Conceptos Categóricos

LOS MITOS EN TORNO DE LA RELACION ENTRE PRESION SANGUINEA Y FLUJO

LOS MITOS EN TORNO DE LA RELACION ENTRE PRESION SANGUINEA Y FLUJO

(especial para SIIC © Derechos reservados)
Esta revisión pone de manifiesto la importancia del tratamiento de la hipotensión teniendo en cuenta los diferentes mecanismos implicados en su fisiopatología y el papel del tratamiento con vasopresores, cuya administración, en algunos casos, podría ser perjudicial.  
Autor:
Peter Roessler
Columnista Experto de SIIC

Institución:
Windsor Private Hospital


Artículos publicados por Peter Roessler
Recepción del artículo
28 de Junio, 2017
Aprobación
1 de Diciembre, 2017
Primera edición
15 de Diciembre, 2017
Segunda edición, ampliada y corregida
5 de Junio, 2018

Resumen
La hipotensión asociada con la vasodilatación inducida por el uso de agentes anestésicos es muy frecuente, un fenómeno que ha motivado la utilización casi generalizada de vasopresores, con la finalidad de restaurar la presión sanguínea a los niveles registrados antes de la anestesia. En Australia, entre todas las medicaciones que se usan en la anestesia, el costo de los vasopresores es un factor significativo en los costos de los sistemas de salud. La utilización de vasopresores debe basarse en los posibles beneficios y riesgos asociados. Desde hace tiempo se acepta que la presión arterial debe mantenerse con la finalidad de preservar la perfusión. Sin embargo, la evaluación detallada indica que este concepto podría surgir de la interpretación errónea de las leyes básicas de la física, como las leyes de Newton y de Ohm. En este trabajo se propone, en función de los principios de la física, que sólo las fuerzas pueden motivar el aceleramiento de los objetos. Para que la presión sea un conductor del flujo, debería ser una fuerza. Sin embargo, la presión es el resultado de fuerzas que actúan sobre una superficie determinada y, por ende, no representa en sí misma una fuerza y no puede ser un conductor de flujo. El flujo sanguíneo es resultado del equilibrio entre las fuerzas de propulsión y de resistencia; en este contexto se debe reconsiderar el supuesto beneficio de aumentar las fuerzas de resistencia, un fenómeno que, en realidad, motivará una reducción del flujo. En el estudio se cuestiona el uso de vasopresores, como también la relación básica, ampliamente aceptada, entre la presión sanguínea y el flujo sanguíneo.

Palabras clave
presión arterial, flujo sanguíneo, vasopresores, perfusión, hipotensión, vasodilatación, anestésicos


Artículo completo

(castellano)
Extensión:  +/-9.44 páginas impresas en papel A4
Exclusivo para suscriptores/assinantes

Abstract
Hypotension resulting from vasodilatation associated with administration of anaesthetic agents is very common. This has resulted in the almost ubiquitous use of vasopressors with a view to restoring blood pressure to pre-anaesthesia levels. In Australia, of all the medications used in anaesthesia, the cost of vasopressors is a significant factor in contributing to healthcare costs. The rationale for use of vasopressors warrants consideration with regard to their benefits as well as potential harm arising from their use. It has long been accepted that blood pressure needs to be maintained in order to maintain perfusion. However, on close scrutiny such thinking may simply be a misinterpretation of the basic laws of physics with respect to both Newton’s laws and Ohm’s law. This article develops the physics-based argument that only forces can cause objects to accelerate. For pressure to be a driver of flow it must therefore be a force. However, pressure is the result of forces acting over an area, and consequently is not a force in itself. Therefore, it cannot be a driver of flow. Blood flow is the result of the balance of propulsive and resistive forces, which raises the question as to the benefit of increasing resistive forces, which in fact will reduce flow. The use of vasopressors is challenged in this article as is the basic accepted relationship between blood pressure and blood flow.

Key words
hypotension, blood pressure, blood flow, vasopressors, perfusion, vasodilatation, anaesthetics


Full text
(english)
para suscriptores/ assinantes

Clasificación en siicsalud
Artículos originales > Expertos del Mundo >
página   www.siicsalud.com/des/expertocompleto.php/

Especialidades
Principal: AnestesiologíaCuidados Intensivos
  Relacionadas: Cardiología,  Educación Médica,  Emergentología,  Farmacología,  Medicina Farmacéutica



Comprar este artículo
Extensión: 9.44 páginas impresas en papel A4

file05.gif (1491 bytes) Artículos seleccionados para su compra



Enviar correspondencia a:
Peter Roessler, 20 The Avenue, Windsor, Australia
Bibliografía del artículo
1. Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal perioperative management of arterial blood pressure. Integrated Blood Pressure Control 7:49-59, 2014.
2. Bijker JB, Van Klei WA, Kappen TH, Van Wolfswinkel L, Moons KG, Kalkman CJ. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anaesthesiology 107(2):213-220. 2007
3. Klohr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal anaesthesia for caesarian section: literature search and application to parturients. Acta Anaesthesiaol Scand 54(8):909-921, 2010.
4. Sivertsson R. Effect of blood pressure reduction on tissue perfusion. Journal of Internal Medicine 205(S628):13-16, 1979.
5. Dubin A, Pozo MO, Casabella CA, Palizas Jr F, Murias G, Moseinco MC, Edul VSK, Palizas F, Estenssoro E, Ince C. Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care 13(3):R92, 2009.
6. Currigan DA, Hughes RJA, Wright CE, Angus JA, Doeding PF. Vasoconstrictor responses to vasopressor agents in human pulmonary and radial arteries. Anaesthesiology 121(5):930-936, 2014.
7. Meng L, Tran NP, Alexander BS, Laniing K, Chen G, Kain ZN, Cannesson M. The impact of phenylephrine, ephedrine, and increased preload on third-generation vigileo-flo trac and esophageal Doppler cardiac output measurements. Anaesthesia & Analgesia 113(4):751-757, 2011.
8. Moore C, Dobson A, Kinagi M, Dillon B. Comparison of blood pressure measured at the arm, ankle, and calf. Anaesthesia 63(12):1327-3131, 2008.
9. Hulin I, Kinova S, Paulis L, Slavkovsky P, Duris I, Mravec B. Diastolic blood pressure as a major determinant of tissue perfusion: potential clinical consequences.Bratisl. Lek Listy 111(1):54-56, 2010.
10. Sivertsson R. Effects of blood pressure reduction on tissue perfusion. Journal of Internal Medicine 205:13-16, 1979.
11. Parati G, Di Rienzo M, Omboni S, Ulian L, Mancia G. Blood pressure variability over 24 hours: its different components and its relationship to the arterial baroreflex. J Sleep Res 4(Suppl 1):21-29, 1995.
12. Raven PB, Chapleau MW. Blood pressure regulation xi: overview and future research directions. Eur J Appl Physiol 114(3):579-586, 2014.
13. Johnson PC. Autoregulation of Blood flow. Circulation Research 59(5):483-495, 1986.
14. Langfitt TW et al (eds). Cerebral circulation and metabolism. New Yor, Berlin, Heidelberg, Springer-Verlag, pp. 3-6, 1975.
15. Cupples WA, Braam B. Asessment of renal autoregulation. Am J Renal Physiol 292;F1105-F1123, 2007.
16. Schubert RW, Whalen WJ, Nair P. Myocardial PO2 distribution: Relationship to coronary autoregulation. Am J Physiol 234:361-370, 1978.
17. Ekstrom-Jodal B. On the relation between blood pressure and blood flow in the canine brain with particular regard to the mechanism responsible for cerebral blood flow autoregulation. Acta Physiol Scand (Suppl) 350:1-61, 1970.
18. Dunser MW, Takala J, Brunauer A, Bakker J. Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach. Critical Care 17:326-331, 2013.
19. Levy M. The cardiac and vascular factors that determine systemic blood flow. Circ Research 44(6):739-747, 1979.
20. Peterson LH. The dynamics of pulsatile blood flow. Circ Res 2(2):127-139, 1954.
21. Pinsky MR. The right ventricle: interaction with the pulmonary circulation. Crit Care 20:266-274, 2016.
22. Minners J, Allgeier M, Gohlke-Baerwolf D, Kienzle RP, Neumann FJ, Jander N. Inconsistencies of echocardiographic criteria for the grading of aortic vlave stenosis. Eur Heart J 29:1043-1048, 2008.
23. Henderson WR, Griesdale DEG, Walley KR, Sheel AW. Clinical review: Guyton - the role of mean circulatory filling pressure and right atrial pressure in controlling cardiac output. Crit Care 14(6):243-248, 2010.
24. Daniels JW, Mole PA, Shaffrath JD, Stebbins CL. Effects of caffeine on blood pressure, heart rate, and forearm blood flowduring dynamic leg exercises. J Appl Physiol 85(1):154-159, 1998.
25. Cardoso Jr CG, Gomides RS, Quieroz ACC, Pinto LG, Lobo FS, Tinucci T, Mion Jr D, Forjaz CLM. Acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure. Clinics 65(3);317-325, 2010.
26. Pescatello LS, Fargo AE, Leach Jr CN, Scherzer HH. Short-term effect of dynamic exercise on arterial blood pressure. Circulation 83(5):1557-1561, 1991.
27. Mette SO, Ottesen JT, Tran HT, Ellwien LM, Lipsitz LA, Novak V. Blood pressure and blood flow cariation during postural change from sitting to standing: model development and validation. J Appl Phsiol 99(4):1523-1537, 2005.
28. Raven PB, Chapleau MW. Blood pressure regulation X!: Overview and future research directions. Eur J Appl Physiol 114(3):579-586, 2014.
29. Lindop MJ. Complications and morbidity of controlled hypotension. BJA 47:799-803, 1975.
30. Enderby GEH. A report on mortality and morbidity following 9,107 hypotensive anaesthetics. BJA 33:109-113, 1961.
31. Monk TG, Bronsert MR, Henderson WG, Mangione MP, Sum-Ping STJ, Bentt DR, Nguyen JD, Richman JS, Meguid RA, Hammermeister KE. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anaesthesiology 123(2):307-319, 2015.
32. Walsh M, Devereaux PJ, Garg AX, Kurz A, Turan A, Rodseth RN, Cywinski J, Thabane L, Sessler DI. Relationship between intraoperativee mean arterial pressure and clinical outomes after noncardiac surgery. Toward an empirical definition of hypotension. Anaesthesiology 119(3):507-515, 2013.
33. Semat H. Physics, Chapter 9: Hydrodynamics (Fluids in Motion). Robert Katz Publications 143:165-180, 1958.
34. Fry DL. Acute vascular endothelial changes associated with increased velocity gradients. Circulation Research 22:165-197, 1968.
35. Limburg M, Wijdicks EFM, Li H. Ischaemic stroke after surgical procedures. Neurology 50(4):895-901, 1998.
36. Steen PA, Tinker JH, Tarhan S. Myocardial reinfarction after anehsthesia and surgery. JAMA 239(24):2566-2570, 1978.
37. Abuelo JG. Mormotensive ischaemic acute renal failure. NEJM 357(8):797-805, 2007.
38. Fodale V, Santamaria LB, Schifilliti D, Mandal PK. Anaesthetics and postoperative cognitive dysfunction: a pathological mechanism mimicking Alzheimer's disease. Anaesthesia 65:388-395, 2010.
39. Kam PCA, Calcroft RM. Peri-operative stroke in general surgical patients. Anaesthesia 25;879-883, 1997.
40. Hirsch J, DePalma G, Tsai TT, Sands LP, Leung JM. Impact of intraoperative hypotension and blood pressure fluctuations on early postoperative delirium after non-cardica surgery. BJA 115(3):418-426, 2015.
41. Selim M. Perioperative stroke. NEJM 356(7):706-713, 2007.
42. Thiele RH, Nemergut EC, Lynch C. The clinical implications of isolated alpha(1) adrenergic stimulation. Anaesth Analg 113(2):297-304, 2011.
43. Mets B. Should norepinephrine, rather than phenylephrine, be considered the primary vasopressor in anaesthetic practice? Anaesth Analg 122(5):1707-1714, 2016.
44. Cho SY, Kim SJ, Jeong CW, Jeong CY, Chung SS, Lee J, Yoo KY. Under gerneal anaesthesia arginine vasopressin prevents hypotension but impairs cerebral oxygenation during arthroscopic shoulder surgery in the beach chair position. Anaesth Analg 117(6):1436-1443, 2013.
45. Abrahams J. Mechanisms of action of the organic nitrates in the treatment of myocardial ischaemia. Am J Cardiol 70(8):B30-B42, 1992.
46. Carabello BA. Georg Ohm and the changing character of aortic stenosis, it's not your grandfather's Oldsmobile. Circulation 125:2295-2297, 2012.

 
 
 
 
 
 
 
 
 
 
 
 
Está expresamente prohibida la redistribución y la redifusión de todo o parte de los contenidos de la Sociedad Iberoamericana de Información Científica (SIIC) S.A. sin previo y expreso consentimiento de SIIC.
ua31618