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    "textoCompleto" => "<p class="elsevierStylePara">EVOLUCION DE LA PARADA CARDIORRESPIRATORIA</p><p class="elsevierStylePara">Se considera &#34;muerte s&#250;bita&#34;&#44; lo que se conoce como parada cardiorrespiratoria &#40;PCR&#41;&#44; aquellas muertes inesperadas que ocurren de manera aguda&#44; en un per&#237;odo breve&#44; generalmente en minutos desde el inicio de los s&#237;ntomas&#46;</p><p class="elsevierStylePara">La supervivencia de una PCR extrahospitalaria puede oscilar entre 1&#44;4&#37; en Nueva York<span class="elsevierStyleSup">1</span> y un 38&#37;<span class="elsevierStyleSup">2</span>&#46; En nuestro pa&#237;s&#44; en la reciente tesis de &#193;lvarez<span class="elsevierStyleSup">3</span> que revisa los resultados de 3&#46;642 PCR en las que se inici&#243; reanimaci&#243;n cardiopulmonar &#40;RCP&#41; recogidas en publicaciones entre 1987 y 1999&#44; la supervivencia al alta hospitalaria fue del 10&#44;1&#37; en PCR extrahospitalarias&#46; Respecto a las PCR intrahospitalarias tambi&#233;n hay una gran dispersi&#243;n de los resultados&#44; que oscilan entre el 0&#37;<span class="elsevierStyleSup">4</span> y el 35&#37;<span class="elsevierStyleSup">5</span> de supervivencia&#46; Las causas de estas variaciones no se deben s&#243;lo a diferencias en el tratamiento de estos pacientes&#44; sino a que se comparan poblaciones diferentes&#44; PCR que ocurren en unidades muy distintas del hospital&#44; etc&#46;&#44; por lo que los resultados globales&#44; sin estratificar&#44; no nos permiten sacar conclusiones en muchas ocasiones&#46; Ballew y Philbrick<span class="elsevierStyleSup">6</span> realizaron una excelente revisi&#243;n de 68 publicaciones sobre las diferencias que exist&#237;an en la forma de recoger las PCR intrahospitalarias y la inutilidad de comparar los datos globales&#46; La &#250;nica forma de comparar casu&#237;sticas es mediante un registro uniforme que permita homogeneizar las posibles variables que pueden darse en la RCP de las PCR&#44; como los propuestos en los consensos de Utstein<span class="elsevierStyleSup">7&#44;8</span>&#46;</p><p class="elsevierStylePara"> Otra dificultad que se presenta al comparar estudios es la variable &#40;<span class="elsevierStyleItalic">end-point</span>&#41; a considerar para determinar que una determinada medida es beneficiosa o no&#59; se han recomendado actuaciones terap&#233;uticas s&#243;lo por conseguir que m&#225;s pacientes con PCR ingresen con vida en el hospital aunque no haya diferencias en la supervivencia al alta hospitalaria<span class="elsevierStyleSup">9&#44;10</span>&#46;</p><p class="elsevierStylePara"> Pocos estudios analizan la recuperaci&#243;n funcional neurol&#243;gica tras una PCR en los pacientes que son dados de alta del hospital&#44; a pesar de que la recuperaci&#243;n de una buena funci&#243;n neurol&#243;gica al alta se considera el patr&#243;n oro a conseguir con las maniobras de RCP<span class="elsevierStyleSup">11&#44;12</span>&#46; En las Recomendaciones 2000&#44; se analizaron 20 publicaciones valorables encontradas en una b&#250;squeda en MEDLINE &#40;1989-1999&#41; que midieran la proporci&#243;n de pacientes con PCR extrahospitalarias que eran dados de alta del hospital con buena o s&#243;lo moderada alteraci&#243;n de la funci&#243;n neurol&#243;gica&#59; en total fueron 25&#46;805 pacientes con PCR&#44; y se encontr&#243; que eran s&#243;lo el 5&#44;5&#37; de los pacientes<span class="elsevierStyleSup">12</span>&#46; De los pacientes que sobreviven a una PCR extrahospitalaria y son dados de alta del hospital&#44; entre el 4 y el 12&#37; quedan con afecci&#243;n neurol&#243;gica grave o coma<span class="elsevierStyleSup">13&#44;14</span>&#46; Publicaciones m&#225;s antiguas refieren resultados peores con un 18&#37; de pacientes en coma<span class="elsevierStyleSup">15</span> y un 24&#37; de los pacientes en coma&#44; estado vegetativo persistente &#40;EVP&#41; o alteraciones neurol&#243;gicas importantes<span class="elsevierStyleSup">16</span>&#46; En un hospital espa&#241;ol&#44; el 7&#44;8&#37; de los pacientes &#40;10&#47;128 pacientes&#41; que pudieron ser dados de alta del hospital qued&#243; con deficiencias neurol&#243;gicas muy invalidantes&#44; entre ellas en EVP<span class="elsevierStyleSup">17</span>&#46;</p><p class="elsevierStylePara">Por &#250;ltimo&#44; incluso los estudios que analizan la funci&#243;n neurol&#243;gica al alta no suelen citar la proporci&#243;n de pacientes con EVP&#59; la mayor&#237;a de estos pacientes se engloban entre los que fallecen sin ser dados de alta del hospital o han quedado con afecci&#243;n neurol&#243;gica grave&#46; Para la presente revisi&#243;n se ha efectuado una b&#250;squeda de publicaciones desde 1980 hasta la actualidad en MEDLINE mediante los t&#233;rminos <span class="elsevierStyleItalic">cardiopulmonary resuscitation OR cardiac arrest AND vegetative state</span>&#44; en adultos&#46; S&#243;lo 3 de las 43 publicaciones encontradas eran series de enfermos con PCR en las que se indicaba expresamente el porcentaje de pacientes que quedaba en estado vegetativo<span class="elsevierStyleSup">18-20</span>&#46; En estas series &#40;una de las publicaciones es un metaan&#225;lisis de 98 series previas<span class="elsevierStyleSup">18</span>&#41; la incidencia de EVP es inferior al 14&#37;<span class="elsevierStyleSup">19&#44;20</span>&#46;</p><p class="elsevierStylePara"> M&#201;TODO</p><p class="elsevierStylePara">En la presente revisi&#243;n se analizan los aspectos de la RCP de los que hay evidencia cient&#237;fica en cuanto a que mejoran la supervivencia de la PCR&#46; Para ello se ha utilizado la bibliograf&#237;a analizada en las Recomendaciones 2000 para RCP y cuidados cardiovasculares de urgencia&#44; publicadas simult&#225;neamente en <span class="elsevierStyleItalic">Circulation</span> y <span class="elsevierStyleItalic">Resuscitation</span> en agosto 2000<span class="elsevierStyleSup">11</span>&#46; Estas recomendaciones son el resultado de una revisi&#243;n exhaustiva de toda la evidencia cient&#237;fica en reanimaci&#243;n publicada en los &#250;ltimos a&#241;os mediante una rigurosa metodolog&#237;a&#44; con valoraci&#243;n del grado de evidencia tras un an&#225;lisis de la calidad de cada publicaci&#243;n de acuerdo con unos criterios previamente consensuados<span class="elsevierStyleSup">11</span> &#40;tablas 1 y 2&#41; y que son los mismos que se han utilizado en esta revisi&#243;n&#44; tanto en el an&#225;lisis de los estudios revisados en las Recomendaciones 2000 como en la revisi&#243;n de los estudios publicados con posterioridad&#44; con el fin de mantener una uniformidad&#46;</p><p class="elsevierStylePara"><img src="64v28n03-13060074tab01.gif"></img></p><p class="elsevierStylePara"><img src="64v28n03-13060074tab02.gif"></img></p><p class="elsevierStylePara">Al no existir pr&#225;cticamente estudios que analicen la utilidad de las maniobras de RCP en relaci&#243;n con la repercusi&#243;n neurol&#243;gica&#44; para la revisi&#243;n de los estudios analizados se consider&#243; que las maniobras de RCP de las que hay evidencia que salvan m&#225;s vida tienen tambi&#233;n m&#225;s posibilidades de recuperar m&#225;s enfermos con buena funci&#243;n neurol&#243;gica&#44; como han demostrado algunos estudios que muestran que la capacidad funcional de los enfermos recuperados tras la RCP se relaciona con la calidad de la RCP&#44; posiblemente por reducir la isquemia cerebral durante la PRC &#40;menos tiempo de isquemia y mejor perfusi&#243;n cerebral durante la RCP y los primeros momentos de recuperaci&#243;n de la circulaci&#243;n espont&#225;nea &#91;ROSC&#93;&#44; etc&#46;&#41;<span class="elsevierStyleSup">2&#44;21-23</span>&#46;</p><p class="elsevierStylePara">FACTORES PREDICTIVOS DE SUPERVIVENCIA</p><p class="elsevierStylePara">Hay evidencia acerca de que la PCR presenciada tiene m&#225;s posibilidades de supervivencia que la que ocurre sin que haya alg&#250;n testigo presencial<span class="elsevierStyleSup">13&#44;24-28</span>&#44; al tener m&#225;s posibilidades de recibir antes asistencia especializada &#173;el testigo avisa a un sistema de emergencias m&#233;dicas &#40;SEM&#41;&#173; y de que el testigo inicie maniobras de RCP &#40;lo que consigue retrasar el deterioro mioc&#225;rdico y cerebral&#41; &#40;nivel evidencia 4&#58; clase IIb&#41;&#46;</p><p class="elsevierStylePara">Inicio de las maniobras de reanimaci&#243;n cardiopulmonar por parte de los testigos de la parada cardiorrespiratoria</p><p class="elsevierStylePara">Se dispone de evidencia de que si los testigos de la PCR inician maniobras de RCP mientras llega el SME&#44; la supervivencia es mayor por que se mantiene m&#225;s tiempo a la v&#237;ctima con perfusi&#243;n mioc&#225;rdica y cerebral mientras se espera la realizaci&#243;n del tratamiento resolutivo de la PRC<span class="elsevierStyleSup">13&#44;25&#44;26&#44;29-32</span>&#46;</p><p class="elsevierStylePara">Las diferencias observadas en la supervivencia en estudios de regresi&#243;n log&#237;stica pueden variar entre un 6 y un 10&#37; con unas <span class="elsevierStyleItalic">odds ratio</span> que oscilan entre el 1&#44;5 y el 3&#44;7&#44; dependiendo de si los testigos realizan la RCP o no<span class="elsevierStyleSup">29-31&#44;33&#44;34</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46; En alguna serie no se han observado&#44; sin embargo&#44; diferencias significativas en la funci&#243;n neurol&#243;gica final de los enfermos que sobreviven&#44; hicieran o no RCP los testigos de la PCR<span class="elsevierStyleSup">16</span>&#46;</p><p class="elsevierStylePara">El tiempo entre el colapso y el inicio de la RCP es un factor determinante en la supervivencia lograda en la PCR<span class="elsevierStyleSup">35</span>&#46; Un inicio de la RCP pasados 2 min del colapso puede condicionar una reducci&#243;n de la supervivencia a la mitad<span class="elsevierStyleSup">32</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46;</p><p class="elsevierStylePara">La calidad de la RCP tambi&#233;n es un factor importante de supervivencia&#46; Algunos estudios encuentran que s&#243;lo la RCP efectiva aumenta la supervivencia<span class="elsevierStyleSup">36-38</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46; Sin embargo&#44; no parece que necesariamente tenga que ser una RCP &#34;est&#225;ndar&#34;&#46; La RCP con s&#243;lo compresi&#243;n tor&#225;cica parece ser tan efectiva como la RCP con compresi&#243;n tor&#225;cica y ventilaci&#243;n boca-boca&#44; al menos en la RCP guiada por tel&#233;fono<span class="elsevierStyleSup">39</span> &#40;nivel de evidencia 2&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara">Tipo de ritmo card&#237;aco encontrado</p><p class="elsevierStylePara">Hay evidencia de que si el ritmo encontrado&#44; cuando &#233;ste se monitoriza por primera vez&#44; es una fibrilaci&#243;n ventricular &#40;FV&#41;&#44; las v&#237;ctimas de una PCR tienen m&#225;s posibilidades de supervivencia<span class="elsevierStyleSup">13&#44;24-26&#44;28&#44;30&#44;32&#44;40</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46; La FV incluso se relaciona con una mejor recuperaci&#243;n neurol&#243;gica entre los pacientes que sobreviven<span class="elsevierStyleSup">23</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46;</p><p class="elsevierStylePara">En los casos en que el primer ritmo monitorizado no es una FV &#40;asistolia o actividad el&#233;ctrica sin pulso&#41;&#44; los factores que se asocian con una mayor supervivencia son el intervalo entre el colapso y la llegada del equipo de soporte vital avanzado &#40;SVA&#41;<span class="elsevierStyleSup">34&#44;41</span> y la realizaci&#243;n de RCP por los testigos de la PCR<span class="elsevierStyleSup">34&#44;42</span>&#46;</p><p class="elsevierStylePara"> Desfibrilaci&#243;n temprana</p><p class="elsevierStylePara">La desfibrilaci&#243;n se considera el procedimiento que&#44; considerado de madera aislada&#44; salva m&#225;s vidas de las personas que presentan una PCR&#46; Cuanto menos tiempo transcurra entre el colapso y la desfibrilaci&#243;n&#44; m&#225;s posibilidades de recuperaci&#243;n tendr&#225; la v&#237;ctima en FV<span class="elsevierStyleSup">2&#44;24&#44;32&#44;40&#44;43</span> &#40;nivel de evidencia 3-4&#58; clase IIa&#41;&#46; Un an&#225;lisis gr&#225;fico de datos integrados mostr&#243; que por cada minuto que se retrase la desfibrilaci&#243;n tras el colapso de la v&#237;ctima&#44; las posibilidades de sobrevivir disminuyen un 10&#37;<span class="elsevierStyleSup">44</span>&#46; El estudio m&#225;s demostrativo de la utilidad de la desfibrilaci&#243;n temprana es el de Valenzuela et al<span class="elsevierStyleSup">2</span>&#46; Este estudio prospectivo no aleatorizado mostr&#243; una supervivencia del 59&#37; &#40;53&#47;90&#41; en las PCR presenciadas cuyo ritmo inicial fue una FV&#44; y en las que se administr&#243; la primera descarga a los 4&#44;4 &#40;2&#44;9&#41; min del colapso&#46; La supervivencia fue del 79&#37; &#40;26&#47;35&#41; si la primera descarga de desfibrilaci&#243;n se efectu&#243; en los primeros 3 min del colapso y del 49&#37; &#40;27&#47;55&#41; si la primera descarga se realizaba pasados los 3 min &#40;p &#61; 0&#44;02&#41;&#46; Ninguno de los supervivientes eran dependientes de otras personas para desarrollar su vida diaria al final del estudio<span class="elsevierStyleSup">2</span>&#46;</p><p class="elsevierStylePara">La evidencia disponible respecto a la importancia de la desfibrilaci&#243;n temprana ha hecho que las Recomendaciones 2000 consideren la desfibrilaci&#243;n temprana en la FV&#44; antes de 3 min del colapso en los hospitales y centros de salud&#44; como una recomendaci&#243;n clase I<span class="elsevierStyleSup">11&#44;45</span>&#46; Sin embargo&#44; la realizaci&#243;n de la desfibrilaci&#243;n por personal no sanitario &#40;primeros actuantes&#41; con desfibriladores externos autom&#225;ticos no ha demostrado todav&#237;a mejores resultados que la desfibrilaci&#243;n por el personal de los SEM&#44; salvo que la administraci&#243;n de la primera descarga sea muy temprana&#44; en los primeros 5 min<span class="elsevierStyleSup">46-55</span> &#40;nivel de evidencia 2-4&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara"> Entre los pocos estudios que encuentran diferencias en la recuperaci&#243;n neurol&#243;gica relacionada con una intervenci&#243;n terap&#233;utica est&#225; el que analiza el empleo de desfibriladores que realizan descargas con ondas bif&#225;sicas de baja energ&#237;a comparados con los que usan la tradicional onda monof&#225;sica de alta energ&#237;a&#58; el 87&#37; de los pacientes con buena funci&#243;n neurol&#243;gica entre los que sobreviven al alta &#40;onda bif&#225;sica&#41; comparados con el 53&#37; &#40;onda monof&#225;sica&#41; &#40;p &#61; 0&#44;04&#44; intervalo de confianza &#91;IC&#93; del 95&#37;&#44; 6-62&#37;&#41;&#44; aunque en este estudio no hubo diferencias en la supervivencia al alta del hospital<span class="elsevierStyleSup">14</span> &#40;nivel de evidencia 1&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara">Soporte vital avanzado</p><p class="elsevierStylePara">El soporte vital avanzado &#40;SVA&#41; tiene un papel menos importante en la supervivencia del PCR que el soporte vital b&#225;sico &#40;SVB&#41; y la desfibrilaci&#243;n temprana&#44; ahora considerada parte del SVB al ser posible la desfibrilaci&#243;n con DEA por parte del personal no sanitario<span class="elsevierStyleSup">11</span>&#46;</p><p class="elsevierStylePara">En las PCR intrahospitalarias&#44; donde el SVA puede ser realizado m&#225;s f&#225;cilmente&#44; la supervivencia de la PCR tambi&#233;n est&#225; ligada a la rapidez con que se realice la desfibrilaci&#243;n o se inicie el resto de la medidas de SVA cuando &#233;sta no est&#225; indicada&#44; al tipo de ritmo encontrado y a que el personal que presencia la PCR inicie maniobras de RCP mientras llega el equipo de paro&#44; al igual que sucede con la PCR extrahospitalaria<span class="elsevierStyleSup">56&#44;57</span>&#46;</p><p class="elsevierStylePara">La intubaci&#243;n orotraqueal se considera el m&#233;todo de elecci&#243;n para asegurar la permeabilidad de la tr&#225;quea durante las maniobras de SVA&#59; sin embargo&#44; no hay estudios prospectivos que estudian la influencia de la intubaci&#243;n orotraqueal en la supervivencia de las PCR<span class="elsevierStyleSup">58</span>&#46; Ante la posibilidad de mala colocaci&#243;n o desplazamiento del tubo durante la RCP o al trasladar al paciente<span class="elsevierStyleSup">59</span>&#44; se ha propuesto la necesidad de exigir al personal que intuba durante el SVA un m&#237;nimo de horas de formaci&#243;n y pr&#225;ctica anual&#44; y recomendar el uso de sistemas para comprobar la correcta colocaci&#243;n del tubo traqueal<span class="elsevierStyleSup">11&#44;58</span> &#40;nivel de evidencia 4&#58; clases IIa y IIb&#41;&#46; En poblaci&#243;n pedi&#225;trica se ha llegado recomendar la ventilaci&#243;n con bolsa y mascarilla con ox&#237;geno como procedimiento de elecci&#243;n inicial en SVA&#44; especialmente si el tiempo de traslado es breve&#44; teniendo en cuenta la alta incidencia de tubos traqueales mal colocados en esta poblaci&#243;n<span class="elsevierStyleSup">60</span> &#40;nivel de evidencia 2&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara">La medicaci&#243;n empleada durante el SVA fue sometida a una revisi&#243;n cr&#237;tica en los &#250;ltimos a&#241;os<span class="elsevierStyleSup">61&#44;62</span>&#44; aunque algunos ensayos cl&#237;nicos recientes han permitido una valoraci&#243;n de la utilidad de alg&#250;n f&#225;rmaco durante el SVA&#46;</p><p class="elsevierStylePara">Un an&#225;lisis de regresi&#243;n log&#237;stica multivariable encontr&#243; una asociaci&#243;n significativa entre el uso durante el SVA de adrenalina&#44; atropina&#44; bicarbonato&#44; calcio y lidoca&#237;na&#44; y la RCP sin &#233;xito<span class="elsevierStyleSup">61</span>&#44; aunque el dise&#241;o del estudio no permit&#237;a obtener conclusiones valorables &#40;nivel de evidencia 4&#58; clase indeterminada&#41;&#46;</p><p class="elsevierStylePara"> Sobre el empleo de adrenalina&#44; a pesar de ser el medicamento m&#225;s universalmente indicado en las recomendaciones<span class="elsevierStyleSup">11&#44;63</span>&#44; no se dispone de una evidencia clara para su utilizaci&#243;n por lo que fue considerada clase indeterminada en las &#250;ltimas recomendaciones<span class="elsevierStyleSup">11&#44;64</span>&#46; Se dispone de m&#225;s evidencia con respecto al empleo de dosis altas de adrenalina &#40;superiores a 1 mg&#41;&#44; que actualmente se considera no est&#225;n indicadas bas&#225;ndose en los resultados de 8 ensayos cl&#237;nicos controlados valorables publicados los &#250;ltimos a&#241;os&#44; que acumulan 9&#46;462 casos de PCR que muestran que no hay diferencias ni en el alta hospitalaria respecto a la dosis altas o est&#225;ndar &#40;2&#44;9 frente a 3&#44;0&#37;&#41; ni en la recuperaci&#243;n con buena funci&#243;n neurol&#243;gica &#40;2&#44;2 frente a 2&#44;3&#37;&#41;<span class="elsevierStyleSup">64</span> &#40;nivel de evidencia 1-2&#58; clase III&#41;&#44; teniendo en cuenta&#44; adem&#225;s&#44; que hay evidencia de que el uso de dosis acumulativas de adrenalina se asocia con una funci&#243;n neurol&#243;gica alterada&#44; tras la recuperaci&#243;n de una PCR por FV<span class="elsevierStyleSup">65</span> y que en una revisi&#243;n del Registro Sueco de Paro Card&#237;aco el empleo de adrenalina se asocia con una mayor mortalidad<span class="elsevierStyleSup">32</span> &#40;nivel de evidencia 4&#58; clase indeterminada&#41;&#46;</p><p class="elsevierStylePara"> Actualmente hay evidencia de que la amiodarona es el antiarr&#237;tmico de elecci&#243;n en la PCR con FV refractaria a la administraci&#243;n de 3 descargas con el desfibrilador y tras la administraci&#243;n de 1 mg de adrenalina<span class="elsevierStyleSup">10&#44;66</span> &#40;nivel de evidencia 1-2&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara"> Respecto a otras medidas recomendadas en el SVA&#44; como el uso de la vasopresina como alternativa a la adrenalina<span class="elsevierStyleSup">9&#44;67</span> y el empleo de ayudas a la compresi&#243;n tor&#225;cica<span class="elsevierStyleSup">68-70</span>&#44; los resultados de los estudios realizados no son concluyentes&#44; no encuentran beneficio o est&#225;n pendientes de ser refrendados con estudios controlados&#46;</p>"
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        "resumen" => "La capacidad funcional de los enfermos recuperados tras la reanimaci&#243;n cardiopulmonar &#40;RCP&#41; se relaciona con la calidad de la RCP&#44; posiblemente al reducirse la isquemia cerebral durante la parada cardiorrespiratoria &#40;PCR&#41;&#46; Los factores predictivos de supervivencia ante una PCR son&#58; PCR presenciada&#59; inicio de las maniobras de RCP por parte de los testigos de la PCR&#44; dado que el tiempo entre el colapso y el inicio de la RCP y la calidad de &#233;sta son dos factores determinantes en la supervivencia lograda en la PCR&#59; el tipo de ritmo card&#237;aco encontrado&#59; la desfibrilaci&#243;n temprana y el soporte vital avanzado&#46; De todos estos factores&#44; la evidencia respecto a la importancia de la desfibrilaci&#243;n temprana ha llevado a que las recomendaciones del 2000 consideren la desfibrilaci&#243;n temprana en la fibrilaci&#243;n ventricular&#44; antes de 3 min del colapso en los hospitales y centros de salud&#44; como una recomendaci&#243;n clase I&#46;"
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Factores predictivos de supervivencia durante la reanimación cardiopulmonar
Factors predictive of survival in cardiopulmonary resuscitation
FJ. de Latorre Artechea
a Servicio de Medicina Intensiva. Hospital Universitari Vall d'Hebron. Barcelona. España.
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    "textoCompleto" => "<p class="elsevierStylePara">EVOLUCION DE LA PARADA CARDIORRESPIRATORIA</p><p class="elsevierStylePara">Se considera &#34;muerte s&#250;bita&#34;&#44; lo que se conoce como parada cardiorrespiratoria &#40;PCR&#41;&#44; aquellas muertes inesperadas que ocurren de manera aguda&#44; en un per&#237;odo breve&#44; generalmente en minutos desde el inicio de los s&#237;ntomas&#46;</p><p class="elsevierStylePara">La supervivencia de una PCR extrahospitalaria puede oscilar entre 1&#44;4&#37; en Nueva York<span class="elsevierStyleSup">1</span> y un 38&#37;<span class="elsevierStyleSup">2</span>&#46; En nuestro pa&#237;s&#44; en la reciente tesis de &#193;lvarez<span class="elsevierStyleSup">3</span> que revisa los resultados de 3&#46;642 PCR en las que se inici&#243; reanimaci&#243;n cardiopulmonar &#40;RCP&#41; recogidas en publicaciones entre 1987 y 1999&#44; la supervivencia al alta hospitalaria fue del 10&#44;1&#37; en PCR extrahospitalarias&#46; Respecto a las PCR intrahospitalarias tambi&#233;n hay una gran dispersi&#243;n de los resultados&#44; que oscilan entre el 0&#37;<span class="elsevierStyleSup">4</span> y el 35&#37;<span class="elsevierStyleSup">5</span> de supervivencia&#46; Las causas de estas variaciones no se deben s&#243;lo a diferencias en el tratamiento de estos pacientes&#44; sino a que se comparan poblaciones diferentes&#44; PCR que ocurren en unidades muy distintas del hospital&#44; etc&#46;&#44; por lo que los resultados globales&#44; sin estratificar&#44; no nos permiten sacar conclusiones en muchas ocasiones&#46; Ballew y Philbrick<span class="elsevierStyleSup">6</span> realizaron una excelente revisi&#243;n de 68 publicaciones sobre las diferencias que exist&#237;an en la forma de recoger las PCR intrahospitalarias y la inutilidad de comparar los datos globales&#46; La &#250;nica forma de comparar casu&#237;sticas es mediante un registro uniforme que permita homogeneizar las posibles variables que pueden darse en la RCP de las PCR&#44; como los propuestos en los consensos de Utstein<span class="elsevierStyleSup">7&#44;8</span>&#46;</p><p class="elsevierStylePara"> Otra dificultad que se presenta al comparar estudios es la variable &#40;<span class="elsevierStyleItalic">end-point</span>&#41; a considerar para determinar que una determinada medida es beneficiosa o no&#59; se han recomendado actuaciones terap&#233;uticas s&#243;lo por conseguir que m&#225;s pacientes con PCR ingresen con vida en el hospital aunque no haya diferencias en la supervivencia al alta hospitalaria<span class="elsevierStyleSup">9&#44;10</span>&#46;</p><p class="elsevierStylePara"> Pocos estudios analizan la recuperaci&#243;n funcional neurol&#243;gica tras una PCR en los pacientes que son dados de alta del hospital&#44; a pesar de que la recuperaci&#243;n de una buena funci&#243;n neurol&#243;gica al alta se considera el patr&#243;n oro a conseguir con las maniobras de RCP<span class="elsevierStyleSup">11&#44;12</span>&#46; En las Recomendaciones 2000&#44; se analizaron 20 publicaciones valorables encontradas en una b&#250;squeda en MEDLINE &#40;1989-1999&#41; que midieran la proporci&#243;n de pacientes con PCR extrahospitalarias que eran dados de alta del hospital con buena o s&#243;lo moderada alteraci&#243;n de la funci&#243;n neurol&#243;gica&#59; en total fueron 25&#46;805 pacientes con PCR&#44; y se encontr&#243; que eran s&#243;lo el 5&#44;5&#37; de los pacientes<span class="elsevierStyleSup">12</span>&#46; De los pacientes que sobreviven a una PCR extrahospitalaria y son dados de alta del hospital&#44; entre el 4 y el 12&#37; quedan con afecci&#243;n neurol&#243;gica grave o coma<span class="elsevierStyleSup">13&#44;14</span>&#46; Publicaciones m&#225;s antiguas refieren resultados peores con un 18&#37; de pacientes en coma<span class="elsevierStyleSup">15</span> y un 24&#37; de los pacientes en coma&#44; estado vegetativo persistente &#40;EVP&#41; o alteraciones neurol&#243;gicas importantes<span class="elsevierStyleSup">16</span>&#46; En un hospital espa&#241;ol&#44; el 7&#44;8&#37; de los pacientes &#40;10&#47;128 pacientes&#41; que pudieron ser dados de alta del hospital qued&#243; con deficiencias neurol&#243;gicas muy invalidantes&#44; entre ellas en EVP<span class="elsevierStyleSup">17</span>&#46;</p><p class="elsevierStylePara">Por &#250;ltimo&#44; incluso los estudios que analizan la funci&#243;n neurol&#243;gica al alta no suelen citar la proporci&#243;n de pacientes con EVP&#59; la mayor&#237;a de estos pacientes se engloban entre los que fallecen sin ser dados de alta del hospital o han quedado con afecci&#243;n neurol&#243;gica grave&#46; Para la presente revisi&#243;n se ha efectuado una b&#250;squeda de publicaciones desde 1980 hasta la actualidad en MEDLINE mediante los t&#233;rminos <span class="elsevierStyleItalic">cardiopulmonary resuscitation OR cardiac arrest AND vegetative state</span>&#44; en adultos&#46; S&#243;lo 3 de las 43 publicaciones encontradas eran series de enfermos con PCR en las que se indicaba expresamente el porcentaje de pacientes que quedaba en estado vegetativo<span class="elsevierStyleSup">18-20</span>&#46; En estas series &#40;una de las publicaciones es un metaan&#225;lisis de 98 series previas<span class="elsevierStyleSup">18</span>&#41; la incidencia de EVP es inferior al 14&#37;<span class="elsevierStyleSup">19&#44;20</span>&#46;</p><p class="elsevierStylePara"> M&#201;TODO</p><p class="elsevierStylePara">En la presente revisi&#243;n se analizan los aspectos de la RCP de los que hay evidencia cient&#237;fica en cuanto a que mejoran la supervivencia de la PCR&#46; Para ello se ha utilizado la bibliograf&#237;a analizada en las Recomendaciones 2000 para RCP y cuidados cardiovasculares de urgencia&#44; publicadas simult&#225;neamente en <span class="elsevierStyleItalic">Circulation</span> y <span class="elsevierStyleItalic">Resuscitation</span> en agosto 2000<span class="elsevierStyleSup">11</span>&#46; Estas recomendaciones son el resultado de una revisi&#243;n exhaustiva de toda la evidencia cient&#237;fica en reanimaci&#243;n publicada en los &#250;ltimos a&#241;os mediante una rigurosa metodolog&#237;a&#44; con valoraci&#243;n del grado de evidencia tras un an&#225;lisis de la calidad de cada publicaci&#243;n de acuerdo con unos criterios previamente consensuados<span class="elsevierStyleSup">11</span> &#40;tablas 1 y 2&#41; y que son los mismos que se han utilizado en esta revisi&#243;n&#44; tanto en el an&#225;lisis de los estudios revisados en las Recomendaciones 2000 como en la revisi&#243;n de los estudios publicados con posterioridad&#44; con el fin de mantener una uniformidad&#46;</p><p class="elsevierStylePara"><img src="64v28n03-13060074tab01.gif"></img></p><p class="elsevierStylePara"><img src="64v28n03-13060074tab02.gif"></img></p><p class="elsevierStylePara">Al no existir pr&#225;cticamente estudios que analicen la utilidad de las maniobras de RCP en relaci&#243;n con la repercusi&#243;n neurol&#243;gica&#44; para la revisi&#243;n de los estudios analizados se consider&#243; que las maniobras de RCP de las que hay evidencia que salvan m&#225;s vida tienen tambi&#233;n m&#225;s posibilidades de recuperar m&#225;s enfermos con buena funci&#243;n neurol&#243;gica&#44; como han demostrado algunos estudios que muestran que la capacidad funcional de los enfermos recuperados tras la RCP se relaciona con la calidad de la RCP&#44; posiblemente por reducir la isquemia cerebral durante la PRC &#40;menos tiempo de isquemia y mejor perfusi&#243;n cerebral durante la RCP y los primeros momentos de recuperaci&#243;n de la circulaci&#243;n espont&#225;nea &#91;ROSC&#93;&#44; etc&#46;&#41;<span class="elsevierStyleSup">2&#44;21-23</span>&#46;</p><p class="elsevierStylePara">FACTORES PREDICTIVOS DE SUPERVIVENCIA</p><p class="elsevierStylePara">Hay evidencia acerca de que la PCR presenciada tiene m&#225;s posibilidades de supervivencia que la que ocurre sin que haya alg&#250;n testigo presencial<span class="elsevierStyleSup">13&#44;24-28</span>&#44; al tener m&#225;s posibilidades de recibir antes asistencia especializada &#173;el testigo avisa a un sistema de emergencias m&#233;dicas &#40;SEM&#41;&#173; y de que el testigo inicie maniobras de RCP &#40;lo que consigue retrasar el deterioro mioc&#225;rdico y cerebral&#41; &#40;nivel evidencia 4&#58; clase IIb&#41;&#46;</p><p class="elsevierStylePara">Inicio de las maniobras de reanimaci&#243;n cardiopulmonar por parte de los testigos de la parada cardiorrespiratoria</p><p class="elsevierStylePara">Se dispone de evidencia de que si los testigos de la PCR inician maniobras de RCP mientras llega el SME&#44; la supervivencia es mayor por que se mantiene m&#225;s tiempo a la v&#237;ctima con perfusi&#243;n mioc&#225;rdica y cerebral mientras se espera la realizaci&#243;n del tratamiento resolutivo de la PRC<span class="elsevierStyleSup">13&#44;25&#44;26&#44;29-32</span>&#46;</p><p class="elsevierStylePara">Las diferencias observadas en la supervivencia en estudios de regresi&#243;n log&#237;stica pueden variar entre un 6 y un 10&#37; con unas <span class="elsevierStyleItalic">odds ratio</span> que oscilan entre el 1&#44;5 y el 3&#44;7&#44; dependiendo de si los testigos realizan la RCP o no<span class="elsevierStyleSup">29-31&#44;33&#44;34</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46; En alguna serie no se han observado&#44; sin embargo&#44; diferencias significativas en la funci&#243;n neurol&#243;gica final de los enfermos que sobreviven&#44; hicieran o no RCP los testigos de la PCR<span class="elsevierStyleSup">16</span>&#46;</p><p class="elsevierStylePara">El tiempo entre el colapso y el inicio de la RCP es un factor determinante en la supervivencia lograda en la PCR<span class="elsevierStyleSup">35</span>&#46; Un inicio de la RCP pasados 2 min del colapso puede condicionar una reducci&#243;n de la supervivencia a la mitad<span class="elsevierStyleSup">32</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46;</p><p class="elsevierStylePara">La calidad de la RCP tambi&#233;n es un factor importante de supervivencia&#46; Algunos estudios encuentran que s&#243;lo la RCP efectiva aumenta la supervivencia<span class="elsevierStyleSup">36-38</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46; Sin embargo&#44; no parece que necesariamente tenga que ser una RCP &#34;est&#225;ndar&#34;&#46; La RCP con s&#243;lo compresi&#243;n tor&#225;cica parece ser tan efectiva como la RCP con compresi&#243;n tor&#225;cica y ventilaci&#243;n boca-boca&#44; al menos en la RCP guiada por tel&#233;fono<span class="elsevierStyleSup">39</span> &#40;nivel de evidencia 2&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara">Tipo de ritmo card&#237;aco encontrado</p><p class="elsevierStylePara">Hay evidencia de que si el ritmo encontrado&#44; cuando &#233;ste se monitoriza por primera vez&#44; es una fibrilaci&#243;n ventricular &#40;FV&#41;&#44; las v&#237;ctimas de una PCR tienen m&#225;s posibilidades de supervivencia<span class="elsevierStyleSup">13&#44;24-26&#44;28&#44;30&#44;32&#44;40</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46; La FV incluso se relaciona con una mejor recuperaci&#243;n neurol&#243;gica entre los pacientes que sobreviven<span class="elsevierStyleSup">23</span> &#40;nivel de evidencia 4&#58; clase IIb&#41;&#46;</p><p class="elsevierStylePara">En los casos en que el primer ritmo monitorizado no es una FV &#40;asistolia o actividad el&#233;ctrica sin pulso&#41;&#44; los factores que se asocian con una mayor supervivencia son el intervalo entre el colapso y la llegada del equipo de soporte vital avanzado &#40;SVA&#41;<span class="elsevierStyleSup">34&#44;41</span> y la realizaci&#243;n de RCP por los testigos de la PCR<span class="elsevierStyleSup">34&#44;42</span>&#46;</p><p class="elsevierStylePara"> Desfibrilaci&#243;n temprana</p><p class="elsevierStylePara">La desfibrilaci&#243;n se considera el procedimiento que&#44; considerado de madera aislada&#44; salva m&#225;s vidas de las personas que presentan una PCR&#46; Cuanto menos tiempo transcurra entre el colapso y la desfibrilaci&#243;n&#44; m&#225;s posibilidades de recuperaci&#243;n tendr&#225; la v&#237;ctima en FV<span class="elsevierStyleSup">2&#44;24&#44;32&#44;40&#44;43</span> &#40;nivel de evidencia 3-4&#58; clase IIa&#41;&#46; Un an&#225;lisis gr&#225;fico de datos integrados mostr&#243; que por cada minuto que se retrase la desfibrilaci&#243;n tras el colapso de la v&#237;ctima&#44; las posibilidades de sobrevivir disminuyen un 10&#37;<span class="elsevierStyleSup">44</span>&#46; El estudio m&#225;s demostrativo de la utilidad de la desfibrilaci&#243;n temprana es el de Valenzuela et al<span class="elsevierStyleSup">2</span>&#46; Este estudio prospectivo no aleatorizado mostr&#243; una supervivencia del 59&#37; &#40;53&#47;90&#41; en las PCR presenciadas cuyo ritmo inicial fue una FV&#44; y en las que se administr&#243; la primera descarga a los 4&#44;4 &#40;2&#44;9&#41; min del colapso&#46; La supervivencia fue del 79&#37; &#40;26&#47;35&#41; si la primera descarga de desfibrilaci&#243;n se efectu&#243; en los primeros 3 min del colapso y del 49&#37; &#40;27&#47;55&#41; si la primera descarga se realizaba pasados los 3 min &#40;p &#61; 0&#44;02&#41;&#46; Ninguno de los supervivientes eran dependientes de otras personas para desarrollar su vida diaria al final del estudio<span class="elsevierStyleSup">2</span>&#46;</p><p class="elsevierStylePara">La evidencia disponible respecto a la importancia de la desfibrilaci&#243;n temprana ha hecho que las Recomendaciones 2000 consideren la desfibrilaci&#243;n temprana en la FV&#44; antes de 3 min del colapso en los hospitales y centros de salud&#44; como una recomendaci&#243;n clase I<span class="elsevierStyleSup">11&#44;45</span>&#46; Sin embargo&#44; la realizaci&#243;n de la desfibrilaci&#243;n por personal no sanitario &#40;primeros actuantes&#41; con desfibriladores externos autom&#225;ticos no ha demostrado todav&#237;a mejores resultados que la desfibrilaci&#243;n por el personal de los SEM&#44; salvo que la administraci&#243;n de la primera descarga sea muy temprana&#44; en los primeros 5 min<span class="elsevierStyleSup">46-55</span> &#40;nivel de evidencia 2-4&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara"> Entre los pocos estudios que encuentran diferencias en la recuperaci&#243;n neurol&#243;gica relacionada con una intervenci&#243;n terap&#233;utica est&#225; el que analiza el empleo de desfibriladores que realizan descargas con ondas bif&#225;sicas de baja energ&#237;a comparados con los que usan la tradicional onda monof&#225;sica de alta energ&#237;a&#58; el 87&#37; de los pacientes con buena funci&#243;n neurol&#243;gica entre los que sobreviven al alta &#40;onda bif&#225;sica&#41; comparados con el 53&#37; &#40;onda monof&#225;sica&#41; &#40;p &#61; 0&#44;04&#44; intervalo de confianza &#91;IC&#93; del 95&#37;&#44; 6-62&#37;&#41;&#44; aunque en este estudio no hubo diferencias en la supervivencia al alta del hospital<span class="elsevierStyleSup">14</span> &#40;nivel de evidencia 1&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara">Soporte vital avanzado</p><p class="elsevierStylePara">El soporte vital avanzado &#40;SVA&#41; tiene un papel menos importante en la supervivencia del PCR que el soporte vital b&#225;sico &#40;SVB&#41; y la desfibrilaci&#243;n temprana&#44; ahora considerada parte del SVB al ser posible la desfibrilaci&#243;n con DEA por parte del personal no sanitario<span class="elsevierStyleSup">11</span>&#46;</p><p class="elsevierStylePara">En las PCR intrahospitalarias&#44; donde el SVA puede ser realizado m&#225;s f&#225;cilmente&#44; la supervivencia de la PCR tambi&#233;n est&#225; ligada a la rapidez con que se realice la desfibrilaci&#243;n o se inicie el resto de la medidas de SVA cuando &#233;sta no est&#225; indicada&#44; al tipo de ritmo encontrado y a que el personal que presencia la PCR inicie maniobras de RCP mientras llega el equipo de paro&#44; al igual que sucede con la PCR extrahospitalaria<span class="elsevierStyleSup">56&#44;57</span>&#46;</p><p class="elsevierStylePara">La intubaci&#243;n orotraqueal se considera el m&#233;todo de elecci&#243;n para asegurar la permeabilidad de la tr&#225;quea durante las maniobras de SVA&#59; sin embargo&#44; no hay estudios prospectivos que estudian la influencia de la intubaci&#243;n orotraqueal en la supervivencia de las PCR<span class="elsevierStyleSup">58</span>&#46; Ante la posibilidad de mala colocaci&#243;n o desplazamiento del tubo durante la RCP o al trasladar al paciente<span class="elsevierStyleSup">59</span>&#44; se ha propuesto la necesidad de exigir al personal que intuba durante el SVA un m&#237;nimo de horas de formaci&#243;n y pr&#225;ctica anual&#44; y recomendar el uso de sistemas para comprobar la correcta colocaci&#243;n del tubo traqueal<span class="elsevierStyleSup">11&#44;58</span> &#40;nivel de evidencia 4&#58; clases IIa y IIb&#41;&#46; En poblaci&#243;n pedi&#225;trica se ha llegado recomendar la ventilaci&#243;n con bolsa y mascarilla con ox&#237;geno como procedimiento de elecci&#243;n inicial en SVA&#44; especialmente si el tiempo de traslado es breve&#44; teniendo en cuenta la alta incidencia de tubos traqueales mal colocados en esta poblaci&#243;n<span class="elsevierStyleSup">60</span> &#40;nivel de evidencia 2&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara">La medicaci&#243;n empleada durante el SVA fue sometida a una revisi&#243;n cr&#237;tica en los &#250;ltimos a&#241;os<span class="elsevierStyleSup">61&#44;62</span>&#44; aunque algunos ensayos cl&#237;nicos recientes han permitido una valoraci&#243;n de la utilidad de alg&#250;n f&#225;rmaco durante el SVA&#46;</p><p class="elsevierStylePara">Un an&#225;lisis de regresi&#243;n log&#237;stica multivariable encontr&#243; una asociaci&#243;n significativa entre el uso durante el SVA de adrenalina&#44; atropina&#44; bicarbonato&#44; calcio y lidoca&#237;na&#44; y la RCP sin &#233;xito<span class="elsevierStyleSup">61</span>&#44; aunque el dise&#241;o del estudio no permit&#237;a obtener conclusiones valorables &#40;nivel de evidencia 4&#58; clase indeterminada&#41;&#46;</p><p class="elsevierStylePara"> Sobre el empleo de adrenalina&#44; a pesar de ser el medicamento m&#225;s universalmente indicado en las recomendaciones<span class="elsevierStyleSup">11&#44;63</span>&#44; no se dispone de una evidencia clara para su utilizaci&#243;n por lo que fue considerada clase indeterminada en las &#250;ltimas recomendaciones<span class="elsevierStyleSup">11&#44;64</span>&#46; Se dispone de m&#225;s evidencia con respecto al empleo de dosis altas de adrenalina &#40;superiores a 1 mg&#41;&#44; que actualmente se considera no est&#225;n indicadas bas&#225;ndose en los resultados de 8 ensayos cl&#237;nicos controlados valorables publicados los &#250;ltimos a&#241;os&#44; que acumulan 9&#46;462 casos de PCR que muestran que no hay diferencias ni en el alta hospitalaria respecto a la dosis altas o est&#225;ndar &#40;2&#44;9 frente a 3&#44;0&#37;&#41; ni en la recuperaci&#243;n con buena funci&#243;n neurol&#243;gica &#40;2&#44;2 frente a 2&#44;3&#37;&#41;<span class="elsevierStyleSup">64</span> &#40;nivel de evidencia 1-2&#58; clase III&#41;&#44; teniendo en cuenta&#44; adem&#225;s&#44; que hay evidencia de que el uso de dosis acumulativas de adrenalina se asocia con una funci&#243;n neurol&#243;gica alterada&#44; tras la recuperaci&#243;n de una PCR por FV<span class="elsevierStyleSup">65</span> y que en una revisi&#243;n del Registro Sueco de Paro Card&#237;aco el empleo de adrenalina se asocia con una mayor mortalidad<span class="elsevierStyleSup">32</span> &#40;nivel de evidencia 4&#58; clase indeterminada&#41;&#46;</p><p class="elsevierStylePara"> Actualmente hay evidencia de que la amiodarona es el antiarr&#237;tmico de elecci&#243;n en la PCR con FV refractaria a la administraci&#243;n de 3 descargas con el desfibrilador y tras la administraci&#243;n de 1 mg de adrenalina<span class="elsevierStyleSup">10&#44;66</span> &#40;nivel de evidencia 1-2&#58; clase IIa&#41;&#46;</p><p class="elsevierStylePara"> Respecto a otras medidas recomendadas en el SVA&#44; como el uso de la vasopresina como alternativa a la adrenalina<span class="elsevierStyleSup">9&#44;67</span> y el empleo de ayudas a la compresi&#243;n tor&#225;cica<span class="elsevierStyleSup">68-70</span>&#44; los resultados de los estudios realizados no son concluyentes&#44; no encuentran beneficio o est&#225;n pendientes de ser refrendados con estudios controlados&#46;</p>"
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        "resumen" => "La capacidad funcional de los enfermos recuperados tras la reanimaci&#243;n cardiopulmonar &#40;RCP&#41; se relaciona con la calidad de la RCP&#44; posiblemente al reducirse la isquemia cerebral durante la parada cardiorrespiratoria &#40;PCR&#41;&#46; Los factores predictivos de supervivencia ante una PCR son&#58; PCR presenciada&#59; inicio de las maniobras de RCP por parte de los testigos de la PCR&#44; dado que el tiempo entre el colapso y el inicio de la RCP y la calidad de &#233;sta son dos factores determinantes en la supervivencia lograda en la PCR&#59; el tipo de ritmo card&#237;aco encontrado&#59; la desfibrilaci&#243;n temprana y el soporte vital avanzado&#46; De todos estos factores&#44; la evidencia respecto a la importancia de la desfibrilaci&#243;n temprana ha llevado a que las recomendaciones del 2000 consideren la desfibrilaci&#243;n temprana en la fibrilaci&#243;n ventricular&#44; antes de 3 min del colapso en los hospitales y centros de salud&#44; como una recomendaci&#243;n clase I&#46;"
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ISSN: 02105691
Idioma original: Español
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