{"id":116161,"date":"2018-03-11T10:45:07","date_gmt":"2018-03-11T10:45:07","guid":{"rendered":""},"modified":"2018-03-11T10:45:07","modified_gmt":"2018-03-11T10:45:07","slug":"estudio-comparativo-del-efecto-de-las-soluciones-equiosmolares-de-manitol-20-versus-salino-hipertonico-3-sobre-la-hemostasia-sangua%c2%adnea-evaluado-mediante-tromboelastometria-rotacional-durante-cir","status":"publish","type":"post","link":"https:\/\/www.deberes.net\/tesis\/hematologia\/estudio-comparativo-del-efecto-de-las-soluciones-equiosmolares-de-manitol-20-versus-salino-hipertonico-3-sobre-la-hemostasia-sangua%c2%adnea-evaluado-mediante-tromboelastometria-rotacional-durante-cir\/","title":{"rendered":"Estudio comparativo del efecto de las soluciones equiosmolares de manitol 20% versus salino hipert\u00f3nico 3% sobre la hemostasia sangu\u00ednea evaluado mediante tromboelastometr\u00eda rotacional durante cirugia intracraneal electiva"},"content":{"rendered":"<h2>Tesis doctoral de <strong> Diego Fuentes Garc\u00eda <\/strong><\/h2>\n<p>Resumen  introducci\u00f3n: el objetivo principal de esta tesis doctoral fue comparar el efecto de las soluciones equiosmolares de manitol 20% y ssh 3% sobre la hemostasia sangu\u00ednea mediante tromboelastometr\u00eda rotacional (rotem) y pruebas est\u00e1ndar de laboratorio, as\u00ed como evaluar el grado de asociaci\u00f3n entre ambas pruebas. Los objetivos secundarios fueron el estudio de la eficacia de ambas soluciones sobre la relajaci\u00f3n encef\u00e1lica y la presencia de efectos indeseables mediante el an\u00e1lisis de la osmolaridad plasm\u00e1tica, balance hidroelectrol\u00edtico y variables hemodin\u00e1micas en pacientes sometidos a cirug\u00eda intracraneal electiva por diferentes enfermedades neurol\u00f3gicas.   m\u00e9todos: ensayo cl\u00ednico prospectivo, randomizado y triple ciego. Tras la aprobaci\u00f3n por el comit\u00e9 de \u00e9tica de nuestro hospital y la obtenci\u00f3n del consentimiento informado, fueron reclutados pacientes con estado f\u00edsico asa?Iii programados para cirug\u00eda intracraneal por diversas patolog\u00edas neuroquir\u00fargicas (tumor cerebral, aneurisma o malformaci\u00f3n arteriovenosa). Los pacientes recibieron 3 ml\/kg de manitol 20% (osmolaridad 1098 mosm\/l, n=30) o ssh 3% (osmolaridad 1026 mosm\/l, n=30) en el momento de la incisi\u00f3n quir\u00fargica. Se registraron variables rotem mediante an\u00e1lisis extem, intem y fibtem (ct, cft, \u00e1ngulo alfa, mcf), hematocrito, hemoglobina, coagulaci\u00f3n est\u00e1ndar (recuento plaquetario, fibrin\u00f3geno, tp, ttpa, d\u00edmero-d), osmolaridad y electrolitos en sangre arterial y orina, variables hemodin\u00e1micas (ic, vvs, irvs, ivs; presi\u00f3n arterial y pvc), balance h\u00eddrico, gasometr\u00eda arterial, glucosa y lactato. Las mediciones se efectuaron antes de la infusi\u00f3n de la soluci\u00f3n hiperosmolar y 30, 120 y 360 min tras su infusi\u00f3n. El cirujano evalu\u00f3 el estado de relajaci\u00f3n encef\u00e1lica en una escala de cuatro puntos (1,relajado; 2,satisfactorio; 3,tenso; 4,abultado). El estudio estad\u00edstico se realiz\u00f3 mediante anova de una v\u00eda y prueba t de student para medidas repetidas en cada grupo, y correlaci\u00f3n de pearson entre variables de rotem y laboratorio.   resultados: no se encontraron diferencias significativas en las variables demogr\u00e1ficas entre grupos. El an\u00e1lisis de rotem no detect\u00f3 diferencias entre grupos en los par\u00e1metros ct, cft, alfa y mcf, con valores dentro de la normalidad. Las variables de laboratorio (hemoglobina, hematocrito, recuento plaquetario y pruebas est\u00e1ndar de coagulaci\u00f3n) fueron similares en ambos grupos sin observar cambios significativos con respecto a la situaci\u00f3n basal. El an\u00e1lisis de regresi\u00f3n lineal simple mostr\u00f3 una correlaci\u00f3n moderada entre el mcf y el fibrin\u00f3geno, siendo d\u00e9bil la correlaci\u00f3n entre cft extem y el fibrin\u00f3geno y recuento plaquetario. No se observaron diferencias en la relajaci\u00f3n encef\u00e1lica entre grupos siendo \u00f3ptima en el 76 %  de pacientes en el grupo manitol y en el 87% en el grupo ssh. Se evidenci\u00f3 un aumento similar de osmolaridad en sangre con los dos agentes y un descenso de osmolaridad urinaria. El sodio aument\u00f3 significativamente tras la administraci\u00f3n del ssh 3% a diferencia del grupo manitol 20% donde se observ\u00f3 una disminuci\u00f3n significativa a los 30 min seguido de un aumento que fue significativo a los 360 min. La glucemia y lactato aumentaron de forma similar en ambos grupos, sin encontrar diferencias en las variables hemodin\u00e1micas.   conclusiones: las soluciones equiosmolares de manitol 20% y ssh 3% durante cirug\u00eda intracraneal electiva no producen alteraciones hemost\u00e1ticas evidenciables mediante rotem, a diferencia de los estudios in vitro, ni mediante pruebas est\u00e1ndar de laboratorio. Existe una asociaci\u00f3n moderada entre variables como mcf y el fibrin\u00f3geno o recuento plaquetario, sin correlaci\u00f3n directa. El uso de rotem no ser\u00eda una prueba imprescindible en el lugar de asistencia del paciente neuroquir\u00fargico,  siempre y cuando no existan alteraciones hemost\u00e1ticas o hemorragia grave perioperatorias. La administraci\u00f3n de 3 ml\/kg de manitol 20% o de ssh 3%  proporciona condiciones quir\u00fargicas y de relajaci\u00f3n encef\u00e1lica \u00f3ptimas en estos pacientes, siendo segura su utilizaci\u00f3n en neurocirug\u00eda, ya que no evidenciaron alteraciones hemodin\u00e1micas, de osmolaridad ni electrol\u00edticas cl\u00ednicamente relevantes.                         effect of equiosmolar solutions of 20% mannitol vs 3% hypertonic saline on blood hemostasis assessed by rotational thromboelastometry during elective intracranial surgery: a randomized comparative survey  abstract  background: the main goal in this thesis was to compare the effect of equiosmolar solutions of 20% mannitol and 3% hypertonic saline (hs) on blood hemostasis by means of rotational thromboelastometry (rotem) and standard coagulation tests, and also to assess the association between these tests. Secondary objectives were to study the effectiveness of both solutions on brain relaxation and the presence of side effects by measuring plasma osmolarity, fluid and electrolyte balance and hemodynamic variables in patients scheduled to elective intracranial surgery for different neurological pathologies.   methods: a prospective, randomized, triple-blinded clinical trial was performed. After irb approval and signing of informed consent, patients with asa physical status ?Iii undergoing intracranial surgery for diverse neurosurgical pathologies (brain tumor, aneurism, arteriovenous malformation) were recruited, receiving either 3 ml\/kg of 20% mannitol (osmolarity 1098 mosm\/l, n=30) or 3% hs (osmolarity 1026 mosm\/l,n=30) before surgical incision. Rotem variables by extem, intem and fibtem tests (ct, cft, alpha angle, mcf) were analyzed along with hematocrit, hemoglobin, standard coagulation tests (platelet count, fibrinogen, pt, aptt, d-dimer), osmolarity with electrolytes in arterial blood and urine, hemodynamic variables (ci, svv, svri, svi, blood pressure and cvp), fluid balance, arterial gasometry, glucose and lactate. Measurement points were performed before infusion of hyperosmolar solution and 30, 120 and 360 min after its infusion. Neurosurgeon assessed brain relaxation in a four point score (1, relaxed, 2, satisfactory, 3, firm, 4, swollen). Statistical analysis was performed by one-way anova and student&apos;s t-test for repeated measures in each group, with pearson correlation test between rotem and laboratory variables.    results: no differences were found in demographic variables between groups. Rotem analysis showed no differences between groups relating to ct, cft, alpha angle and mcf parameters, with values within normal. Laboratory variables (hemoglobin, hematocrit, platelet count and standard coagulation tests) were similar in both groups without significant changes related to baseline. Simple linear regression analysis evidenced a moderate correlation between mcf and fibrinogen, with a weak correlation between extem cft and fibrinogen and platelet count. There were no differences in brain relaxation between groups, even it was optimal in 76% of patients in mannitol group and in 87% in hs group. A similar increase in serum osmolarity was observed with the two agents along with a decrease in urine osmolarity. Sodium had a significant increase after 3% hs administration, in contrast to 20% mannitol which associated to a significant decrease after 30 min and a significant rise after 360 min. Glucose and lactate increased in a similar way in both groups, without differences in hemodynamic variables.  conclusions: equiosmolar solutions of 20% mannitol and 3% hs during elective intracranial surgery do not originate any hemostatic impairment demonstrable either by rotem, in contrast to in-vitro studies, or standard laboratory tests. A moderate association was evidenced between variables such as mcf and fibrinogen or platelet count, without a direct correlation. Use of rotem is not an essential &quot;point-of-care&quot; test for neurosurgical patients, whenever no hemostatic impairment or severe perioperative hemorrhage are proved. Administration of 3 ml\/kg of 20% mannitol or 3% hs provides optimal surgical and brain relaxation conditions in these patients, and its use is safe in neurosurgery as no hemodynamic, osmolarity or electrolyte impairment were clinically relevant.<\/p>\n<p>&nbsp;<\/p>\n<h3>Datos acad\u00e9micos de la tesis doctoral \u00ab<strong>Estudio comparativo del efecto de las soluciones equiosmolares de manitol 20% versus salino hipert\u00f3nico 3% sobre la hemostasia sangu\u00ednea evaluado mediante tromboelastometr\u00eda rotacional durante cirugia intracraneal electiva<\/strong>\u00ab<\/h3>\n<ul>\n<li><strong>T\u00edtulo de la tesis:<\/strong>\u00a0 Estudio comparativo del efecto de las soluciones equiosmolares de manitol 20% versus salino hipert\u00f3nico 3% sobre la hemostasia sangu\u00ednea evaluado mediante tromboelastometr\u00eda rotacional durante cirugia intracraneal electiva <\/li>\n<li><strong>Autor:<\/strong>\u00a0 Diego Fuentes Garc\u00eda <\/li>\n<li><strong>Universidad:<\/strong>\u00a0 Murcia<\/li>\n<li><strong>Fecha de lectura de la tesis:<\/strong>\u00a0 21\/07\/2014<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3>Direcci\u00f3n y tribunal<\/h3>\n<ul>\n<li><strong>Director de la tesis<\/strong>\n<ul>\n<li>Francisco Acosta Villegas<\/li>\n<\/ul>\n<\/li>\n<li><strong>Tribunal<\/strong>\n<ul>\n<li>Presidente del tribunal: Jos\u00e9 Mar\u00eda Moraleda jim\u00e9nez <\/li>\n<li>Miguel angel Perez-espejo Martinez (vocal)<\/li>\n<li>ildefonso Ingelmo ingelmo (vocal)<\/li>\n<li>Manuel Barbera alacreu (vocal)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Tesis doctoral de Diego Fuentes Garc\u00eda Resumen introducci\u00f3n: el objetivo principal de esta tesis doctoral fue comparar el efecto de 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