Manejo Inicial de

Líquidos en el

Paciente Crítico

Dr. Andrés Blanco Montero

¿Cómo hacer la reanimación hídrica

en el paciente crítico?

¿Todos los líquidos son iguales?

Cambio de paradigmas

PVC >8-12 mmHg

TAM > 65 mmHg

GU > 0.5 mlKgh

SavO2 > 70%

Llenado capilar < 2

seg

TAM > 65 mmHg

GU > 0.5 mlKgh

SavO2 > 70%

Normalizar Lactato

Reducción mortalidad

15-18%

Recomendaciones Hídricas

1B • Cristaloide como líquido inicial en la reanimación

1B

• Evitar el uso de almidones como expansores de volumen (Hidroxietil almidón)

2C

• Utilizar Albúmina cuando el paciente requiere grandes cantidades de cristaloides

1C

• Inicial con bolos de solución cristaloide de 30 mL/Kg valorando su respuesta

UG

• La manera de administrar soluciones está basada en la valoración y mejoría hemodinámica

GC 3.3 a 6.0 L/min/m2

SvO2 > 70 Integridad

Neurológica GU >1 mllkghr

Extremidades Calientes

Pulsos adecuados

TAM para la edad

Llenado capilar < 2”

¿Con que reanimamos?

Solución fisiológica

Acidosis metabólica hiperclorémica

Alteraciones en la flujo renal

Expansor plasmático

Incremento TAM

Mejoría del GC

Efecto hemorreológico

Disminución edema miocárdico

Incremento de sustancias vasoactivas

Efecto inmunomodulador

Efectos transitorios

Hypertonic versusnear isotonic crystalloid for fluid

resuscitation in critically ill patients (Review)

Bunn F, RobertsIG, Tasker R, Trivedi D

Thisisareprint of aCochranereview, prepared and maintained byTheCochraneCollaboration and published in TheCochraneLibrary

2004, Issue3

http://www.thecochranelibrary.com

Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients (Review)

Copyright © 2008 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.

Hypertonic versusnear isotonic crystalloid for fluid

resuscitation in critically ill patients(Review)

Bunn F, RobertsIG, Tasker R, Trivedi D

Thisisareprint of aCochranereview, preparedandmaintained byTheCochraneCollaboration andpublished in TheCochraneLibrary

2004, Issue3

http://www.thecochranelibrary.com

Hypertonic versusnear isotonic crystalloid for fluid resuscitation in critically ill patients(Review)

Copyright © 2008 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.

[Intervention Review]

Hypertonic versusnear isotonic crystalloid for fluid

resuscitation in critically ill patients

FrancesBunn1, Ian G Roberts2, Robert Tasker3, DakshaTrivedi1

1Centrefor Research in PrimaryandCommunityCare, Universityof Hertfordshire, Hatfield, UK. 2CochraneInjuriesGroup, London

School of Hygiene & Tropical Medicine, London, UK. 3University of Cambridge School of Clinical Medicine, Department of

Paediatrics, Cambridge, UK

Contact address: FrancesBunn, Centre for Research in Primary and Community Care, University of Hertfordshire, CollegeLane,

Hatfield, Hertfordshire, AL10 9PN, UK. f.bunn@herts.ac.uk.

Editorial group:CochraneInjuriesGroup.

Publication statusand date: Edited (no changeto conclusions), published in Issue4, 2008.

Review content assessed asup-to-date: 14 October 2007.

Citation: Bunn F, RobertsIG, Tasker R, Trivedi D. Hypertonic versusnear isotonic crystalloid for fluid resuscitation in critically ill

patients. CochraneDatabaseof SystematicReviews2004, Issue3. Art. No.: CD002045. DOI: 10.1002/14651858.CD002045.pub2.

Copyright © 2008 TheCochraneCollaboration. Published by John Wiley & Sons, Ltd.

A B S T R A C T

Background

Hypertonic solutions are considered to have a greater ability to expand blood volume and thuselevate blood pressure and can be

administered as a small volume infusion over a short time period. On the other hand, the use of hypertonic solutions for volume

replacement may also haveimportant disadvantages.

Objectives

To determinewhether hypertoniccrystalloid decreasesmortality in patientswith hypovolaemia.

Search methods

We searched the Cochrane InjuriesGroup’sspecialised register, MEDLINE, EMBASE, The Cochrane Library, issue 3, 2007, The

National Research Register issue3, 2007 and theBritish Library’sElectronic Tableof ContentsZETOC. Wealso checked reference

listsof all articlesidentified. Thesearcheswerelast updated in October 2007

Selection criteria

Randomised trials comparing hypertonic to isotonic and near isotonic crystalloid in patients with trauma or burns or who were

undergoingsurgery.

Datacollection and analysis

Two authorsindependently extracted thedataand assessed thequality of thetrials.

Main results

Fourteen trialswith a total of 956 participantsare included in themeta-analysis. Thepooled relativerisk (RR) for death in trauma

patientswas0.84 (95% confidence interval [CI] 0.69 to1.04); in patientswith burns1.49 (95% CI 0.56 to 3.95); and in patients

undergoing surgery 0.51 (95% CI 0.09 to 2.73). In theone trial that gavedataon disability using theGlasgow outcomescale, the

relativerisk for apoor outcomewas1.00 (95% CI 0.82 to 1.22).

1Hypertonic versusnear isotonic crystalloid for fluid resuscitation in critically ill patients(Review)

Copyright © 2008 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.

• 956 Estudios

• Ninguna evidencia disponible que

demuestre que la solución hipertónica sea

mejor a los cristaloides en la reanimación

de pacientes con trauma, quemadura o

quirúrgicos

Incremento contractilidad

Disminución de la disfunción diastólica

Aumento del volumen intravascular

Disminución de vasoactivos

Sin cambios en la perfusión mucosa gástrica

Sin cambios en la microcirculación sublingual

............................................................................................................................................

Volume Expansion with Albumin Compared

to Gelofusine in Children with Severe Malaria:

Results of a Controlled TrialSamuel Akech1, Samson Gwer1, Richard Idro1, Greg Fegan1,2, Alice C. Eziefula1, Charles R. J. C. Newton1,3,

Michael Levin4, Kathryn Maitland1,4*

1 Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research–Coast, Kilifi, Kenya, 2 Infectious

Diseases Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom, 3 NeurosciencesUnit, Institute of Child Health,

London, United Kingdom, 4 Department of Paediatrics and Wellcome Trust Centre for Clinical Tropical Medicine, Faculty of Medicine, Imperial College,

London, United Kingdom

Trial Registration: ISRCTN:35536139

Funding: This study was supportedby a project grant (045194) awardedby the Wellcome Trust. CRJCN holdsa Wellcome Trust Senior Fellowship(070114). KM was supported by agrant from Children of St Mary’sIntensive Care. The funders playedno part in data collection, analysis, orpresentation of these data.

Competing Interests: The authorshave declared that no competinginterests exist.

Citation: Akech S, Gwer S, Idro R,Fegan G, Eziefula AC, et al. (2006)Volume expansion with albumincompared to Gelofusine in childrenwith severe malaria: Results of acontrolled trial. PLoS Clin Trials 1(5):e21. DOI: 10.1371/journal.pctr.0010021

Received: March 16, 2006Accepted: July 14, 2006Published: September 15, 2006

DOI: 10.1371/journal.pctr.0010021

Copyright: Ó 2006 Akech et al. Thisis an open-access article distributedunder the terms of the CreativeCommons Attribut ion License, whichpermits unrestricted use,distribution, and reproduction in anymedium, provided the originalauthor and source are credited.

Abbreviations: BCS, Blantyre comascore; CI, confidence interval; ITT,intention to treat; PP, per protocol

* To whom correspondence shouldbe addressed. E-mail: kmaitland@kilifi.kemri-wellcome.org

ABSTRACT

Objectives: Previous studies have shown that in children with severe malaria, resuscitation

with albumin infusion results in a lower mortality than resuscitation with saline infusion.

Whether the apparent benefit of albumin is due solely to its colloidal properties, and thus

might also be achieved with other synthetic colloids, or due to the many other unique

physiological properties of albumin is unknown. As albumin is costly and not readily available

in Africa, examination of more affordable colloids is warranted. In order to inform the design of

definitive phase III trials we compared volume expansion with Gelofusine (succinylated

modified fluid gelatin 4% intravenous infusion) with albumin.

Design: This study was a phase II safety and efficacy study.

Setting: The study was conducted at Kilifi District Hospital, Kenya.

Participants: The participants were children admitted with severe falciparum malaria

(impaired consciousness or deep breathing), metabolic acidosis (base deficit . 8 mmol/l), and

clinical features of shock.

Interventions: The interventions were volume resuscitation with either 4.5% human albumin

solution or Gelofusine.

Outcome Measures: Primary endpoints were the resolution of shock and acidosis; secondary

endpoints were in-hospital mortality and adverse events including neurological sequelae.

Results: A total of 88 children were enrolled: 44 received Gelofusine and 44 received albumin.

There was no significant difference in the resolution of shock or acidosis between the groups.

Whilst no participant developed pulmonary oedema or fluid overload, fatal neurological events

were more common in the group receiving gelatin-based intervention fluids. Mortality was

lower in patients receiving albumin (1/44; 2.3%) than in those treated with Gelofusine (7/44;

16%) by intention to treat (Fisher’s exact test, p ¼ 0.06), or 1/40 (2.5%) and 4/40 (10%),

respectively, for those treated per protocol (p ¼ 0.36). Meta-analysis of published trials to

provide a summary estimate of the effect of albumin on mortality showed a pooled relative risk

of death with albumin administration of 0.19 (95% confidence interval 0.06–0.59; p ¼ 0.004

compared to other fluid boluses).

Conclusions: In children with severe malaria, we have shown a consistent survival benefit of

receiving albumin infusion compared to other resuscitation fluids, despite comparable effects

on the resolution of acidosis and shock. The lack of similar mortality benefit from Gelofusine

suggests that the mechanism may involve a specific neuroprotective effect of albumin, rather

than solely the effect of the administered colloid. Further exploration of the benefits of albumin

is warranted in larger clinical trials.............................................................................................................................................................................................

www.plosclinicaltrials.org September | 2006 | e210001

PLoSCLINICAL TRIALS

............................................................................................................................................

Volume Expansion with Albumin Compared

to Gelofusine in Children with Severe Malaria:

Results of a Controlled TrialSamuel Akech1, Samson Gwer1, Richard Idro1, Greg Fegan1,2, Alice C. Eziefula1, Charles R. J. C. Newton1,3,

Michael Levin4, Kathryn Maitland1,4*

1 Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research–Coast, Kilifi, Kenya, 2 Infectious

Diseases Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom, 3 NeurosciencesUnit, Institute of Child Health,

London, United Kingdom, 4 Department of Paediatrics and Wellcome Trust Centre for Clinical Tropical Medicine, Faculty of Medicine, Imperial College,

London, United Kingdom

Trial Registration: ISRCTN:35536139

Funding: This study was supportedby a project grant (045194) awardedby the Wellcome Trust. CRJCN holdsa Wellcome Trust Senior Fellowship(070114). KM was supported by agrant from Children of St Mary’sIntensive Care. The funders playedno part in data collection, analysis, orpresentation of these data.

Competing Interests: The authorshave declared that no competinginterests exist.

Citation: Akech S, Gwer S, Idro R,Fegan G, Eziefula AC, et al. (2006)Volume expansion with albumincompared to Gelofusine in childrenwith severe malaria: Results of acontrolled trial. PLoS Clin Trials 1(5):e21. DOI: 10.1371/journal.pctr.0010021

Received: March 16, 2006Accepted: July 14, 2006Published: September 15, 2006

DOI: 10.1371/journal.pctr.0010021

Copyright: Ó 2006 Akech et al. Thisis an open-access article distributedunder the terms of the CreativeCommons Attribut ion License, whichpermits unrestricted use,distribution, and reproduction in anymedium, provided the originalauthor and source are credited.

Abbreviations: BCS, Blantyre comascore; CI, confidence interval; ITT,intention to treat; PP, per protocol

* To whom correspondence shouldbe addressed. E-mail: kmaitland@kilifi.kemri-wellcome.org

ABSTRACT

Objectives: Previous studies have shown that in children with severe malaria, resuscitation

with albumin infusion results in a lower mortality than resuscitation with saline infusion.

Whether the apparent benefit of albumin is due solely to its colloidal properties, and thus

might also be achieved with other synthetic colloids, or due to the many other unique

physiological properties of albumin is unknown. As albumin is costly and not readily available

in Africa, examination of more affordable colloids is warranted. In order to inform the design of

definitive phase III trials we compared volume expansion with Gelofusine (succinylated

modified fluid gelatin 4% intravenous infusion) with albumin.

Design: This study was a phase II safety and efficacy study.

Setting: The study was conducted at Kilifi District Hospital, Kenya.

Participants: The participants were children admitted with severe falciparum malaria

(impaired consciousness or deep breathing), metabolic acidosis (base deficit . 8 mmol/l), and

clinical features of shock.

Interventions: The interventions were volume resuscitation with either 4.5%human albumin

solution or Gelofusine.

Outcome Measures: Primary endpoints were the resolution of shock and acidosis; secondary

endpoints were in-hospital mortality and adverse events including neurological sequelae.

Results: A total of 88 children were enrolled: 44 received Gelofusine and 44 received albumin.

There was no significant difference in the resolution of shock or acidosis between the groups.

Whilst no participant developed pulmonary oedema or fluid overload, fatal neurological events

were more common in the group receiving gelatin-based intervention fluids. Mortality was

lower in patients receiving albumin (1/44; 2.3%) than in those treated with Gelofusine (7/44;

16%) by intention to treat (Fisher’s exact test, p ¼ 0.06), or 1/40 (2.5%) and 4/40 (10%),

respectively, for those treated per protocol (p ¼ 0.36). Meta-analysis of published trials to

provide a summary estimate of the effect of albumin on mortality showed apooled relative risk

of death with albumin administration of 0.19 (95% confidence interval 0.06–0.59; p ¼ 0.004

compared to other fluid boluses).

Conclusions: In children with severe malaria, we have shown a consistent survival benefit of

receiving albumin infusion compared to other resuscitation fluids, despite comparable effects

on the resolution of acidosis and shock. The lack of similar mortality benefit from Gelofusine

suggests that the mechanism may involve a specific neuroprotective effect of albumin, rather

than solely the effect of the administered colloid. Further exploration of the benefitsof albumin

is warranted in larger clinical trials.............................................................................................................................................................................................

www.plosclinicaltrials.org September | 2006 | e210001

PLoSCLINICAL TRIALS

............................................................................................................................................

Volume Expansion with Albumin Compared

to Gelofusine in Children with Severe Malaria:

Results of a Controlled TrialSamuel Akech1, Samson Gwer1, Richard Idro1, Greg Fegan1,2, Alice C. Eziefula1, Charles R. J. C. Newton1,3,

Michael Levin4, Kathryn Maitland1,4*

1 Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research–Coast, Kilifi, Kenya, 2 Infectious

DiseasesEpidemiology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom, 3 NeurosciencesUnit, Institute of Child Health,

London, United Kingdom, 4 Department of Paediatrics and Wellcome Trust Centre for Clinical Tropical Medicine, Faculty of Medicine, Imperial College,

London, United Kingdom

Trial Registration: ISRCTN:35536139

Funding: This study was supportedby a project grant (045194) awardedby the Wellcome Trust. CRJCN holdsa Wellcome Trust Senior Fellowship(070114). KM was supported by agrant from Children of St Mary’sIntensive Care. The funders playedno part in data collection, analysis, orpresentation of these data.

Competing Interests: The authorshave declared that no competinginterests exist.

Citation: Akech S, Gwer S, Idro R,Fegan G, Eziefula AC, et al. (2006)Volume expansion with albumincompared to Gelofusine in childrenwith severe malaria: Results of acontrolled trial. PLoS Clin Trials 1(5):e21. DOI: 10.1371/journal.pctr.0010021

Received: March 16, 2006Accepted: July 14, 2006Published: September 15, 2006

DOI: 10.1371/journal.pctr.0010021

Copyright: Ó 2006 Akech et al. Thisis an open-access article distributedunder the terms of the CreativeCommons Attribut ion License, whichpermits unrestricted use,distribution, and reproduction in anymedium, provided the originalauthor and source are credited.

Abbreviations: BCS, Blantyre comascore; CI, confidence interval; ITT,intention to treat; PP, per protocol

* To whom correspondence shouldbe addressed. E-mail: kmaitland@kilifi.kemri-wellcome.org

ABSTRACT

Objectives: Previous studies have shown that in children with severe malaria, resuscitation

with albumin infusion results in a lower mortality than resuscitation with saline infusion.

Whether the apparent benefit of albumin is due solely to its colloidal properties, and thus

might also be achieved with other synthetic colloids, or due to the many other unique

physiological properties of albumin is unknown. As albumin is costly and not readily available

in Africa, examination of more affordable colloids is warranted. In order to inform the design of

definitive phase III trials we compared volume expansion with Gelofusine (succinylated

modified fluid gelatin 4% intravenous infusion) with albumin.

Design: This study was a phase II safety and efficacy study.

Setting: The study was conducted at Kilifi District Hospital, Kenya.

Participants: The participants were children admitted with severe falciparum malaria

(impaired consciousness or deep breathing), metabolic acidosis (base deficit . 8 mmol/l), and

clinical features of shock.

Interventions: The interventions were volume resuscitation with either 4.5%human albumin

solution or Gelofusine.

Outcome Measures: Primary endpoints were the resolution of shock and acidosis; secondary

endpoints were in-hospital mortality and adverse events including neurological sequelae.

Results: A total of 88 children were enrolled: 44 received Gelofusine and 44 received albumin.

There was no significant difference in the resolution of shock or acidosis between the groups.

Whilst no participant developed pulmonary oedema or fluid overload, fatal neurological events

were more common in the group receiving gelatin-based intervention fluids. Mortality was

lower in patients receiving albumin (1/44; 2.3%) than in those treated with Gelofusine (7/44;

16%) by intention to treat (Fisher’s exact test, p ¼ 0.06), or 1/40 (2.5%) and 4/40 (10%),

respectively, for those treated per protocol (p ¼ 0.36). Meta-analysis of published trials to

provide a summary estimate of the effect of albumin on mortality showed a pooled relative risk

of death with albumin administration of 0.19 (95% confidence interval 0.06–0.59; p ¼ 0.004

compared to other fluid boluses).

Conclusions: In children with severe malaria, we have shown a consistent survival benefit of

receiving albumin infusion compared to other resuscitation fluids, despite comparable effects

on the resolution of acidosis and shock. The lack of similar mortality benefit from Gelofusine

suggests that the mechanism may involve a specific neuroprotective effect of albumin, rather

than solely the effect of the administered colloid. Further exploration of the benefitsof albumin

is warranted in larger clinical trials.............................................................................................................................................................................................

www.plosclinicaltrials.org September | 2006 | e210001

PLoSCLINICAL TRIALS

Colloids versuscrystalloids for fluid resuscitation in critically

ill patients (Review)

Perel P, RobertsI, Ker K

Thisisareprint of aCochranereview, prepared and maintained byTheCochraneCollaboration and published in TheCochraneLibrary

2013, Issue2

http://www.thecochranelibrary.com

Colloidsversus crystalloidsfor fluid resuscitation in critically ill patients (Review)

Copyright © 2013 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.

Colloidsversuscrystalloids for fluid resuscitation in critically

ill patients (Review)

Perel P, RobertsI, Ker K

Thisisareprint of aCochranereview, preparedandmaintained byTheCochraneCollaboration andpublished in TheCochraneLibrary

2013, Issue2

http://www.thecochranelibrary.com

Colloidsversuscrystalloidsfor fluid resuscitation in critically ill patients (Review)

Copyright © 2013 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.

[Intervention Review]

Colloidsversuscrystalloidsfor fluid resuscitation in critically

ill patients

Pablo Perel1, Ian Roberts1, KatharineKer1

1CochraneInjuriesGroup, London School of Hygiene& Tropical Medicine, London, UK

Contact address: Pablo Perel, Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, Keppel Street, London,

WC1E7HT, UK. pablo.perel@Lshtm.ac.uk.

Editorial group: CochraneInjuriesGroup.

Publication statusand date: Edited (no changeto conclusions), published in Issue3, 2013.

Reviewcontent assessed asup-to-date: 17 October 2012.

Citation: Perel P, Roberts I, Ker K. Colloidsversuscrystalloidsfor fluid resuscitation in critically ill patients. CochraneDatabaseof

SystematicReviews2013, Issue2. Art. No.: CD000567. DOI: 10.1002/14651858.CD000567.pub6.

Copyright © 2013 TheCochraneCollaboration. Published by John Wiley & Sons, Ltd.

A B S T R A C T

Background

Colloidsolutionsarewidelyused influid resuscitation of critically ill patients. Thereareseveral choicesof colloid, and thereisongoing

debateabout therelativeeffectivenessof colloidscompared tocrystalloid fluids.

Objectives

To assesstheeffectsof colloidscompared tocrystalloidsfor fluid resuscitation in critically ill patients.

Search methods

Wesearched theCochraneInjuriesGroup SpecialisedRegister (17 October 2012), theCochraneCentral Register of Controlled Trials

(TheCochraneLibrary) (Issue10, 2012), MEDLINE(Ovid) 1946 toOctober 2012, EMBASE(Ovid) 1980 toOctober 2012, ISI Web

of Science: ScienceCitation Index Expanded (1970 to October 2012), ISI Web of Science: ConferenceProceedingsCitation Index-

Science(1990 to October 2012), PubMed (October 2012), www.clinical trials.gov and www.controlled-trials.com. Wealso searched

thebibliographiesof relevant studiesand review articles.

Selection criteria

Randomisedcontrolledtrials(RCTs) of colloidscomparedtocrystalloids, inpatientsrequiringvolumereplacement.Weexcludedcross-

over trialsand trialsinvolvingpregnant women and neonates.

Datacollection and analysis

Two review authors independently extracted data and rated quality of allocation concealment. We analysed trials with a ’double-

intervention’, such asthosecomparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. Westratified theanalysis

according to colloid typeand quality of allocation concealment.

Main results

Weidentified 78 eligibletrials; 70 of thesepresented mortality data.

Colloidscompared tocrystalloids

Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk

ratio (RR) from these trialswas 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality

1Colloidsversuscrystalloidsfor fluid resuscitation in critically ill patients(Review)

Copyright © 2013 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.

• 78 Estudios

• Ninguna evidencia de que los coloides

disminuyan la mortalidad en pacientes con

trauma, quemaduras o quirúrgicos

• El uso de pentalmidón puede incrementar la

mortalidad

• Mayor costo de los coloides

JAMA 2013:310(17):1809-1817

• NO diferencia en

mortalidad a 28

días

• NO Incremento

en falla renal con

colides

ORIGINAL ARTICLE

Albumin Replacement in Patients with

Severe Sepsis or Septic Shock Pietro Caironi, M.D., Gianni Tognoni, M.D., Serge Masson, Ph.D., Roberto Fumagalli, M.D.,

Antonio Pesenti, M.D., Marilena Romero, Ph.D., Caterina Fanizza, M.Stat., Luisa Caspani,

M.D., Stefano Faenza, M.D., Giacomo Grasselli, M.D., Gaetano Iapichino, M.D., Massimo

Antonelli, M.D., Vieri Parrini, M.D., Gilberto Fiore, M.D., Roberto Latini, M.D., and Luciano

Gattinoni, M.D. for the ALBIOS Study Investigators

N Engl J Med 2014; 370:1412-1421April 10, 2014DOI:

10.1056/NEJMoa1305727

1818 pacientes en 100 UCIs

Sol Cristaloide vs. Cristaloide +

albúmina

No diferencia en sobrevida

53,448 pacientes en 360 hospitales

Retrospectivo

Terapias con soluciones balanceadas

disminuyó la mortalidad

jul

La acumulación en

el balance positivo

a las 48, 72 y 96

horas aumenta la

mortalidad

Solución Consideraciones negativas

COLOIDES (en general) Alto costo/sobrecarga/Falla renal/alteración

hemostáticas

Albúmina Alto costo

Gelatinas Eficacia limitada/reacciones alérgicas

Pentalmidón Alteración hemostáticas/falla renal/vida media

alta

CRISTALOIDES (general) Vida media corta/cambios electrolíticos

Sol. Fisiológica 0.9% Acidosis hiperclorémica

Ringer lactato Hipotonicidad

Plasmalyte Sobrecarga de gluconato y acetato

Respuesta a Líquidos

Respuesta a los líquidos

Sólo para mejorar el Gasto Cardíaco

Util en la zona ascendente de la curva de Frank-Starling

En la zona plana de la curva no puede causar más daño

Cambios en el volumen sistólico durante la

ventilación

Curva pletismografía

Levantamiento de la piernas

Interacciones cardiopulmoanres

Conclusiones

La utilización de antibióticos de manera temprana y

una reanimación hídrica han disminuido la

mortalidad

Las guías actuales deben ser evaluadas con

mejores estudios

Sobrecarga de volumen se asocia a mayor

morbilidad (SDRA, IRA, CID) y mortalidad

Si existe sobrecarga >10% del peso corporal valorar

uso de diurético o terapias de reemplazo

Conclusiones

Reconocer la heterogeneidad del choque

Utilizar métodos invasivos y no invasivos para

determinar la necesidad de volumen

Medición de otros marcadores de inflamación

(lactato)

Utilización de volumen en las diferentes etapas de

atención

Conclusiones

El tipo de solución utilizada está relacionada con

el pronóstico del paciente

Estrategias encaminadas a disminuir el cloro en las

soluciones

Utilizar albúmina en pacientes que requieran

grandes cantidades de líquidos

No llevar al paciente a sus “variables fisiológicas”

= buscar estabilidad clínica