Hemorragia Crítica

10.5.6 

Pregunta de antecedente 6

En neonatos y niños, ¿qué recomendaciones se deben hacer para tratar la hemorragia crítica?

Evidencia

La definición de hemorragia crítica no está bien establecida en pacientes neonatales y pediátricos. Además, la evidencia sobre qué intervenciones y estrategias tienen los mejores resultados se limita a informes de casos, series de casos, experiencia de un solo centro y pequeños informes retrospectivos (349-352).

Al igual que ocurre con los pacientes adultos, la hemorragia crítica ocurre con mayor frecuencia en escenarios de traumatismos accidentales y no accidentales, cirugías mayores (particularmente cirugías cardíacas y espinales, procedimientos neuroquirúrgicos seleccionados y trasplante hepático) y hemorragia gastrointestinal. En los pacientes neonatos, la exanguinación debida a la hemorragia fetal intraparto o anteparto y la hemorragia subgaleal masiva son afecciones poco comunes, pero están entre las indicaciones para una transfusión de gran volumen.

El Módulo 1 – Sangrado crítico / Transfusión masiva proporciona información general y recomendaciones.

Sin embargo, en general, la evidencia es de nivel bajo y se deriva de estudios sobre poblaciones adultas; por lo tanto, puede no ser directamente aplicable a niños y neonatos

En la población pediátrica, hay variaciones fisiológicas relacionadas con la edad (particularmente en el sistema hemostático) que pueden exacerbar los efectos de sangrado crítico y transfusión de gran volumen. Es probable que estas variaciones fisiológicas tengan el mayor impacto en neonatos, lactantes y niños pequeños.

También hay una marcada variación de la volemia con la edad. Se ha sugerido que la transfusión masiva pediátrica se define como la transfusión de más del 50% del volumen sanguíneo total (VST) en 3 horas, la transfusión de más del 100% VST en 24 horas o el soporte transfusional para reemplazar la pérdida sanguínea de más del 10% VST por minuto (353). Debido a las variaciones en la masa corporal y en el volumen sanguíneo relacionadas con la edad y el peso, los volúmenes de transfusión y el contenido de los paquetes de protocolos de sangrado críticos deben ajustarse por edad o peso (o ambos).

El tratamiento clínico debe tener en cuenta que las soluciones anticoagulantes-conservantes afectan el estado ácido-base y pueden causar hipocalcemia, y que la hipotermia daña la coagulación global (incluyendo la función plaquetaria).

Las instituciones deben desarrollar un protocolo de sangrado crítico específico para pacientes neonatales y pediátricos que tenga en cuenta lo siguiente:

– Orientación sobre cuándo activar
– Quién contactar y cómo contactar con ellos (números de teléfono relevantes)
– Roles y responsabilidades
– Medidas de seguridad rápidas, como usar cánulas de gran calibre cuando sea posible
– Ajustar a la edad o al peso:

• Contenido de los paquetes de protocolos de sangrado críticos
• Volúmenes o dosis de productos sanguíneos utilizados

– Definición de los productos que se incluirán en los paquetes iniciales, secundarios y posteriores (ejemplo: concentrado de glóbulos rojos, PFC, plaquetas y crioprecipitado)
– Indicaciones para el uso del crioprecipitado
– Utilización de las POCT de viscoelasticidad (TEG/ROTEM), definición de su función
– Definición de responsabilidades para la desactivación del protocolo de sangrado crítico, con información de contacto relevante.

Puede ser útil desarrollar protocolos paralelos para el manejo clínico y de laboratorio. Este último debe incluir la dosificación del producto y la administración a la cabecera. La vía clínica debe incluir orientación sobre cuándo realizar las pruebas de laboratorio, qué pruebas a solicitar, interpretación de los resultados y efecto en la selección y dosis del producto.

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