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Hipotermia teraputica
Carlos Aguilera F.
Contenido de presentacin
Definicin y clasificacin de hipotermia teraputica y encefalopata hipxico isqumica Fisiologa de la termorregulacin corporal Hipotermia en el sistema nervioso Fisiopatologa en la EHI Manejo de hipotermia post paro cardiorespiratorio recuperado
Fisiologa de la termorregulacin
La temperatura corporal depende de la relacin entre la produccin y prdida de calor Recordar: - Centros de regulacin de la temperatura - Ciclo circadiano de la temperatura
Stoelting RK, Hillier SC. Thermoregulation. En: Stoelting RK, Hillier SC. (eds) Pharmacology and physiology in anesthetic practice. Philadelphia. Lippicott Williams and Wilkins. 2006: 688-695
Respuesta a la hipotermia
La primera respuesta es conductual Posteriormente bajo 36,5 se produce vasoconstriccin superficial por activacin de shunts A-V de 100 um de la dermis. (25% reduccin prdida calor)
A los 35,5 se produce calofro el cual aumenta la tasa metablica 4-5 veces.
SNC e hipotermia
Por cada 1 de disminucin T enceflica, la tasa metablica disminuye 6-7% Reduce PIC por disminucin FSC
Podra tener un efecto anticonvulsivante
Fisiopatologa de la EHI
Interrupcin del flujo sanguneo cerebral
Isquemia
Reperfusin
Necrosis celular
Apoptosis
AutoFagocitosis
Lipolisis
cido araquidnico
Radicales libres
Inflamacin
(Se inicia entre las 2 y 4 hrs)
Activacin de caspasas
M.T. Froehler, R.G. Geocadin / Journal of the Neurological Sciences 261 (2007) 118126
Proceso destructivo que sigue a la isquemia-reperfusin que puede ser prevenido o significativamente mitigado por hipotermia leve a moderada Letras negras = mecanismos precoces Letras grises = mecanismo tardos
Kees H. Polderman. Mechanism of action, physiological effects, and complications of hypothermia. Crit Care Med 2009.Vol 37 N7
CONCEPTOS GENERALES
- PCR reanimado = enfre con lo que tenga disponible - Mantener temperatura central entre 32 -34C - Duracin 24 hrs -Recalentamiento gradual
Equipos de enfriamiento
BeneChill
CoolGard ALSIUS
FIN
Marion DW. Controlled normothermia in neurologic intensive care. Crit Care Med. 2004; 32 (S): S43-S45.
Hipotermia y ACV
Proceso destructivo que sigue a la isquemia-reperfusin que puede ser prevenido o significativamente mitigado por hipotermia leve a moderada Letras negras = mecanismos precoces Letras grises = mecanismo tardos
Kees H. Polderman. Mechanism of action, physiological effects, and complications of hypothermia. Crit Care Med 2009.Vol 37 N7
Therapeutic hypothermia for acute ischemic stroke: ready to start large randomized trials? H Bart van der Worp,1,4 Malcolm R Macleod,2,4* and Rainer Kollmar3, for the European Stroke Research Network for Hypothermia (EuroHYP) Received February 15, 2010; Revised February 22, 2010; Accepted February 22, 2010.
Hipotermia y TEC
James L. Fox, MD;* Erik N. Vu, MD;* Mary Doyle-Waters, MLIS, MA; Jeffrey R. Brubacher, MD; Riyad Abu-Laban, MD, MHSc; Zengxuan Hu, MD, PhD. Prophylactic hypothermia for traumatic brain injury: a quantitative systematic review. CJEM 2010;12(4):355-64
Forest plot showing relative risk of mortality in trials of short- and long-term cooling compared with standard therapy
CJEM 2010;12(4):355-64
Forest plot showing relative risk of good neurologic outcome in trials of short- and long-term cooling compared with standard therapy.
Experiencia en neurointensivo
Concluye La hipotermia entre 32-34, por al menos 72 hrs o al normalizarce la PIC por 24 hrs entrega beneficio clnico en TEC severo. Favorece menor mortalidad y mejor pronstico neurolgico
Experiencia en neurointensivo
Conclusiones
Herramienta teraputica Relativamente fcil de realizar Considerar recalentamiento gradual De uso creciente en TEC moderado- severo y stroke por 48 hrs.
Caso clnico
F.P.A Masculino, 22 aos Accidente de trnsito, probable atricin craneana TEC grave el 06/02/2012, craniectoma descompresiva izquierda Ingresa a UCI 10/02/2012, ampliacin de craniectoma izquierda el 11/02/2012
40
35
30
25 T 20 PIC
15
10
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Tiem po en horas x 2
Calentamiento
40 35
30
25
20
Temp. En C PIC
15
10
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Tiempo en horas
17/02/2012 al 19/02/2012
Isquemia enceflica
Dao celular
Stroke. 2010 Aug;41(8):1684-9. Epub 2010 Jul 8. Hypothermia reduces perihemorrhagic edema after intracerebral hemorrhage. Kollmar R, Staykov D, Drfler A, Schellinger PD, Schwab S, Bardutzky J. Neurology Department, University of Erlangen, Erlangen, Germany. rainer.kollmar@uk-erlangen.de Abstract BACKGROUND AND PURPOSE: The prognosis of spontaneous intracerebral hemorrhage (sICH) is poor because of the mass effect arising from the hematoma and the associated peri-hemorrhagic edema, leading to increased intracranial pressure. Because the efficacy of surgical and anti-edematous treatment strategies is limited, we investigated the effects of mild induced hypothermia in patients with large sICH. METHODS: Twelve patients with supratentorial sICH >25 mL were treated by hypothermia of 35 degrees C for 10 days. Evolution of hematoma volume and perifocal edema was measured by cranial CT. Functional outcome was assessed after 90 days. These patients were compared to patients (n=25; inclusion criteria: sICH volume >25 mL, no acute restriction of medical therapy on admission) from the local hemorrhage data bank (n=312). Side effects of hypothermia were analyzed. RESULTS: All patients from both groups needed mechanical ventilation and were treated in a neurocritical care unit. All hypothermic patients (mean age, 60+/-10 years) survived until day 90, whereas 7 patients died in the control group (mean age, 67+/-7 years). Absolute hematoma size on admission was 58+/-29 mL (hypothermia) compared to 57+/-31 mL (control). In the hypothermia group, edema volume remained stable during 14 days (day 1, 53+/-43 mL; day 14, 57+/-45 mL), whereas edema significantly increased in the control group from 40+/-28 mL (day 1) to 88+/-47 mL (day 14). ICH continuously dissolved in both groups. Pneumonia rate was 100% in the hypothermia group and 76% in controls (P=0.08). No significant side effects of hypothermia were observed. CONCLUSIONS: Hypothermia prevented the increase of peri-hemorrhagic edema in patients with large sICH
Descripcin Catter Alsius con kit de inicio. Incluye Sonda Foley. Catter Alsius con kit de inicio. Incluye Sonda Foley. ** Arriendo del equipo por da.
1709 articulos, 12 estudios con 1327 participantes were selected for quantitative analysis. Eight of these studies cooled according to a long-term or goaldirected strategy, and 4 used a short-term strategy
James L. Fox, MD;* Erik N. Vu, MD;* Mary Doyle-Waters, MLIS, MA; Jeffrey R. Brubacher, MD; Riyad Abu-Laban, MD, MHSc; Zengxuan Hu, MD, PhD. Prophylactic hypothermia for traumatic brain injury: a quantitative systematic review. CJEM 2010;12(4):355-64
Experiencia en neurointensivo
12 ensayos, con 1069 pcte incluidos 543 hipotermia 526 normotermia
Concluye: beneficio clnico a 32-33 y por ms de 48 hrs y recalentados en las proximas 24 hrs tienen menor mortalidad y mejor pronstico neurolgico en TEC mod-severo
McIntyre LA. Prolonged Therapeutic Hypothermia after traumatic injury in adults A systematic Review . JAMA 2003;289:2992-2999 Henderson WR et al Hypothermia in the management of traumatic brain injury:A systematic review and meta analysis. Intensive Care Med 2003;29:1637-1644
Experiencia en neurointensivo
Experiencia en neurointensivo
Experiencia en neurointensivo
FIN