lunes, 7 de mayo de 2018

Vasoplejia / Vasoplegia

Mayo 7, 2018. No. 3074

Vasoplejia en pacientes con sepsis y shock séptico: vías y mecanismos.
Vasoplegia in patients with sepsis and septic shock: pathways and mechanisms.
J Int Med Res. 2018 Apr;46(4):1303-1310. doi: 10.1177/0300060517743836. Epub 2018 Jan 14.
Abstract
Sepsis is one of the most frequent causes of death among patients in intensive care units. Many therapeutic strategies have been assessed without the desired success rates. A key risk factor for death is hypotension due to vasodilatation with vascular hyposensitivity. However, the pathways underlying this process remain unclear. Endotoxemia induces inflammatory mediators, and this is followed by vasoplegia and decreased cardiac contractility. Although inhibition of these mediators diminishes mortality rates in animal models, this phenomenon has not been confirmed in humans. Downregulation of vasoconstrictive receptors such as angiotensin receptors, adrenergic and vasopressin receptors is seen in sepsis, which is associated with a hyporesponsiveness to vasoconstrictive mediators. Animal studies have verified that receptor downregulation is linked to the above-mentioned inflammatory mediators. Anti-inflammatory therapy with glucocorticoids reportedly improves responsiveness to catecholamines with higher survival in rats, although this has not been shown to be clinically significant in humans. Hence, there is an urgent need for in-depth studies investigating the underlying mechanisms of vasoplegia to allow for development of effective therapeutic strategies for the treatment of sepsis.
KEYWORDS: Vasoplegia; cytokines; endotoxemia; hypotension; sepsis; vasoactive receptors
Manejo de la vasoplejia: pasado, presente y futuro
Vasoplegia treatments: the past, the present, and the future.
Levy B1,2,3, Fritz C4,5,6, Tahon E4, Jacquot A4, Auchet T4, Kimmoun A4,5,6.
Crit Care. 2018 Feb 27;22(1):52. doi: 10.1186/s13054-018-1967-3.
Abstract
Vasoplegia is a ubiquitous phenomenon in all advanced shock states, including septic, cardiogenic, hemorrhagic, and anaphylactic shock. Its pathophysiology is complex, involving various mechanisms in vascular smooth muscle cells such as G protein-coupled receptor desensitization (adrenoceptors, vasopressin 1 receptors, angiotensin type 1 receptors), alteration of second messenger pathways, critical illness-related corticosteroid insufficiency, and increased production of nitric oxide. This review, based on a critical appraisal of the literature, discusses the main current treatments and future approaches. Our improved understanding of these mechanisms is progressively changing our therapeutic approach to vasoplegia from a standardized to a personalized multimodal treatment with the prescription of several vasopressors. While norepinephrine is confirmed as first line therapy for the treatment of vasoplegia, the latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hyporesponsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine and early prescription of vasopressin. This new approach is seemingly justified by the need to limit adrenoceptor desensitization as well as sympathetic overactivation given its subsequent deleterious impacts on hemodynamics and inflammation. Finally, based on new pathophysiological data, two potential drugs, selepressin and angiotensin II, are currently being evaluated.
KEYWORDS: Catecholamines; Circulatory failure; Septic shock; Vasoconstrictor agents; Vasoplegic syndrome
Síndrome vasopléjico
Janet Silvia Aguirre-Sáncheza, Eduardo Bucio-Retab, Leonel Martínez-Ramírezb, Drander M. López-Pinedab, Luis Efren Santos-Martínezb, Fernando Florez-Figueroa
Arch Cardiol Mex 2011;81 Supl 2:58-63
Introducción
La cirugía cardiovascular, que se realiza desde mediados del siglo XX, es un procedimiento ampliamente difundido y utilizado en la medicina asistencial contemporánea. Sus complicaciones son múltiples y se han estudiado desde los albores de este tipo de intervenciones. Las cardiovasculares son las más frecuentes y constituyen, además, las causas de muerte más comunes. Desde hace unos años se ha advertido la aparición relativamente frecuente de un cuadro posoperatorio caracterizado en esencia por hipotensión arterial grave, presiones de llenado ventricular bajas y respuesta terapéutica parcial a la expansión del espacio intravascular con grandes volúmenes de líquidos. Algunos grupos médicos denominaron inicialmente a esta complicación síndrome vasopléjico (SV), en referencia a la vasodilatación marcada que la caracteriza; su expresión máxima es el choque por vasodilatación.

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