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Colegio de Medicina Interna de México.

2010, Número 4

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Med Int Mex 2010; 26 (4)


Tratamiento de la depresión miocárdica por sepsis con levosimendan. Serie de casos y revisión de la bibliografía

Rincón VJA, Martínez MJ, Monteón BI, Córdova PVH

Idioma: Español
Referencias bibliográficas: 81
Paginas: 324-336
Archivo PDF: 486.03 Kb.


RESUMEN

Antecedentes: levosimendan es un inotrópico vasodilatador indicado para el tratamiento de la insuficiencia cardiaca descompensada. En comparación con otros inotrópicos incrementa la contractilidad miocárdica sin aumentar el consumo de oxígeno, además de ejercer efectos anti-apoptóticos y antiinflamatorios. Sin embargo, la experiencia con este fármaco en pacientes con choque séptico es limitada.
Objetivo: reportar los efectos hemodinámicos de levosimendan cuando se indica a pacientes con choque séptico con depresión miocárdica documentada.
Material y método: serie de casos de 11 pacientes con choque séptico de origen bacteriano y depresión miocárdica documentada con ecocardiograma, cuyo tratamiento incluyó levosimendan a dosis de 0.05 mcg/kg/min hasta 0.2 mcg/kg/min y tiempos de infusión entre 4 y 156 horas. En un lapso de 48 horas se midieron: presión arterial media, presión venosa central, frecuencia cardiaca, saturación de oxígeno venosa central, fracción de eyección del ventrículo izquierdo, calificación de APACHE II, pH, exceso de base y lactato arteriales, creatinina y requerimientos de vasopresores. En un subgrupo de cinco pacientes se midieron, también: índice cardiaco, volumen sistólico, resistencias vasculares sistémica y pulmonar, presión pulmonar media, presión de oclusión de arteria pulmonar, aporte y extracción de oxígeno.
Resultados: levosimendan mejoró la fracción de expulsión del ventrículo izquierdo de 33.9 ± 7.1% a 50.5 ± 10.7% (p=0.0001), así como el pH arterial, las concentraciones de lactato y exceso de base arterial (p‹ 0.05) y disminuyó la resistencia vascular sistémica (p=0.009) sin repercusión en la presión arterial media. En el subgrupo de monitoreo invasivo se observó un incremento en el índice cardiaco de 2.02 ± 0.1 L/min/m2 a 2.7 ± 0.5 L/min/m2 a las 48 horas (p = 0.004), junto con un descenso no significativo en las presiones de llenado auricular izquierdo y derecho. Estos efectos hemodinámicos resultaron en un decremento significativo en las dosis de vasopresores.
Conclusiones: en este grupo de pacientes con choque séptico y depresión miocárdica levosimendan revirtió, efectivamente, el síndrome de bajo gasto sin incremento en el requerimiento de vasopresores.


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