Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte

La identificación temprana del Síndrome de distress respiratorio agudo (SDRA) en pacientes con choque puede permitir estrategias protectoras oportunas. El agua extravascular pulmonar (EVLW) es un posible marcador de SDRA. No está claro si EVLW medida al inicio del choque identifica tempranamente los...

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Autores:
Sánchez Gálvez, Héctor Fabio
Tipo de recurso:
Fecha de publicación:
2021
Institución:
Universidad Autónoma de Bucaramanga - UNAB
Repositorio:
Repositorio UNAB
Idioma:
spa
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oai:repository.unab.edu.co:20.500.12749/14031
Acceso en línea:
http://hdl.handle.net/20.500.12749/14031
Palabra clave:
Medical sciences
Health sciences
Critical care medicine
Patient monitoring
Extravascular Lung Water
Acute Respiratory Distress Syndrome
Thermodilution
Shortness of breath
Lung diseases
Respiratory insufficiency
Ciencias médicas
Cuidados intensivos (Medicina)
Monitoreo de pacientes
Dificultad respiratoria
Enfermedades de los pulmones
Insuficiencia respiratoria
Ciencias de la salud
Síndrome de distrés respiratorio agudo
Agua pulmonar extravascular
Shock
Termodilucion
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openAccess
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http://creativecommons.org/licenses/by-nc-nd/2.5/co/
id UNAB2_85033ac3e45fa089324b1b990963e370
oai_identifier_str oai:repository.unab.edu.co:20.500.12749/14031
network_acronym_str UNAB2
network_name_str Repositorio UNAB
repository_id_str
dc.title.spa.fl_str_mv Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
dc.title.translated.spa.fl_str_mv Association between pulmonary extra-vascular water with ARDS and mortality in adult patients in circulatory shock. Cohort study
title Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
spellingShingle Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
Medical sciences
Health sciences
Critical care medicine
Patient monitoring
Extravascular Lung Water
Acute Respiratory Distress Syndrome
Thermodilution
Shortness of breath
Lung diseases
Respiratory insufficiency
Ciencias médicas
Cuidados intensivos (Medicina)
Monitoreo de pacientes
Dificultad respiratoria
Enfermedades de los pulmones
Insuficiencia respiratoria
Ciencias de la salud
Síndrome de distrés respiratorio agudo
Agua pulmonar extravascular
Shock
Termodilucion
title_short Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
title_full Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
title_fullStr Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
title_full_unstemmed Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
title_sort Asociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorte
dc.creator.fl_str_mv Sánchez Gálvez, Héctor Fabio
dc.contributor.advisor.none.fl_str_mv Meléndez Flórez, Héctor Julio
Naranjo Junoy, Francisco Fernando
dc.contributor.author.none.fl_str_mv Sánchez Gálvez, Héctor Fabio
dc.contributor.cvlac.spa.fl_str_mv Naranjo Junoy, Francisco Fernando [0000176095]
Meléndez Flórez, Héctor Julio [0000320609]
dc.contributor.orcid.spa.fl_str_mv Naranjo Junoy, Francisco Fernando [0000-0001-8628-8743]
dc.contributor.researchgate.spa.fl_str_mv Naranjo Junoy, Francisco Fernando [Francisco-Naranjo-Junoy-2075424896]
Meléndez Flórez, Héctor Julio [Hector-Florez-3]
dc.subject.keywords.spa.fl_str_mv Medical sciences
Health sciences
Critical care medicine
Patient monitoring
Extravascular Lung Water
Acute Respiratory Distress Syndrome
Thermodilution
Shortness of breath
Lung diseases
Respiratory insufficiency
topic Medical sciences
Health sciences
Critical care medicine
Patient monitoring
Extravascular Lung Water
Acute Respiratory Distress Syndrome
Thermodilution
Shortness of breath
Lung diseases
Respiratory insufficiency
Ciencias médicas
Cuidados intensivos (Medicina)
Monitoreo de pacientes
Dificultad respiratoria
Enfermedades de los pulmones
Insuficiencia respiratoria
Ciencias de la salud
Síndrome de distrés respiratorio agudo
Agua pulmonar extravascular
Shock
Termodilucion
dc.subject.lemb.spa.fl_str_mv Ciencias médicas
Cuidados intensivos (Medicina)
Monitoreo de pacientes
Dificultad respiratoria
Enfermedades de los pulmones
Insuficiencia respiratoria
dc.subject.proposal.spa.fl_str_mv Ciencias de la salud
Síndrome de distrés respiratorio agudo
Agua pulmonar extravascular
Shock
Termodilucion
description La identificación temprana del Síndrome de distress respiratorio agudo (SDRA) en pacientes con choque puede permitir estrategias protectoras oportunas. El agua extravascular pulmonar (EVLW) es un posible marcador de SDRA. No está claro si EVLW medida al inicio del choque identifica tempranamente los pacientes en riesgo de desarrollar SDRA o morir. Investigamos la asociación entre EVLW medida tempranamente con desarrollo de SDRA y mortali-dad. Objetivo: Determinar asociación entre agua extra-vascular pulmonar indexada a peso predicho (EVLWI) con SDRA y mortalidad en una cohorte de pacientes en choque. Materiales y Métodos: Estudio observacional, analítico tipo cohorte retrospectiva de 147 pacien-tes en estado de choque, ingresados a UCI de tercer nivel. El EVLW fue medida al ingreso a UCI e indexada al peso ideal (EVLWI). Sé estudió la asociación de este índice con desarrollo de SDRA y la mortalidad a 28 días. Se aplico análisis Bivariado y Multivariado así como un modelo de regresión logística para establecer la relación y fuerza de asociación entre EVLWI con SDRA y mortalidad ajustando por variables demográficas y clínicas. Se aplicó un modelo de riesgos proporcionales de Cox, donde la mortalidad en función del tiempo fue relacionada con variables independientes que fueron significativas. Resultados: Los pacientes que desarrollaron SDRA tenían valores mas altos de EVLWI, que los pacientes que no desarrollaron SDRA. (14.0 ml/kg Vs. 8.0 ml/kg respectivamente) (RR 2,66 IC 1,68 - 4,22) (p 0.00). No encontramos asociación entre EVLWI medida al inicio con mortalidad a los 28 días de egreso de la UCI (RR 1,17; IC: 0.88 - 1.56) (p 0.26). La mediana del tiempo de supervivencia general fue de 14 días (IC 95% 6,08 – 21,91). Conclusiones: El EVLWI se asoció con desarrollo de SDRA, pero no con mortalidad al día 28. Se requieren estudios prospectivos que comprueben esta asociación.
publishDate 2021
dc.date.accessioned.none.fl_str_mv 2021-08-26T16:30:14Z
dc.date.available.none.fl_str_mv 2021-08-26T16:30:14Z
dc.date.issued.none.fl_str_mv 2021
dc.type.driver.none.fl_str_mv info:eu-repo/semantics/masterThesis
dc.type.local.spa.fl_str_mv Tesis
dc.type.redcol.none.fl_str_mv http://purl.org/redcol/resource_type/TM
dc.identifier.uri.none.fl_str_mv http://hdl.handle.net/20.500.12749/14031
dc.identifier.instname.spa.fl_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
dc.identifier.reponame.spa.fl_str_mv reponame:Repositorio Institucional UNAB
dc.identifier.repourl.spa.fl_str_mv repourl:https://repository.unab.edu.co
url http://hdl.handle.net/20.500.12749/14031
identifier_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
reponame:Repositorio Institucional UNAB
repourl:https://repository.unab.edu.co
dc.language.iso.spa.fl_str_mv spa
language spa
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9. Mallat J., Pepy F., Lemyze M., et al. (2012) Extravascular lung water indexed or not to predicted body weight is a predictor of mortality in septic shock patients. J Crit Care; 27: 376 - 383. DOI: 10.1016/j.jcrc.2012.03.009
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38. Goepfert M., Reuter D., Akyol D., Lamm P., Kilger E,. Goetz A. , (2007) Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients. Intensive Care Med; 33: 96–103
39. Bognar Z., Foldi V., Rezman B., Bogar L., Csontos C., (2010) Extravascular lung water index as a sign of developing sepsis in burns. BURNS; 36: 1263 - 1270
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41. Monnet X., Teboul J.L., (2017) Transpulmonary thermodilution: advantages and limits. Crit Care; 21: 147. DOI 10.1186/s13054-017-1739-5
42. Cecconi M., De Backer D., Antonelli M., et al; (2014) Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med (2014) 40:1795–1815
43. Kuzkov V., Mikhail Y., et al; (2006) Extravascular lung water determined with single transpulmonary thermodilution correlates with the severity of sepsis-induced acute lung injury. Crit Care Med 2006; 34:1647–1653
44. Fu-Tsai Chung., Chung-Shu Lee., et al; (2017) Alveolar recruitment maneuver attenuates extravascular lung water in acute respiratory distress syndrome. Medicine (2017) 96:30(e7627)
45. Wang Weiyi., Xu Ning., et al; (2019) Changes of Extravascular Lung Water as an Independent Prognostic Factor for Early Developed ARDS in Severely Burned Patients. Journal of Burn Care & Research 2019; 41 (2): 403 – 408
46. Pan Pan., Xiang Long., et al; (2019) Critical hemodynamic therapy oriented resuscitation helping reduce lung water production and improve survival. Chinese Medical Journal 2019;132(10)
47. Tagami Takashi., Hock on Marcus., (2018) Extravascular lung water measurements in acute respiratory distress syndrome: why, how, and when?. Curr Opin Crit Care 2018, 24:209–215
48. Vignon Philippe., Evrard Bruno., et al; (2020) Fluid administration and monitoring in ARDS: which management? Intensive care med 2020, doi.org/10.1007/s00134-020-063100
49. Huber W, Findeisen M, Lahmer T, Herner A, Rasch S, Mayr U, et al. (2020) Prediction of outcome in patients with ARDS: A prospective cohort study comparing ARDS-definitions and other ARDS-associated parameters, ratios and scores at intubation and over time. PLoS ONE 15 (5): e0232720. https://doi.org/10.1371/journal. pone.0232720
50. Rasch Sebastian Rasch., Schmidle Paul., et al; (2021) Increased extravascular lung water index (EVLWI) reflects rapid non‐cardiogenic edema and mortality in COVID‐19 associated ARDS. Scientific Reports (2021) 11:11524. doi.org/10.1038/s41598-021-91043-3
51. Shi Rui., Lai Christopher., et al; (2021) COVID-19 ARDS is characterized by higher extravascular lung water than non-COVID-19 ARDS: the PiCCOVID study. Crit Care (2021) 25:186. doi.org/10.1186/s13054-021-03594-6
52. Beurton Alexandra., Teboul Jean-Louis., Monnet Xavier., (2021) Transpulmonary thermodilution techniques in the hemodynamically unstable patient. Curr Opin Crit Care 2019, 25:273 – 279. DOI:10.1097/MCC.0000000000000608
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dc.publisher.grantor.spa.fl_str_mv Universidad Autónoma de Bucaramanga UNAB
dc.publisher.faculty.spa.fl_str_mv Facultad Ciencias de la Salud
dc.publisher.program.spa.fl_str_mv Especialización en Medicina Crítica y Cuidado Intensivo del Adulto
institution Universidad Autónoma de Bucaramanga - UNAB
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spelling Meléndez Flórez, Héctor JulioNaranjo Junoy, Francisco FernandoSánchez Gálvez, Héctor FabioNaranjo Junoy, Francisco Fernando [0000176095]Meléndez Flórez, Héctor Julio [0000320609]Naranjo Junoy, Francisco Fernando [0000-0001-8628-8743]Naranjo Junoy, Francisco Fernando [Francisco-Naranjo-Junoy-2075424896]Meléndez Flórez, Héctor Julio [Hector-Florez-3]Colombia2021-08-26T16:30:14Z2021-08-26T16:30:14Z2021http://hdl.handle.net/20.500.12749/14031instname:Universidad Autónoma de Bucaramanga - UNABreponame:Repositorio Institucional UNABrepourl:https://repository.unab.edu.coLa identificación temprana del Síndrome de distress respiratorio agudo (SDRA) en pacientes con choque puede permitir estrategias protectoras oportunas. El agua extravascular pulmonar (EVLW) es un posible marcador de SDRA. No está claro si EVLW medida al inicio del choque identifica tempranamente los pacientes en riesgo de desarrollar SDRA o morir. Investigamos la asociación entre EVLW medida tempranamente con desarrollo de SDRA y mortali-dad. Objetivo: Determinar asociación entre agua extra-vascular pulmonar indexada a peso predicho (EVLWI) con SDRA y mortalidad en una cohorte de pacientes en choque. Materiales y Métodos: Estudio observacional, analítico tipo cohorte retrospectiva de 147 pacien-tes en estado de choque, ingresados a UCI de tercer nivel. El EVLW fue medida al ingreso a UCI e indexada al peso ideal (EVLWI). Sé estudió la asociación de este índice con desarrollo de SDRA y la mortalidad a 28 días. Se aplico análisis Bivariado y Multivariado así como un modelo de regresión logística para establecer la relación y fuerza de asociación entre EVLWI con SDRA y mortalidad ajustando por variables demográficas y clínicas. Se aplicó un modelo de riesgos proporcionales de Cox, donde la mortalidad en función del tiempo fue relacionada con variables independientes que fueron significativas. Resultados: Los pacientes que desarrollaron SDRA tenían valores mas altos de EVLWI, que los pacientes que no desarrollaron SDRA. (14.0 ml/kg Vs. 8.0 ml/kg respectivamente) (RR 2,66 IC 1,68 - 4,22) (p 0.00). No encontramos asociación entre EVLWI medida al inicio con mortalidad a los 28 días de egreso de la UCI (RR 1,17; IC: 0.88 - 1.56) (p 0.26). La mediana del tiempo de supervivencia general fue de 14 días (IC 95% 6,08 – 21,91). Conclusiones: El EVLWI se asoció con desarrollo de SDRA, pero no con mortalidad al día 28. Se requieren estudios prospectivos que comprueben esta asociación.I. INTRODUCCION 9 II. PLANTEAMIENTO DEL PROBLEMA 10 III. PREGUNTAS DE INVESTIGACION 17 IV. HIPOTESIS DE TRABAJO 17 V. MARCO TEORICO Y ESTADO DEL ARTE 17 V.1. Síndrome de Distress Respiratorio Agudo 17 V.1.1. Etiología 19 V.1.2. Fisiopatologia 19 V.1.3. Tratamiento 21 a. Ventilación protectora pulmonar 21 b. Fluidoterapia 22 c. Ventilación mecánica en prono 22 V.2. Los estados de choque 23 V.2.1. Clasificación 24 V.3. Agua Extravascular Pulmonar 24 V.4. Termodilucion Transpulmonar 29 VI. JUSTIFICACION 30 VII. OBJETIVOS 30 VII.1. Objetivo General 30 VII.2. Objetivos específicos 30 VIII. METODOLOGIA 30 VIII.1.Tipo de estudio 30 VIII.2.Población a estudio 30 VIII.3. Tamaño de la muestra 31 VIII.4.Criterios de inclusión 31 VIII.5.Criterios de exclusión 31 VIII.6.Variables de estudio 32 VIII.7. Fuentes y ttécnicas de recolección de datos 32 VIII.8. Control de sesgos 33 IX. ASPECTOS ETICOS Y LEGALES 33 X. ANALISIS ESTADISTICO 35 X.1. Características generales o Análisis Univariado 35 X.2. Análisis comparativo o Bivariado 35 X.3. Análisis multivariado 35 X.4. Análisis de supervivencia regresion de Cox 35 XI. RESULTADOS 37 Características Generales 37 XI.1 Características generales y clinicas 37 XI.2. SDRA según EVLWI y variables clínicas 43 XI.3. Análisis de Mortalidad 44 XI.3. 1 Mortalidad, EVLWI y SDRA 44 XI.3. 2 Análisis entre Mortalidad, SDRA y EVLWI 45 XI.3. 3 Análisis de supervivencia a 28 días y regresión de Cox para mortalidad 46 XII. DISCUSION 50 XIII. CONCLUSIONES 56 XIV. DIVULGACION Y SOCIALIZACION 56 XV. ALCANCE DEL TRABAJO DE GRADO 56 XVI. BIBLIOGRAFÍA 57 XVII ANEXOS 62EspecializaciónThe early identification of Acute Respiratory Distress Syndrome (ARDS) in patients with shock may allow timely protective strategies. Extravascular pulmonary water (EVLW) is a possible marker for ARDS. It is not clear whether EVLW measured at onset of shock identifies patients at risk of developing ARDS or dying early. We investigated the association between EVLW measured early with the development of ARDS and mortality. Objective: To determine the association between extra-vascular pulmonary water indexed to predicted weight (EVLWI) with ARDS and mortality in a cohort of patients in shock. Materials and Methods: Observational, analytical, retrospective cohort-type study of 147 patients in shock, admitted to third-level ICU. EVLW was measured at ICU admission and indexed to ideal weight (EVLWI). The association of this index with the development of ARDS and 28-day mortality was studied. Bivariate and multivariate analysis was applied, as well as a logistic regression model to establish the relationship and strength of association between EVLWI with ARDS and mortality, adjusting for demographic and clinical variables. A Cox proportional hazards model was applied, where mortality as a function of time was related to independent variables that were significant. Results: The patients who developed ARDS had higher EVLWI values ​​than the patients who did not develop ARDS. (14.0 ml / kg Vs. 8.0 ml / kg respectively) (RR 2.66 CI 1.68 - 4.22) (p 0.00). We found no association between EVLWI measured at baseline with mortality 28 days after discharge from the ICU (RR 1.17; CI: 0.88 - 1.56) (p 0.26). The median overall survival time was 14 days (95% CI 6.08-21.91). Conclusions: EVLWI was associated with the development of ARDS, but not with mortality at day 28. Prospective studies are required to verify this association.application/pdfspahttp://creativecommons.org/licenses/by-nc-nd/2.5/co/Abierto (Texto Completo)info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2Atribución-NoComercial-SinDerivadas 2.5 ColombiaAsociación entre agua extra-vascular pulmonar con Sdra y mortalidad en pacientes adultos en choque circulatorio. Estudio de cohorteAssociation between pulmonary extra-vascular water with ARDS and mortality in adult patients in circulatory shock. Cohort studyEspecialista en Medicina Crítica y Cuidado Intensivo del AdultoUniversidad Autónoma de Bucaramanga UNABFacultad Ciencias de la SaludEspecialización en Medicina Crítica y Cuidado Intensivo del Adultoinfo:eu-repo/semantics/masterThesisTesishttp://purl.org/redcol/resource_type/TMMedical sciencesHealth sciencesCritical care medicinePatient monitoringExtravascular Lung WaterAcute Respiratory Distress SyndromeThermodilutionShortness of breathLung diseasesRespiratory insufficiencyCiencias médicasCuidados intensivos (Medicina)Monitoreo de pacientesDificultad respiratoriaEnfermedades de los pulmonesInsuficiencia respiratoriaCiencias de la saludSíndrome de distrés respiratorio agudoAgua pulmonar extravascularShockTermodilucion1. Matthay M.A., Ware L.B., Zimmerman G.A. (2012).The acute respiratory distress syndrome. J Clin Invest; 122 (8): 2731-2740. DOI 10.1172/JCI603312. Ware L.B, Matthay M.A. (2000). The acute respiratory distress syndrome. NEJM; 342 (18): 1334 - 1349.3. 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DOI:10.1097/MCC.0000000000000608ORIGINAL2021_Tesis_Hector_Fabio_Sanchez.pdf2021_Tesis_Hector_Fabio_Sanchez.pdfTesisapplication/pdf2718495https://repository.unab.edu.co/bitstream/20.500.12749/14031/1/2021_Tesis_Hector_Fabio_Sanchez.pdf09e31bb6961cfc82086f368e5892d402MD51open access2021_Licencia_Hector_Fabio_Sanchez.pdf2021_Licencia_Hector_Fabio_Sanchez.pdfLicenciaapplication/pdf65511https://repository.unab.edu.co/bitstream/20.500.12749/14031/2/2021_Licencia_Hector_Fabio_Sanchez.pdf8f47573f6928ed709b805fda6ac3b4c0MD52metadata only accessLICENSElicense.txtlicense.txttext/plain; charset=utf-81748https://repository.unab.edu.co/bitstream/20.500.12749/14031/3/license.txt8a4605be74aa9ea9d79846c1fba20a33MD53open accessTHUMBNAIL2021_Tesis_Hector_Fabio_Sanchez.pdf.jpg2021_Tesis_Hector_Fabio_Sanchez.pdf.jpgIM Thumbnailimage/jpeg7970https://repository.unab.edu.co/bitstream/20.500.12749/14031/4/2021_Tesis_Hector_Fabio_Sanchez.pdf.jpgd7e7a02c9243e6260c142e3bef5b3f92MD54open access2021_Licencia_Hector_Fabio_Sanchez.pdf.jpg2021_Licencia_Hector_Fabio_Sanchez.pdf.jpgIM Thumbnailimage/jpeg8186https://repository.unab.edu.co/bitstream/20.500.12749/14031/5/2021_Licencia_Hector_Fabio_Sanchez.pdf.jpgb61ace217f708fa65b258f342861d831MD55metadata only access20.500.12749/14031oai:repository.unab.edu.co:20.500.12749/140312021-08-26 18:01:53.06open accessRepositorio Institucional | Universidad Autónoma de Bucaramanga - UNABrepositorio@unab.edu.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