandoesnecesario,lospacientespueden
colocarseenposicinhorizontalpararealizarprocedimientos,medicioneshemodinmicasyduranteepisodiosde
Page 11 / 41
hipotensin.Lospacientesnodebenseralimentadosporvaenteralmientrasestendecbitosupino.
enposicinsupinadesarrollNAV,comparadosconel9%delosalimentadosenposicinsemidecbito.Sinembargo,
quedandudassobreelcumplimientoestrictodelaelevacindellecho.Cuandoesnecesario,lospacientespueden
colocarseenposicinhorizontalpararealizarprocedimientos,medicioneshemodinmicasyduranteepisodiosde
hipotensin.Lospacientesnodebenseralimentadosporvaenteralmientrasestendecbitosupino.

Nohayestudiosnuevosquemodifiquenlasrecomendacionesdelasltimasguas.Sinembargo,lafaltadenuevas
evidenciasjuntoconlospocosdaosderivadosdeelevarlacabeceradelacamaylaelevadaposibilidadyfrecuencia
desuimplementacindiolugaraunafirmerecomendacin.Estarecomendacinnoaplicaaunpequeosubgrupode
pacientes,comolostraumatizadosconunalesindelacolumnavertebral.

14.Serecomiendalaspruebasderespiracinespontneaenlospacientesconsepsisventilados
mecnicamenteaptosparaeldestete.

Justificacin:Laspruebasderespiracinespontneaincluyenunniveldepresindeapoyobajo,CPAP(5cmH2O)o
usodeuntuboenT.Peroensulugar,comopruebaderespiracinespontneadiariaparapacientesseleccionados
hospitalizadosventiladosmecnicamentedurantemsde24horas,unaguadeprcticaclnicarecientesugiereeluso
demayorpresininspiratoria,loquereduceladuracindelaventilacinmecnicaydeldestete.Laspruebasdeben
realizarsejuntoconunapruebadedespertarespontneo.Elxitodelaspruebasderespiracinespontneaconducea
unaelevadaprobabilidaddexitodelainterrupcindelaventilacinmecnicaconundaomnimo.

15.Serecomiendahacereldestetemecnicoparapacientesventiladosconinsuficienciarespiratoriainducida
porsepsisaptosparaeldestete.

Justificacin:Losprotocolospermitenestandarizaslasvasclnicasparafacilitareltratamientoypuedenincluirpruebas
derespiracinespontnea,reduccingradualdelsoporteydestetegeneradoporcomputadora.Elanlisiscombinado
demuestraqueeldestetebajoprotocoloduramenosqueenlospacientesdestetadosbajolaprcticahabitual.

N.Sedacinyanalgesia

1.Serecomiendalasedacincontinuaointermitenteenpacientesconsepsisventiladosmecnicamente,con
laguadelatitulacinespecfica.

Justificacin.Lalimitacindelasedacinenenfermoscrticosventiladosreduceladuracindelaventilacinmecnica
ylosdasdeinternacinenlaUCIyelhospital,ypermitelamovilizacintemprana.Apesardelafaltadeestudios,hay
pocasrazonesparacreerquealminimizarlasedacin,lospacientesspticosnoobtendrnlosmismosbeneficiosque
otrospacientescrticos.Existenvariasmanerasdereducirlossedantesyladuracindelaventilacinmecnica.Los
protocolosacargodelaenfermera,queincorporanunaescaladesedacin,brindanmejoresresultados.Sinembargo,
elbeneficiodependedelosconocimientosylasprcticaslocales.Independientementedeltipodesedacinelegido,
existenmuchaspruebasindirectasquedemuestranelbeneficiodelimitarlasedacinenpacientesenventilacin
mecnicaysincontraindicaciones,comoasseconsideralamejorprcticaparacualquierenfermocrtico,incluidoslos
pacientesconsepsis.

O.Controldelaglucosa

1.SerecomiendausarprotocolosparaelcontroldelaglucemiaenpacientesdeUCIconsepsis,comenzando
coninsulinacuandohay2glucemiasconsecutivas>180mg/dl.Elobjetivoesalcanzarunaglucemia180mg/dl
ynouna110mg/dl.

2.Serecomiendamonitorearlaglucemiacada12horashastaquelaglucemiaylainfusindeinsulinase
estabilicenluegocada4horasenlospacientesquerecibeninfusionesdeinsulina.

3.Serecomiendainterpretarconprecaucinlasglucemiasmedidascontirasreactivasensangrecapilarporque
puedenserinexactasparraestimarlaglucemiaarterialoplasmtica.

4.Paralaspruebasenelpuntodeatencin,silospacientesportanuncatterarterial,sesugiereusarsangre
arterialynocapilar,ymedirconunglucmetro

Justificacin:Ungranestudiode2001demostrmenormortalidadenlaUCIusandoinsulinaIVintensiva(protocolode
Leuven)paraunaglucemiaobjetivode80110mg/dl.Otroestudiosimilarqueincluypacientesconmsde3dasde
internacinen3UCImdicasnohallunadisminucindelamortalidadgeneral.Debidoaquenohayevidenciadeque
lasglucemiasobjetivode140y180mg/dlseandiferentesdelasglucemiasobjetivode110a140mg/dl,lospanelistas
recomiendanutilizarunaglucemiaobjetivo180mg/dlsinunobjetivomsbajoquelahipoglucemia

P.Terapiadereemplazorenal

1.Sesugierelaterapiadereemplazorenalcontinuaointermitenteenlospacientesconsepsisydaorenal
agudo.

2.Sesugiereusarelmtodocontinuoparafacilitarelmanejodelbalancehdricoenlospacientesspticos
hemodinmicamenteinestables.
Page 12 / 41
3.Sesugierenoutilizarlaterapiadereemplazorenalcontinuaenlospacientesconsepsisylesinrenalaguda
2.Sesugiereusarelmtodocontinuoparafacilitarelmanejodelbalancehdricoenlospacientesspticos
hemodinmicamenteinestables.

3.Sesugierenoutilizarlaterapiadereemplazorenalcontinuaenlospacientesconsepsisylesinrenalaguda
paracorregirlacreatininaolaoliguriasinotrasindicacionesdefinitivasdedilisis.

Justificacin:Aunquenumerososestudiosnoaleatorizadoshanreportadounatendencianosignificativaamejorarla
supervivenciausandomtodoscontinuos,2metanlisisinformaronlaausenciadediferenciassignificativasenla
mortalidadhospitalariaenlospacientesquerecibentantoterapiadereemplazorenalcontinuacomointermitente.El
paneldeexpertosconsideraquelaevidenciaesmoderadaynoapoyaelusodeterapiadereemplazorenalenla
sepsis,independientementedelanecesidaddereemplazorenal.

Q.Terapiaconbicarbonato

1.Sesugierenousarbicarbonatodesodioparamejorarlahemodinamiaoreducirlosvasopresoresen
pacientesconhipoperfusininducidaporacidemialcticaconunpH7,15.

Justificacin:AunquelaterapiaconbicarbonatodesodiopuedesertilparalimitarelvolumencorrienteenelSDRA,
enalgunassituacionesdehipercapnianohaypruebasqueapoyensuusoeneltratamientodelahipoperfusininducida
poracidemialcticaasociadaalasepsis.Laadministracindebicarbonatohasidoasociadaalasobrecargadesodio
yfluidos,alaumentodellactatoylaPaco2yaunadisminucindelcalcioionizadosrico,perolaveracidaddeestas
variablesenlosresultadosesdudosa.Elefectodelaadministracindebicarbonatodesodiosobrelosrequerimientos
hemodinmicosydevasopresoresaunpHmsbajo,ascomoelefectosobrelosresultadosclnicosacualquierpHse
desconocen.

R.Profilaxisdeltromboembolismovenoso

1.Serecomiendalaprofilaxisfarmacolgica(heparinanofraccionadaoheparinadebajopesomolecularpara
prevenireltromboembolismovenosoenausenciadecontraindicacionesparaelusodeestosagentes.

2.Serecomiendalaheparinadebajopesomolecular(HBPM)enlugardelaheparinanofraccionadaparala
profilaxisdeltromboembolismovenosoenausenciadecontraindicacionesparaelusodeesaheparina.

3.Sesugierelaprofilaxisfarmacolgicacombinadaylaprofilaxismecnicadeltromboembolismovenoso,
siemprequeseaposible.

4.Sesugierelaprofilaxismecnicadeltromboembolismovenosocuandolaprofilaxisfarmacolgicaest
contraindicada.

Justificacin:LospacientesdeUCIestnenriesgodetrombosisvenosaprofunda,ascomodeemboliapulmonar.La
incidenciadeTVPadquiridaenlaUCIpuedellegaral10%yladelaEPadquiridadel2%4%.Lospacientescon
septicemiayshockspticotienenriesgodeestacomplicacin.Elusodevasopresores,frecuenteenestospacientes,
esunfactorderiesgodetrombosisvenosaprofundaadquiridaenlaUCI.

S.Profilaxisdelalceradeestrs

1.Serecomiendalaprofilaxisdelalceradeestrsenpacientesconsepsisoshockspticoquetienenfactores
deriesgodesangradogastrointestinal

2.Sesugiereelusodeinhibidoresdelabombadeprotonesodeantagonistasdelreceptordehistamina2
cuandoestindicadalaprofilaxisdelaulceradeestrs.

3.Noserecomiendalaprofilaxisdelalceradeestrsenlospacientessinfactoresderiesgodesangrado
gastrointestinal.

Justificacin:Laslcerasdeestrssedesarrollaneneltractogastrointestinaldenpersonasgravementeenfermasy
puedeasociarseaunamorbilidadsignificativa.Elmecanismoexactosedesconoce,perosecreequeestrelacionado
conlainterrupcindelosmecanismosdeproteccincontraelcidogstrico,lahipoperfusindelamucosagstrica,el
aumentodelaproduccindecidoyeldaooxidativodeltractodigestivo.Losmsfuertespredictoresclnicosde
riesgodehemorragiagastrointestinalenlospacientescrticamenteenfermoseslaventilacinmecnica>48horasylas
coagulopatas.Laenfermedadhepticapreexistente,laterapiadereemplazorenalylosmayorespuntajesdefallo
orgnicofueronpredictoresindependientesdelriesgodesangradogastrointestinal.

T.Nutricin

1.Noserecomiendalanutricinparenteralprecoz,solaocombinadaconlaalimentacinenteral(sinomsbien
iniciartempranolanutricinenteral)enpacientescrticamenteenfermosconsepsisoshockspticoque
puedenseralimentadosporvaenteral

Justificacin:Lanutricinparenteralpuedeasegurarlacantidaddeseadadecaloras,loqueesunaventajasobrela
nutricinenteral,especialmentecuandolospacientespuedenestarsubalimentadosporintoleranciagastrointestinal, Page 13 / 41
Justificacin:Lanutricinparenteralpuedeasegurarlacantidaddeseadadecaloras,loqueesunaventajasobrela
nutricinenteral,especialmentecuandolospacientespuedenestarsubalimentadosporintoleranciagastrointestinal,
comopuedesucederdurantelainternacinenlaUCI.Sinembargo,esmsinvasivaysehaasociadocon
complicaciones,comoelmayorriesgodeinfecciones.Porotraparte,laalimentacinenteralbrindabeneficios
fisiolgicos,loquelaconvierteenunfactorclavedelaatencin.

2.Noserecomiendalanutricinparenteralessolaoencombinacinconalimentosenterales(sinomsbiense
inicialainfusindeglucosaintravenosaysecomienzanaadministrarlosalimentosporvaentricadeacuerdo
alatolerancia,durantelosprimeros7das,enlospacientescrticamenteconsepsisoshocksptico,para
quieneslaalimentacinenteraltemprananoesfactible.

Justificacin:Enalgunospacientesconsepsisoshocksptico,laalimentacinenteraltempranapuedeserimposible
debidoacontraindicacionesrelacionadasconlacirugaolaintoleranciaalaalimentacin.Esposiblequeestos
pacientesrequierannutricinparenteraltempranaconosinalimentacinenteral,parasatisfacerlosobjetivos
nutricionalesvs.laalimentacinenteraltrfica/hipocalricasola,onada,exceptolainfusindeglucosa/dextrosaIVpara
elsuministrodealgunascaloras.

Lospanelistashallaronquelanutricinparenteralprecozconosinelsuplementodelanutricinenteralnoseasocicon
reduccindelamortalidadperosconunmayorriesgodeinfeccin.Losresultadosencuantoaladuracindela
ventilacinenrelacinalanutricinparenteralfuerondivergentes.Comoconclusindesuanlisis,debidoalafaltade
beneficiosobrelamortalidad,elmayorriesgodeinfeccinyelcostoadicionalparalanutricinparenteralenausencia
debeneficio,lospanelistassostienenquelaevidenciaactualnoapoyalainiciacindelanutricinparenteraltemprana
durantelosprimeros7dasdelaatencindelospacientesconcontraindicacionesointoleranciaalanutricin.Sin
embargo,aclaranqueexisteunsubgrupodepacientesmalnutridosquepuedenserelegidosparainiciarlanutricin
parenteraltempranasilaalimentacinenteralnoesfactible.

3.Sesugiereiniciarlaalimentacinenteraltempranaenlugardelelayunoconlasolainfusindeglucosaen
lospacientescrticamenteenfermosconsepsisoshockspticoquepuedenseralimentadosporvaenteral.

4.Sesugierelaalimentacintrfica/hipocalricatempranaolaalimentacinenteraltempranaenpacientes
crticamenteenfermosconsepsisoshocksptico.Siinicialmenteseeligelaalimentacintrfica/hipocalrica,
entonceslosalimentossedebeniradministrandodeacuerdolatoleranciadelpaciente.

Justificacin:Lanutricinenteraltempranaenpacientesconsepsisyshockspticotieneventajasfisiolgicas
potencialesrelacionadasconelmantenimientodelaintegridadintestinalylaprevencindelapermeabilidadintestinal,
laatenuacindelarespuestainflamatoriaylamodulacindelasrespuestasmetablicastambinpuedereducirla
resistenciaalainsulina.

5.Noserecomiendaelusodecidosgrasosomega3comosuplementoinmunolgicoenpacientes
crticamenteenfermosconsepsisoshocksptico.

Justificacin:Elusodecidosgrasosomega3enenfermoscrticoshasidountemadeintersdurantelosltimos
aosdebidoalpotencialinmunomodulador.Sinembargo,lasrevisionessistemticasdesuplementacinconomega3
enpacientescrticamenteenfermosySDRAnohanconfirmadosubeneficioteraputico.Unarevisinimportanteno
hallreduccionessignificativasenlamortalidadperoenelgrupoomega3seredujeronsignificativamentelosdasde
internacinenUCI.Debidoalaincertidumbredelbeneficio,elpotencialdedaohalladoendiversosestudios,yel
excesodecostosydisponibilidaddeloscidosgrasosomega3,lospanelistasrecomiendanfirmementenousarlosen
lospacientesconsepsisyshockspticofueradelasinvestigaciones.

6.Sesugierenohacerelmonitoreorutinariodelvolumenresidualgstrico(VRG)enpacientescrticamente
enfermosconsepsisoshocksptico.Sinembargo,sugierenmedirlosresiduosgstricosenpacientescon
intoleranciaalimentariaoconsideradosconaltoriesgodeaspiracin.

Observaciones:Estarecomendacinserefierealospacientescrticosconsepsisoshocksptico.

Justificacin.Lospacientesgravementeenfermoscorrenelriesgodedismotilidad,laquepuedepredisponerlosa
regurgitacinovmitos,aspiracinydesarrollodelaneumonaporaspiracin(NA).LajustificacinparamedirelVRG
esreducirelriesgodeNA,yaseainterrumpiendoomodificandolaalimentacinenteral,basadosenladeteccindeun
excesoderesiduosgstricos.Pero,losestudiosnohanconfirmadounarelacinentrelamedicindelVRGyla
aparicindevmitosoNA.

Debidoaunareduccinpotencialdelosrecursosdeenfermeraparaelmonitoreodelospacientes,noserecomienda
elmonitoreodelVRGentodoslospacientesconsepsis,amenosquesehayademostradolaintoleranciaala
alimentacin,oriesgodeaspiracinelevado.

7.Sesugiereelusodeagentesprocinticosenenfermoscrticosconsepsisoshockspticoeintoleranciaala
alimentacin.

Justificacin:Laintoleranciaalimentariasedefinecomovmito,aspiracindecontenidogstricooVRGelevado.Por
mltiplesrazones,laintoleranciaalaalimentacinsedesarrollacomnmenteenpacientescrticamenteenfermos.Los Page 14 / 41
Justificacin:Laintoleranciaalimentariasedefinecomovmito,aspiracindecontenidogstricooVRGelevado.Por
mltiplesrazones,laintoleranciaalaalimentacinsedesarrollacomnmenteenpacientescrticamenteenfermos.Los
pacientescongastroparesiapreexistenteodiabetesoaquellosqueestnrecibiendosedantesyvasopresoresestnen
riesgo.Losagentesprocinticos,comolametoclopramida,ladomperidonaylaeritromicinafrecuentementeseutilizan
enUCI.Cadaunodeestosagentestienediferentespropiedadesfarmacodinmicasyfarmacocinticasypuedenestar
asociadosamuertesbitayposiblementeaarritmiasventriculares.

8.Sesugierelacolocacinpostpilricadelostubosdealimentacinenenfermoscrticosconsepsisoshocke
intoleranciaalimentaria,oqueestnriesgodeaspiracin.

Justificacin:Laintoleranciaalimentariasedefineporlapresenciadevmitos,distensinoVRGelevadoqueobligan
ainterrumpirlanutricinenteral.Lospacientescrticosestnenriesgodegastroparesiaeintoleranciaalimentaria.En
aproximadamenteel50%delospacientescrticossepuedehallarevidenciadederetrasoenelvaciamientogstrico.
Laproporcindepacientesquedesarrollarsntomasclnicosesmenosclara.Laintoleranciaalimentariapuede
motivarlainterrupcindelapoyonutricional,vmitos,aspiracindelcontenidogstricooNA.Lafisiopatologanose
conoceporcompletoyesprobablequeseamultifactorial.Lagastroparesiapuedeestarcausadaporlosagentes
farmacolgicosqueseutilizanfrecuentementeenlaUCI(porej.,sedantesopioidesoagentesbloqueantes
neuromusculareshipoperfusingstrica,enelcontextodelshock,hiperglucemiaousodevasopresores.

9.NoserecomiendaelusodeselenioIVparatratarlasepsisyelshocksptico.

Justificacin:Elselenioseutilizconlaesperanzadequepodracorregirlaconocidareduccindesuconcentracinen
lospacientesconsepsis,yasproporcionarunefectofarmacolgicoatravsdeunadefensaantioxidantepero,la
evidenciaparaelusodelselenioIVnoesconvincente.Unimportanteestudioaleatorizadoycontroladorecientenohall
beneficiosenlastasasdemortalidadniunimpactosignificativoenlasepticemia.Tampocosehallarondiferenciasen
losresultadossecundariosdeldesarrollodeneumonanosocomialodasdeinternacinenUCI.

10.Sesugierenousarargininaparatratarlasepsisyelshocksptico.

Justificacin:Enlasepsis,ladisponibilidaddeargininaestreducida,loquepuededisminuirlasntesisdexido
ntrico,laprdidadelaregulacindelamicrocirculaciny,favorecerlaproduccindesuperxidoyperoxinitrito.La
suplementacinconargininapodraprovocarunavasodilatacinindeseadaehipotensin.Losensayosdesuplementos
deLargininaensereshumanoshanmostradoefectosvariablespequeossobrelamortalidad.Losbeneficiosenla
mortalidaddelospacientesspticossonmuydudosos.

11.Noserecomiendaelusodeglutaminaparatratarlasepsisyelshocksptico.

Justificacin:Losnivelesdeglutaminatambinsereducendurantelaenfermedad.Lasuplementacinexgenapuede
mejorarlaatrofiaypermeabilidaddelamucosaintestinal,loquepodraconduciraunadisminucindelatranslocacin
bacteriana.Otrosbeneficiospotencialessonelmejoramientodelafuncindelasclulasinmunolgicas,ladisminucin
delaproduccindecitocinasproinflamatorias,laelevacindelosnivelesdeglutatinydelacapacidadoxidativa.Sin
embargo,laimportanciaclnicadeestoshallazgosnoestclaramenteestablecida.

12.Losexpertosnohicieronningunarecomendacinsobreelusodecarnitinaenlasepsisyelshocksptico.

Justificacin:Lainterrupcinmasivadelmetabolismoenergticocontribuyealagravedaddelasepsisyala
insuficienciaderganosblanco.Lamagnituddelcambiodeenergayloqueesmsimportante,laadaptacin
metablicaalcambioenlademandadeenergaposiblementeinfluyenenlasupervivenciadelpaciente.Lacarnitina,
fabricadaendgenamenteapartirdelalisinaylametionina,esnecesariaparaeltransportedeloscidosgrasosde
cadenalargaenlamitocondriaylageneracindeenerga.Porlotanto,lautilizacindecarnitinaesesencialpara
permitirelpasajedelaglucosaalmetabolismodeloscidosgrasosdecadenalargadurantelacrisisdeenergadela
sepsis.EstaeslabaseparajustificarelempleodeLcarnitinacomounfrmacoteraputicoenlasepsis.Sinembargo,
hayestudiosquenohanpodidocomprobarestaafirmacin.

U.Establecimientodelosobjetivosdeatencin

1.Serecomiendaquelosobjetivosdeatencinypronsticoseandiscutidosconlospacientesyfamiliares.

2.Serecomiendaqueselosobjetivosdeatencinseanincorporadosaltratamientoylaplanificacindela
atencinalfinaldelavida,utilizandopaliativoscuandoseaapropiado.

3.Sesugierequelosobjetivosdeatencinseabordentanprontocomoseaposible,peronomsalldelas72
horasposterioresalaadmisinenlaUCI.

Justificacin:Lospacientesconsepsisyfallamultiorgnicatienenunatasaelevadademortalidad.Algunosno
sobrevivirnotendrnunamalacalidaddevida.Aunqueelresultadodelaterapiaintensivaenlospacientescrticos
puedeserdifcildepronosticarconprecisin,enlaUCIesprimordialestablecermetasteraputicasrealistas,
especialmenteporquelasexpectativasinexactassobreelpronsticosoncomunesentrelossuplentes.Eltratamiento
paraprolongarlavidadeenlaedadavanzadadurantelainternacinenUCIquenoseacompaadebeneficiosnoes
consistenteconelestablecimientodeobjetivosdelaatencin.LosmodelosparaestructurarlasiniciativasparamejorarPage 15 / 41
especialmenteporquelasexpectativasinexactassobreelpronsticosoncomunesentrelossuplentes.Eltratamiento
paraprolongarlavidadeenlaedadavanzadadurantelainternacinenUCIquenoseacompaadebeneficiosnoes
consistenteconelestablecimientodeobjetivosdelaatencin.Losmodelosparaestructurarlasiniciativasparamejorar
laatencinenlaUCIresaltanlaincorporacindelosobjetivosdelaatencinenlosplanesteraputicos,juntoconel
pronstico.

Elusodeconferenciasparalosfamiliarescuidadoresparaidentificardirectivasanticipadasymetasteraputicasdentro
delas72horasposterioresalaadmisinenlaUCIhademostradopromoverlacomunicacinyelentendimientoentre
loslafamiliadelpacienteyelequipotratantemejorarlasatisfaccinfamiliardisminuirelestrs,laansiedadyla
depresinenlosparientessupervivientesfacilitarlatomadedecisionesalfinaldelavidayacortarlosdasde
internacinenlaUCIdelospacientesquemuerenenella.Lapromocindelatomadedecisionescompartidasconlos
pacientesylasfamiliasesbeneficiosapuesaseguralaatencinapropiadaenlaUCIyseevitalaatencinintil.

Resumenycomentarioobjetivo:Dra.MartaPapponetti

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