Sedación y analgesia en pacientes sépticos

Recomendación sobre el uso de sedación y analgesia

– No hay evidencia en la literatura para recomendar el uso de un agente sedante específico sobre los demás, ya que hasta el momento ninguno ha logrado influir en el pronóstico de pacientes con sepsis que requieran sedación (Nivel 2B).

Recomendación de la sedante o analgésico de elección

– No existe evidencia en la literatura para usar un agente analgésico opioide específico en pacientes con sepsis (Nivel 2C).

Recomendación del uso de protocolos para el manejo de sedación y analgesia

– El uso de protocolos para la titulación de agentes sedantes y analgésicos orientados hacia la consecución de metas clínicas, así como la interrupción diaria de estos medicamentos, disminuye el tiempo de ventilación mecánica, la estancia en la UCI y en el hospital en pacientes con sepsis en ventilación mecánica (Nivel 1A).

Recomendación sobre el monitoreo de la sedación y analgesia

– Se recomienda establecer metas para alcanzar una óptima sedación y analgesia, utilizando escalas previamente validadas en pacientes con sepsis que se encuentran en ventilación mecánica (Nivel 1B).

Recomendación acerca del uso de miorrelajantes

– En los pacientes con sepsis, el uso de agentes relajantes musculares se deberá evitar hasta donde sea posible. No existe evidencia en la literatura para usar los relajantes con una indicación específica (Nivel 1B).

Profilaxis de Tromboembolismo Venoso en Sepsis

Recomendación sobre el uso de profilaxis del tromboembolismo venoso

– Recomendamos utilizar profilaxis de TEV en todos los sépticos, porque la frecuencia de TEV en UCI es alta sin profilaxis, y los riesgos derivados de la profilaxis son mínimos (Nivel 1A).

Recomendación de una medicación ideal para prevenir tromboembolismo

– La evidencia existente hasta el momento no permite hacer diferencias en claros beneficios clínicos entre heparina no fraccionada y heparina de bajo peso molecular (Nivel 1B).

Recomendación de profilaxis de tromboembolismo con métodos no farmacológicos

– En pacientes con alto riesgo de sangrado, se recomienda el uso de métodos mecánicos hasta que el riesgo de sangrado disminuya; en ese momento se debe considerar el uso de profilaxis farmacológica (Nivel 1C).
– En pacientes con muy alto riesgo de TEV o con varios factores de riesgo podría considerarse la combinación de profilaxis farmacológica y profilaxis mecánica con compresión neumática intermitente (Nivel 1C).

Soporte Nutricional en el Paciente Séptico

Recomendaciones sobre la administración del soporte nutricional

– El soporte nutricional debe administrarse cuando el paciente no esté en estado de choque y cuando lo tolere, pero no existe evidencia que demuestre que el soporte nutricional mejore la sobrevida en pacientes sépticos (Nivel 2C).

Recomendaciones sobre la ruta preferida de administración del soporte nutricional

– En pacientes con sepsis severa y choque séptico adecuadamente reanimados, con tracto gastrointestinal funcional, se recomienda el uso de nutrición entera (Nivel 1C).

– En pacientes con sepsis severa y choque séptico no se recomienda el uso de inmunonutrición suplementada con arginina (Nivel 1A).

Limitación del Soporte Vital

Recomendación de cuándo limitar el soporte terapéutico

– Sugerimos al grupo de salud a cargo del paciente discutir y comunicar con frecuencia al paciente o sus responsables legales la severidad de la enfermedad, las opciones terapéuticas y la posible futilidad de los tratamientos (Nivel 2C).

Recomendación de quién decide limitar el soporte terapéutico

– Sugerimos involucrar al paciente o a las personas legalmente responsables de los pacientes para que, junto con el personal de la salud tratante, tomen la decisión de limitar el soporte terapéutico (Nivel 2C).

Sepsis en poblaciones especiales: inmunocomprometidos, VIH/sida, cáncer y postransplantados

Recomendación del cubrimiento empírico con antibióticos de amplio espectro

– El paciente inmunocomprometido difiere en términos del posible patógeno que puede causar sepsis severa o choque séptico, incluyendo bacterias inusuales y hongos que pueden tener susceptibilidades únicas a antibióticos, y que requieren tratamientos muy específicos. Sin embargo, se recomienda el uso de antimicrobianos de amplio espectro mientras se obtienen los resultados de cultivos (Nivel 1C).

Recomendaciones sobre la terapia antifúngica

– Como tratamiento empírico en fiebre y neutropenia: de acuerdo con el estado clínico y posibles contraindicaciones, recomendamos usar anfotericina B, fluconazol, caspofungina (Nivel 1A).

– En aspergilosis invasiva se recomienda el uso de voriconazole (Nivel 1A). – En candidiasis diseminada aguda recomendamos usar anfotericina B, fluconazol, caspofungina (Nivel 1A).

Recomendación sobre la terapia empírica antiviral

– No se recomienda la terapia empírica antiviral en pacientes inmunocomprometidos (Nivel 1C).

Recomendaciones sobre el uso de factor estimulante de colonias de granulocitos y el factor estimulante de colonias de granulocitos y macrófagos

– En pacientes neutropénicos febriles podrían utilizarse los factores estimulantes de colonias (Nivel 2C). Sin neutropenia no puede recomendarse el uso de factores estimulantes de colonias (Nivel 1C).

Protocolos para el Manejo de Sepsis

Recomendación acerca del uso de protocolos en la práctica clínica

– Recomendamos usar protocolos basados en estudios originales y posterior validación e implementación en la práctica clínica. La aplicación de un protocolo general para el manejo de la sepsis es sugerido, a pesar de la falta de evidencia.

Recomendaciones de diseminación y estrategias de implementación

– Para mejorar la aplicación de las guías para el tratamiento adecuado de la sepsis, sugerimos utilizar recursos dedicados a desarrollar material educativo y mensajes computarizados con recordatorios.

– Sugerimos incluir un número limitado de recursos para reuniones educacionales, auditoría y retroalimentación, o visitas educacionales. Estas recomendaciones son generalmente factibles, aceptables y potencialmente pueden ser en bajo costo. También sugerimos utilizar materiales dirigidos a la distribución de material educativo.

Agradecimientos

Estamos profundamente agradecidos con nuestros revisores externos: Dr. Antonio Anzueto, Dr. Marc Chalaby, Dr. Alejandro Jiménez, Dr. Kelly Echevarría, Dr. Edgar Celis, Dr. Marco A. Perafán y la licenciada María E. González. Queremos también expresar nuestra gratitud a nuestro corrector de estilo y editor médico el Dr. Diego Roselli y a nuestra bibliotecóloga Lic. Paola Laverde.

Nota:

El presente es un resumen ejecutivo del Primer Consenso Colombiano de Sepsis. El documento en extenso, con las bibliografías referenciadas, ha sido publicado recientemente por la AMCI y la ACIN.

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Correspondencia:
CARMELO DUEÑAS, MD
Correo electrónico: crdc2001@hotmail.com
Bogotá, Colombia. Referencias