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2003, Número 3

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Cir Gen 2003; 25 (3)


Síndrome de exsanguinación. Factores predictivos e indicativos para la institución de la cirugía de control de daños

Asensio JA, Rojo E , Petrone P, Karsidag T, Pardo M, Demiray S, Ramírez J, Roldán G, Pak-art R, Kuncir E

Idioma: Español
Referencias bibliográficas: 88
Paginas: 207-218
Archivo PDF: 161.40 Kb.


RESUMEN

Objetivos: El propósito del presente estudio fue investigar la relación entre la supervivencia y las características de los pacientes: signos vitales, factores relacionados a la lesión y al tratamiento; determinar si un nivel crítico del pH, temperatura y la máxima cantidad estimada de pérdida sanguínea pueden predecir la supervivencia, así como identificar factores predictivos tanto para la supervivencia como para iniciar cirugía de “control del daño”.
Material y métodos: Llevamos a cabo un estudio retrospectivo de 6 años, de 1993 a 1998. Se admitieron 548 pacientes que cumplían uno o más de los siguientes criterios: (1) pérdida estimada de sangre en el intraoperatorio › 2,000 ml, (2) requerimiento de concentrado globular › 1,500 ml durante la resucitación, ó (3) diagnóstico de exsanguinación. Realizamos el análisis en 2 fases: (I) supervivencia versus fallecimientos en la sala de emergencia (SE) y (II) supervivencia versus fallecimientos en el quirófano. Para análisis estadístico usamos: prueba exacta de Fisher, t de Student y análisis de regresión logística.
Resultados: En un universo de estudio de 548 pacientes la media para la Escala Revisada de Trauma (RTS) (por sus siglas en inglés) fue de 4.38 y la media para la Escala se Severidad de la Lesión (ISS) (por sus siglas en inglés) fue de 32. El porcentaje de heridas penetrantes versus trauma cerrado fue de 82% y 18%, respectivamente. Los signos vitales al arribo del paciente en la SE estadísticamente fue de: presión arterial media 63 mmHg, frecuencia cardiaca de 78 latidos por minuto. La media para el pH intraoperatorio fue de 7.15 y la temperatura de 34.3°C. Se registró una mortalidad en 379 de los 548 (69%) pacientes. Los factores predictivos de mortalidad (media) fueron: pH ‹ 7.2, temperatura ‹34°C, reemplazo de sangre en quirófano ›4,000 ml, reemplazo total de fluidos en quirófano › 10,000 ml, pérdida sanguínea estimada › 15 ml/minuto (p 00.1). Para el análisis I (Supervivencia versus fallecimientos en la SE) usamos regresión logística. Identificamos los siguientes factores de riesgo independientes para sobrevida: trauma penetrante, respiración espontánea y la no realización de toracotomía de urgencia en la SE (p 00.1; probabilidad de supervivencia 0.99613). Para el análisis II (supervivencia versus fallecimientos en quirófano) usamos regresión logística.
Encontramos los siguientes factores de riesgo independientes para supervivencia: ISS ‹ 20, respiración espontánea en la SE, reemplazo de paquete globular en quirófano ‹ 4000 ml, la no realización de toracotomía de urgencia en la SE como tampoco en quirófano y la ausencia de lesiones vasculares abdominales (p 0.001 max R2 0.55, concordancia 89%).
Conclusión: Los índices de supervivencia pueden predecirse en pacientes exsanguinados. La cirugía para “control del daño” debe ser realizada usando estos criterios. Debemos utilizar estos patrones de conducta quirúrgica para disminuir la mortalidad de estos pacientes.


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