Cuándo operar un paciente con sepsis en estado crítico

Autores:: Gómez Duque, Mario
Uribe Guzmán, Hedda María
Lleras Riaño, Juan David

Tipo de recurso:: Article of journal

Fecha de publicación:: 2011

Institución:: Fundación Universitaria de Ciencias de la Salud - FUCS

Repositorio:: Repositorio Digital Institucional ReDi

Idioma:: spa

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repository_id_str
dc.title.spa.fl_str_mv	Cuándo operar un paciente con sepsis en estado crítico
dc.title.translated.eng.fl_str_mv	When to operate a septic critically ill patient
title	Cuándo operar un paciente con sepsis en estado crítico
spellingShingle	Cuándo operar un paciente con sepsis en estado crítico sepsis paciente crítico infección intraabdominal pronóstico mortalidad sepsis critically ill patient intra-abdominal infection prognosis mortality rate
title_short	Cuándo operar un paciente con sepsis en estado crítico
title_full	Cuándo operar un paciente con sepsis en estado crítico
title_fullStr	Cuándo operar un paciente con sepsis en estado crítico
title_full_unstemmed	Cuándo operar un paciente con sepsis en estado crítico
title_sort	Cuándo operar un paciente con sepsis en estado crítico
dc.creator.fl_str_mv	Gómez Duque, Mario Uribe Guzmán, Hedda María Lleras Riaño, Juan David
dc.contributor.author.spa.fl_str_mv	Gómez Duque, Mario Uribe Guzmán, Hedda María Lleras Riaño, Juan David
dc.subject.spa.fl_str_mv	sepsis paciente crítico infección intraabdominal pronóstico mortalidad
topic	sepsis paciente crítico infección intraabdominal pronóstico mortalidad sepsis critically ill patient intra-abdominal infection prognosis mortality rate
dc.subject.eng.fl_str_mv	sepsis critically ill patient intra-abdominal infection prognosis mortality rate
publishDate	2011
dc.date.accessioned.none.fl_str_mv	2011-09-01 00:00:00 2022-06-29T19:36:21Z
dc.date.issued.none.fl_str_mv	2011-09-01
dc.date.available.none.fl_str_mv	2011-09-01 00:00:00 2022-06-29T19:36:21Z
dc.type.spa.fl_str_mv	Artículo de revista
dc.type.eng.fl_str_mv	Journal article
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identifier_str_mv	10.31260/RepertMedCir.v20.n3.2011.749 0121-7372 2462-991X
url	https://repositorio.fucsalud.edu.co/handle/001/2773 https://doi.org/10.31260/RepertMedCir.v20.n3.2011.749
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dc.relation.references.spa.fl_str_mv	Solomkin JS, Mazuski JE. Intra-abdominal sepsis: newer interventional and antimicrobial therapies. Infect Dis Clin N Am. 2009; 23 (3): 593-608. 2. OrdoñezC, Puyana J. Management of peritonitis in the critically ill patient. Surg Clin N Am. 2006 Dec; 86 (6): 1323-49. 3. Schein M, Marshall J. Sourcecontrol forsurgical infections. World J. Surg. 2004: 28, 638-45. 4. Mazuski JE, Sawyer RG, Nathens AB, DiPiro JT, Schein M, Kudsk KA, YowlerC. Toe SurgicalInfection Society guidelines on antimicrobial therapy for intra abdominal infections: an executive summary. Surg Infect (Larchmt). 2002; 3 (3):161-73. 5. Penkoske P, Buchman TG. The relationship between the surgeon and the intensivist in the surgical intensive care unit. SurgClin N Am. 2006 Dec; 86 (6):1351-57. 6. Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen after trauma and abdominal sepsis: a strategy for management. J AmColl Surg. 2006 Sep;203(3):390-6 7. Calandra T,Cohen J. Tbe intemational sepsis forum consensus conference on definitions of infection in the intensive care unit.CritCare Med. 2005 Ju!; 33(7):1538-48. 8. Tellado JM, Christou NV, editors. Intra-abdominal infections. Madrid, Spain: Harcourt; 2000. 9. Dellinger RP, Levy MM,Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving sepsis campaign: intemational guidelines for management of severe sepsis and septic shock: 2008.CritCare Med. 2008 Jan; 36(1):296-327. 10. Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections.Clin Infect Dis. 2003; 37(8): 997-1005. 11. Malangoni MA. Current concepts in peritonitis. Curr Gastroenterol Rep. 2003 Aug; 5(4):295-30l. 12. Chromik AM, Meiser A, Holling J, Sülberg D, Daigeler A, Meurer K, et al. Identification of patients at risk for development of tertiary peritonitis on a surgical intensive care unit. J Gastrointest Surg. 2009 Ju!; 13(7): 1358-67. 13. Wittrnann DH, Schein M,CondonRE. Management of secondary peritonitis. Ann Surg. 1996 Jul; 224(1): 10-18. 14. Deitch EA. Role of the gut iymphatic system in multiple organ faiiure. Curr OpinCritCare. 2001 Apr;7(2):92-8. 15. Pinsky MR, Matuschak GM. Multiple system organ failure host defense bomeostasis.CritCareClin. 1989 Apr; 5(2):199-220 16. Larnme B, MahierCW, van Ruler O, Gouma DJ, Reitsma JB, Boermeester MA. Clinical predictors of ongoing infection in secondary peritonitis: systematicreview. World J Surg. 2006 Dec;30(12):2170-8 l. 17. Gotzinger P, Wamser P, Barlan M, Sautner T, Jakesz R, Fugger R. The surgicalconcepts of planned and on-demandreoperation in thetreatment of diffuse intra-abdorninal infection. ActaChir Austriaca. 2000; 32 (4):167-70. 18. Wittrnann DH. Intra-abdorninai infections. Introduction. World J Surg. 1990 Mar Apr; 14(2):145-7. 19. Schein M. Planned reoperations and open management in critica! intra abdominal infections: prospective experience in 52 cases. World J Surg. 1991 Jul-Aug; 15(4): 537-45. 20. Wittmann DH. Stagedabdominalrepair: development and currentpracticeof an advanced operative technique for diThse suppurative peritonitis. ActaChir Austriaca. 2000; 32(4): 171-78. 21. Wittmann DH. The colon. In: Scbeim M, Marshall JC, editors. Source control, a guide to the management surgical infections. New York: Springer - Verlag; 2003. p. 103-108. 22. Gómez M. Manejo del trauma abdominal en tópicos en cuidado intensivo. Trabajo presentado en el primer Consenso Nacional en Cuidado Intensivo; 1999 mayo 16; Cartagena de Indias, Colombia. p 136. 23. Gómez M, Cruz L, Villabón M. Hipertensión intraabdominal y síndrome compartimenta!. En: González MA. Fundamentos de medicina: paciente en estado crítico. 3a ed. Medellín: Corporación para Investigaciones Biológi cas; 2003. p. 180. 24. van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007 Aug 22; 298(8):865-72. 25. Padilla T, Fustinoni O. Síndromes clínicos en esquemas. 17' ed. Buenos Aires : El Ateneo; 2000. p. 33. 26. Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartrnent syndrome: thephysiologicaland clinical consequences of elevated intra-abdominal pressure. JAm Coll Surg. 1995 Jun;l80(6):745-53. 27. Pujol JP. Moderate hypertension defined as sustained elevation of 21-35 mmHg. Paris: U.E.R.X Bichat; 1975. 28. Gómez M, Posada C, Cruz LE. Soporte nutricional en cuidado intensivo experiencia de 4 años. Acta Colomb Cuid Int. 2001; 4(2):109. 29. Fry D. Antibiotic kinetics in febril multiple system trauma patients. In: Cunha BA, editor. lnfectius diseases in critica! care medicine. London: Informa Healthcare;20!0. p 521-35. 30. Gomez E. Trastornos en la hoemostasis de los líquidos. En: Ordoñez CA, Ferrara R, Buitrago R. Cuidado Intensivo y trauma. Bogotá: Distribuna; 2009. p 201. 31. Hutchins RR, Gunning MP, Lucas DN, Allen-Mersh TG, Soni NC. Relaparotomy for suspectedintraperitoneal sepsis after abdominal surgery. World J Surg. 2004 Feb;28(2):137-41. 32. Kopema T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg. 2000 Jan;24(1):32-7. 33. Aydin C, Aytekin FO, Yenisey C, Kabay B, Erdem E, Kocbil G. The effect of different temporary abdominalclosure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis. Langenbecks Arch Surg. 2008 Jan; 393(1):67-73. 34. Kirshtein B, Roy-Shapira A, Lantsberg L, Mizrahi S. Use of the "Bogota bag" for temporary abdominal closure in patients with secondary peritonitis.. Am Surg. 2007 Mar;73(3):249-52. 35. Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen after trauma and abdominal sepsis: a strategy for management. J Am Coll Surg. 2006 Sep;203(3):390-6. 36. Enciso Olivera CO, Guerra Urrego KA, GómezDuque M, Meneses Góngora E. Costos de atención en UCI de un hospital universitario de BogotáD. C. Repert. Med. Cir.2006; 15(3): 133-42. 37. Schoffel U. Timing of intervention. In: Schein M, Marshall JC. Source control: a guide to the management of surgicalinfections. New York: Springer Verlag;2002. p. 279-87. 38. Lamme B, Boerrneester MA, Reitsma JB, Mahler CW, Obertop H, Gouma DJ. Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg. 2002Dec; 89(12):1516-24. 39. Agalar F, Eroglu E, Bulbul M, Agalar C, Tarhan OR, Sari M. Staged abdominalrepair for treatment of moderate to severe secondary peritonitis. World J. Surg. 2005 Feb;29(2): 240-44. 40. AnayaDA, NathensAB.Riskfactorsfor severe sepsis insecondaryperitonitis. Surg lnfect (Larchmt). 2003; 4(4):355-62. 41. Van Goor H. lnterventionalmanagement ofabdominal sepsis: when and how. LangenbecksArch Surg. 2002;387(5-6): 191-200. 42. Adkins AL, Robbins J, Villalba M, Bendick P, Shanley CJ. Open abdomen management of intra-abdominal sepsis. Am Surg. 2004 Feb;70(2):137-40 43. Manejo de la peritonitis y la sepsis intraabdominal en cuidado intensivo. En: Ordoñez CA, Ferrada R, Buitrago R, editors. Cuidado intensivo y trauma. Bogotá:Distribuna; 2003. p. 667-84. 44. Rakic M, PopovicD, Rakic M, et al. Comparison of on-demand vs planned relaparotomy for treatrnent of severe intra-abdominal infections. Croat Med J 2005;46(6):956--63. 45. Sihler KC, Natbens AB. Management of severe sepsis in the surgical patient. Surg Clin NorthAm. 2006Dec;86(6):1457-81. 46. Christou NV, Barie PS,Dellinger EP, et al. Surgical lnfection Society Intra Abdominal lnfectionStudy:prospective evaluation ofmanagement techniques and outcome. Arch Surg 1993;128(2):193-8. 47. Marshall JC, Christou NV, Meakins JL. The gastro intestinal tract: the "undrained abscess" of multiple organ failure. Ann Surg.1993; 218(2):111-9. 48. Borraez OA. Abdomen abierto. En: Quintero Hernández GA, Nieto JA, Lerma CH, editores. Infección en cirugía. Bogotá: Médica Panamericana; 2001. p. 230-37. 49. OzgücH, Yilrnazlar T, Gürlüler E, Ozen Y, Korun N, Zorluoéllu A. Staged abdominal repair in the treatment of intraabdominalinfection: analysis of 102 patients. J Gastrointest Surg. 2003; 7(5):646-51. 50. Biswajit M. Staged abdominal repair (STAR) operation: how I did it. Indian J Surg 2004; 66(3):182-4.
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spelling	Gómez Duque, Mariodcc2959520e96a86f93edc67dcf80a68500Uribe Guzmán, Hedda Maríae18ced60ec3e2d3c239a2889e97b9c61300Lleras Riaño, Juan David43329450c00ac577d41a8e4216c1d3de3002011-09-01 00:00:002022-06-29T19:36:21Z2011-09-012011-09-01 00:00:002022-06-29T19:36:21ZSociedad de Cirugía de Bogotá, Hospital de San José y Fundación Universitaria de Ciencias de la Saludhttps://revistas.fucsalud.edu.co/index.php/repertorio/article/view/749sepsispaciente críticoinfección intraabdominalpronósticomortalidadsepsiscritically ill patientintra-abdominal infectionprognosismortality rateCuándo operar un paciente con sepsis en estado críticoWhen to operate a septic critically ill patientapplication/pdfArtículo de revistaJournal articlehttp://purl.org/coar/resource_type/c_6501http://purl.org/coar/resource_type/c_dcae04bchttp://purl.org/coar/resource_type/c_2df8fbb1info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionTexthttp://purl.org/redcol/resource_type/ARTREVhttp://purl.org/coar/version/c_970fb48d4fbd8a8510.31260/RepertMedCir.v20.n3.2011.7490121-7372https://repositorio.fucsalud.edu.co/handle/001/27732462-991Xhttps://doi.org/10.31260/RepertMedCir.v20.n3.2011.749spaSolomkin JS, Mazuski JE. Intra-abdominal sepsis: newer interventional and antimicrobial therapies. Infect Dis Clin N Am. 2009; 23 (3): 593-608. 2. OrdoñezC, Puyana J. Management of peritonitis in the critically ill patient. Surg Clin N Am. 2006 Dec; 86 (6): 1323-49. 3. Schein M, Marshall J. Sourcecontrol forsurgical infections. World J. Surg. 2004: 28, 638-45. 4. Mazuski JE, Sawyer RG, Nathens AB, DiPiro JT, Schein M, Kudsk KA, YowlerC. Toe SurgicalInfection Society guidelines on antimicrobial therapy for intra abdominal infections: an executive summary. Surg Infect (Larchmt). 2002; 3 (3):161-73. 5. Penkoske P, Buchman TG. The relationship between the surgeon and the intensivist in the surgical intensive care unit. SurgClin N Am. 2006 Dec; 86 (6):1351-57. 6. Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen after trauma and abdominal sepsis: a strategy for management. J AmColl Surg. 2006 Sep;203(3):390-6 7. Calandra T,Cohen J. Tbe intemational sepsis forum consensus conference on definitions of infection in the intensive care unit.CritCare Med. 2005 Ju!; 33(7):1538-48. 8. Tellado JM, Christou NV, editors. Intra-abdominal infections. Madrid, Spain: Harcourt; 2000. 9. Dellinger RP, Levy MM,Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving sepsis campaign: intemational guidelines for management of severe sepsis and septic shock: 2008.CritCare Med. 2008 Jan; 36(1):296-327. 10. Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections.Clin Infect Dis. 2003; 37(8): 997-1005. 11. Malangoni MA. Current concepts in peritonitis. Curr Gastroenterol Rep. 2003 Aug; 5(4):295-30l. 12. Chromik AM, Meiser A, Holling J, Sülberg D, Daigeler A, Meurer K, et al. Identification of patients at risk for development of tertiary peritonitis on a surgical intensive care unit. J Gastrointest Surg. 2009 Ju!; 13(7): 1358-67. 13. Wittrnann DH, Schein M,CondonRE. Management of secondary peritonitis. Ann Surg. 1996 Jul; 224(1): 10-18. 14. Deitch EA. Role of the gut iymphatic system in multiple organ faiiure. Curr OpinCritCare. 2001 Apr;7(2):92-8. 15. Pinsky MR, Matuschak GM. Multiple system organ failure host defense bomeostasis.CritCareClin. 1989 Apr; 5(2):199-220 16. Larnme B, MahierCW, van Ruler O, Gouma DJ, Reitsma JB, Boermeester MA. Clinical predictors of ongoing infection in secondary peritonitis: systematicreview. World J Surg. 2006 Dec;30(12):2170-8 l. 17. Gotzinger P, Wamser P, Barlan M, Sautner T, Jakesz R, Fugger R. The surgicalconcepts of planned and on-demandreoperation in thetreatment of diffuse intra-abdorninal infection. ActaChir Austriaca. 2000; 32 (4):167-70. 18. Wittrnann DH. Intra-abdorninai infections. Introduction. World J Surg. 1990 Mar Apr; 14(2):145-7. 19. Schein M. Planned reoperations and open management in critica! intra abdominal infections: prospective experience in 52 cases. World J Surg. 1991 Jul-Aug; 15(4): 537-45. 20. Wittmann DH. Stagedabdominalrepair: development and currentpracticeof an advanced operative technique for diThse suppurative peritonitis. ActaChir Austriaca. 2000; 32(4): 171-78. 21. Wittmann DH. The colon. In: Scbeim M, Marshall JC, editors. Source control, a guide to the management surgical infections. New York: Springer - Verlag; 2003. p. 103-108. 22. Gómez M. Manejo del trauma abdominal en tópicos en cuidado intensivo. Trabajo presentado en el primer Consenso Nacional en Cuidado Intensivo; 1999 mayo 16; Cartagena de Indias, Colombia. p 136. 23. Gómez M, Cruz L, Villabón M. Hipertensión intraabdominal y síndrome compartimenta!. En: González MA. Fundamentos de medicina: paciente en estado crítico. 3a ed. Medellín: Corporación para Investigaciones Biológi cas; 2003. p. 180. 24. van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007 Aug 22; 298(8):865-72. 25. Padilla T, Fustinoni O. Síndromes clínicos en esquemas. 17' ed. Buenos Aires : El Ateneo; 2000. p. 33. 26. Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartrnent syndrome: thephysiologicaland clinical consequences of elevated intra-abdominal pressure. JAm Coll Surg. 1995 Jun;l80(6):745-53. 27. Pujol JP. Moderate hypertension defined as sustained elevation of 21-35 mmHg. Paris: U.E.R.X Bichat; 1975. 28. Gómez M, Posada C, Cruz LE. Soporte nutricional en cuidado intensivo experiencia de 4 años. Acta Colomb Cuid Int. 2001; 4(2):109. 29. Fry D. Antibiotic kinetics in febril multiple system trauma patients. In: Cunha BA, editor. lnfectius diseases in critica! care medicine. London: Informa Healthcare;20!0. p 521-35. 30. Gomez E. Trastornos en la hoemostasis de los líquidos. En: Ordoñez CA, Ferrara R, Buitrago R. Cuidado Intensivo y trauma. Bogotá: Distribuna; 2009. p 201. 31. Hutchins RR, Gunning MP, Lucas DN, Allen-Mersh TG, Soni NC. Relaparotomy for suspectedintraperitoneal sepsis after abdominal surgery. World J Surg. 2004 Feb;28(2):137-41. 32. Kopema T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg. 2000 Jan;24(1):32-7. 33. Aydin C, Aytekin FO, Yenisey C, Kabay B, Erdem E, Kocbil G. The effect of different temporary abdominalclosure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis. Langenbecks Arch Surg. 2008 Jan; 393(1):67-73. 34. Kirshtein B, Roy-Shapira A, Lantsberg L, Mizrahi S. Use of the "Bogota bag" for temporary abdominal closure in patients with secondary peritonitis.. Am Surg. 2007 Mar;73(3):249-52. 35. Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen after trauma and abdominal sepsis: a strategy for management. J Am Coll Surg. 2006 Sep;203(3):390-6. 36. Enciso Olivera CO, Guerra Urrego KA, GómezDuque M, Meneses Góngora E. Costos de atención en UCI de un hospital universitario de BogotáD. C. Repert. Med. Cir.2006; 15(3): 133-42. 37. Schoffel U. Timing of intervention. In: Schein M, Marshall JC. Source control: a guide to the management of surgicalinfections. New York: Springer Verlag;2002. p. 279-87. 38. Lamme B, Boerrneester MA, Reitsma JB, Mahler CW, Obertop H, Gouma DJ. Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg. 2002Dec; 89(12):1516-24. 39. Agalar F, Eroglu E, Bulbul M, Agalar C, Tarhan OR, Sari M. Staged abdominalrepair for treatment of moderate to severe secondary peritonitis. World J. Surg. 2005 Feb;29(2): 240-44. 40. AnayaDA, NathensAB.Riskfactorsfor severe sepsis insecondaryperitonitis. Surg lnfect (Larchmt). 2003; 4(4):355-62. 41. Van Goor H. lnterventionalmanagement ofabdominal sepsis: when and how. LangenbecksArch Surg. 2002;387(5-6): 191-200. 42. Adkins AL, Robbins J, Villalba M, Bendick P, Shanley CJ. Open abdomen management of intra-abdominal sepsis. Am Surg. 2004 Feb;70(2):137-40 43. Manejo de la peritonitis y la sepsis intraabdominal en cuidado intensivo. En: Ordoñez CA, Ferrada R, Buitrago R, editors. Cuidado intensivo y trauma. Bogotá:Distribuna; 2003. p. 667-84. 44. Rakic M, PopovicD, Rakic M, et al. Comparison of on-demand vs planned relaparotomy for treatrnent of severe intra-abdominal infections. Croat Med J 2005;46(6):956--63. 45. Sihler KC, Natbens AB. Management of severe sepsis in the surgical patient. Surg Clin NorthAm. 2006Dec;86(6):1457-81. 46. Christou NV, Barie PS,Dellinger EP, et al. Surgical lnfection Society Intra Abdominal lnfectionStudy:prospective evaluation ofmanagement techniques and outcome. Arch Surg 1993;128(2):193-8. 47. Marshall JC, Christou NV, Meakins JL. The gastro intestinal tract: the "undrained abscess" of multiple organ failure. Ann Surg.1993; 218(2):111-9. 48. Borraez OA. Abdomen abierto. En: Quintero Hernández GA, Nieto JA, Lerma CH, editores. Infección en cirugía. Bogotá: Médica Panamericana; 2001. p. 230-37. 49. OzgücH, Yilrnazlar T, Gürlüler E, Ozen Y, Korun N, Zorluoéllu A. Staged abdominal repair in the treatment of intraabdominalinfection: analysis of 102 patients. J Gastrointest Surg. 2003; 7(5):646-51. 50. Biswajit M. Staged abdominal repair (STAR) operation: how I did it. Indian J Surg 2004; 66(3):182-4.https://revistas.fucsalud.edu.co/index.php/repertorio/article/download/749/785Núm. 3 , Año 2011 : Julio – Septiembre157314320Revista Repertorio de Medicina y Cirugíainfo:eu-repo/semantics/openAccesshttps://creativecommons.org/licenses/by-nc-sa/4.0/http://purl.org/coar/access_right/c_abf2PublicationOREORE.xmltext/xml2690https://repositorio.fucsalud.edu.co/bitstreams/6c6a7243-722c-48ec-af13-248d43256152/download6fd49df56a4943d2fe26df1c68d8c4f3MD51001/2773oai:repositorio.fucsalud.edu.co:001/27732024-02-02 13:05:59.845https://creativecommons.org/licenses/by-nc-sa/4.0/metadata.onlyhttps://repositorio.fucsalud.edu.coRepositorio Digital de la Fundación Universitaria de Ciencias de la Saludredi@fucsalud.edu.co

Cuándo operar un paciente con sepsis en estado crítico

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