Anestesia y Gestión de la Sangre del Paciente

6.11 Anestesia y gestión de la sangre del paciente

El papel más importante del anestesiólogo debe ser su participación activa en el programa multidisciplinario de gestión de la sangre del paciente, que incluya:

• Optimización preoperatoria del volumen eritrocitario y estado de coagulación.
• Atención meticulosa a la hemostasis quirúrgica
• Minimización de la pérdida de sangre perioperatoria (ej. mediante la optimización de la presión arterial y venosa en el sitio de la cirugía tanto durante como después del procedimiento)
• Manejo adecuado de la anemia postoperatoria

Esta sección se enfoca en la influencia de diferentes agentes anestésicos y técnicas sobre la pérdida sangre perioperatoria, incluyendo:

• Anestesia volátil (por inhalación) versus anestesia intravenosa
• Anestesia regional (principalmente neuroaxial) versus anestesia general
• Ventilación espontánea versus controlada.

El mayor énfasis sobre la preservación de la presión sanguínea arterial, particularmente en el paciente mayor con comorbilidades, ha significado que la práctica de hipotensión intraoperatoria controlada esté siendo usada con menos frecuencia (ver sección de Hemodilución normovolémica aguda).

El impacto que una técnica anestésica particular pueda tener sobre la conservación de la sangre, depende no solamente de las estrategias de conservación sanguínea utilizadas, y de la experiencia del anestesiólogo, sino también del tipo de cirugía y otros factores que contribuyen a la hemorragia, como los anticoagulantes y la técnica quirúrgica empleada.

Los anestesiólogos deben tener conocimiento acerca de los principios de gestión de la sangre del paciente en el perioperatorio.

¿Anestesia volátil o anestesia general intravenosa?

La anestesia general intravenosa basada en propofol, ha sido asociada con la reducción en la pérdida de sangre en varios escenarios, posiblemente debido a los efectos que el propofol tiene sobre la hemodinámica y el tono uterino (251-253).

El propofol, comúnmente combinado con el remifentanil, ha demostrado resultar en menos pérdida de sangre durante la cirugía endoscópica nasosinusal (perdida media de sangre 19 mL vs 128 mL p=0,004) y durante la tonsilectomía (1,2 mL/kg menos; p=0,013) (254), cuando se compara con la anestesia volátil.

De manera similar, en la terminación del embarazo del primer trimestre, la anestesia con propofol redujo la pérdida sanguínea (18,8 mL vs 40,4 mL p=0,0011) (253). Sin embargo, debido a las reducciones absolutas encontradas en la pérdida sanguínea, el impacto clínico de la anestesia intravenosa con respecto a la conservación de sangre debe ser mínimo en este grupo de pacientes.

Una ventaja potencial fue la reducción de la pérdida de sangre observada durante la cirugía de columna realizada bajo anestesia intravenosa basada en propofol, comparada con el sevoflurano (106 mL vs. 315 mL; p=0,004), para el mismo valor objetivo de presión sanguínea (232).

Técnica neuroaxial y otras técnicas regionales importantes comparadas con la anestesia general

Una revisión sistemática encontró que el bloqueo neuroaxial reducía el requerimiento de transfusión en dos o más unidades de glóbulos rojos en alrededor del 50% (p<0,001; OR=0,50, IC 95%: 0,39, 0,66) y que había una reducción similar para el sangrado posoperatorio que necesitaba transfusión (OR=0,45; IC 95% 0,29-0,70) (255). De manera similar, un meta análisis encontró que el bloqueo neuroaxial, reducía la pérdida sangre estimada en aproximadamente 100 -200 mL (p<0,001) (256).

La selección de la técnica de anestesia para la artroplastia total de cadera debe tener en cuenta el beneficio potencial de las técnicas regionales con respecto a la conservación de la sangre.

La pérdida de sangre reducida bajo el bloqueo neuroaxial está asociada con presión arterial y presión venosa central más bajas, con ventilación espontánea y menor presión venosa en la herida (257-260).

Evidencia confiable sobre el bloqueo neuroaxial

La ortopedia es la especialidad en la cual hay la más evidencia confiable sobre el bloqueo neuroaxial en cuanto a la reducción del sangrado quirúrgico. La pérdida de sangre en el reemplazo total de cadera puede ser reducida en un promedio de 275 mL (261) o 30-40% (262). El bloqueo neuroaxial también redujo la pérdida de sangre durante la reparación de fractura de cadera por unos 85 mL (lC 95%:-162,-9), a pesar de que había heterogeneidad significativa (283). De manera similar, el bloqueo neuroaxial con y sin anestesia general para la cirugía de columna espinal seleccionada, también ha sido asociado con reducción de la pérdida de sangre (257,264). También hay evidencia que el bloqueo del plexo lumbar reduce la pérdida de sangre intraoperatoria (22%; 310 mL vs. 617 mL) y total (45%; 712 mL vs. 1074 mL) durante el reemplazo total de cadera (265-266).

A pesar que hay menos evidencia acerca de que la selección de la anestesia tenga un efecto significativo sobre el sangrado perioperatorio en otros tipos de cirugía, los anestesiólogos deben estar al tanto de los posibles beneficios de la anestesia regional, la anestesia intravenosa y la ventilación espontánea en la reducción de la pérdida de sangre.

 Entre otros, varios estudios sugieren que muchos beneficios previamente identificados a la técnica neuroaxial pueden ser históricos, con los mayores beneficios habiendo sido atribuidos a mejoras progresivas en el cuidado quirúrgico, anestésico y perioperatorio (267-269). Sin embargo, los efectos fisiológicos intraoperatorios identificados previamente de las técnicas neuroaxiales sobre la pérdida de sangre, pueden esperarse que persistan en algunas poblaciones quirúrgicas. De otro lado, la heterogeneidad de los datos fue común en los meta análisis (267-269); y otros cambios de práctica, como la menor tolerancia a la hipotensión, pueden reversar algunos mecanismos, como la presión venosa central disminuida, que son responsables de la reducción de la pérdida de sangre.

La evidencia de la anestesia neuroaxial en reducir la transfusión también está presente, pero debe considerarse en el contexto del manejo actual de la sangre.

Un meta análisis reportó una reducción significativa para la población quirúrgica como un todo (un grupo heterogéneo) (255). Un estudio que reportaba la artroplastia total de cadera encontró que la anestesia neuroaxial redujo la tasa de transfusión al 12%, desde el 33% con anestesia general (OR 0,26; 95% lC: 0,06 a 1,05, p<0,001).

Otro estudio encontró que la anestesia neuroaxial estaba asociada con un OR de 0,646 para requerir transfusión (270).

Sin embargo, los resultados de estos estudios deben ser interpretados con precaución dado que se han desarrollado prácticas de transfusión más restrictivas desde que se llevó a cabo la investigación.

De igual forma, la implementación de otras estrategias de conservación de sangre podría reducir o negar los beneficios ilustrados. A pesar de las limitaciones de estos datos, es de esperar que una disminución en el sangrado quirúrgico reduzca la transfusión en al menos un subgrupo de pacientes.

 Tipo de ventilación

La ventilación por presión positiva ha sido asociada con un aumento en la pérdida de sangre intraoperatoria comparado con la ventilación espontánea durante el reemplazo total de articulación de cadera bajo anestesia general (259, 262).

Este efecto posiblemente se debe al impacto que la presión intratoráxica positiva tiene sobre la disminución del retorno venoso y el aumento en la presión venosa en el sitio de operación.

De manera similar, la minimización de la resistencia espiratoria mediante la manipulación de los parámetros de ventilación y la optimización de la enfermedad reactiva de las vías respiratorias debería ayudar al retorno venoso y puede reducir la pérdida de sangre (271). El impacto que tiene la ventilación espontánea sobre la reducción de la transfusión parece no estar clara.

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