Definición, características y abordaje de la vía aérea fisiológicamente difícil en el contexto de intubaciones en distintos escenarios clínicos y hospitalarios: una revisión bibliográfica
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Murillo Rojas, Fernando
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Abstract
Introducción y justificación: el manejo de la vía aérea clásicamente se ha manejado desde un punto de vista meramente anatómico. Las guías internacionales y las publicaciones se han escrito de tal forma que sean pautas para lograr una laringoscopía e intubación exitosa.
Sin embargo, se ha dejado de lado las repercusiones que tiene el contexto y la necesidad de intubar a un paciente. Muchos estudios han definido el concepto de vía aérea fisiológicamente difícil como el conjunto de los siguientes elementos: fragilidad y reserva funcional del paciente, las condiciones fisiológicas y fisiopatológicas y las patologías que llevan a que se defina una intubación.
Clínicamente, este concepto se compone de un espectro de entidades, por ejemplo: hipotensión post intubación, hipoxemia refractaria, shock cardiogénico, alteraciones hemodinámicas durante la ventilación mecánica, hipertensión abdominal, y muerte.
Metodología: se basa en la revisión de artículos científicos indexados, guías de manejo de vía aérea y su análisis para definir pautas de manejo de pacientes que presenten vía aérea fisiológicamente difícil.
Resultados y conclusiones: el análisis de los textos recopilados permite la estructuración de la vía aérea fisiológicamente difícil. Se definen tres perfiles: cardiovasculares, metabólicos y pulmonares. Se deben tomar medidas para optimizar cada uno de ellos previo y posterior a la intubación. A nivel cardiovascular se debe evitar la hipotensión, la caída del gasto cardiaco, vigilar los signos vitales y el estado de volumen intravascular. A nivel pulmonar se debe optimizar la preoxigenación, valorar los cortocircuitos y la capacidad de entrega tisular de oxígeno. El perfil metabólico se basa en valorar el daño a órganos específicos y aquellos que sean susceptibles: hiperlactatemia, hipertensión intraabdominal, fallo renal y fallo hepático. El manejo estructurado de estas variables disminuye el riesgo de que el paciente frágil caiga en colapso posterior a la intubación.
Introduction and justification: airway management has classically been only managed from anatomical point of view. International guidelines and publications have been written in such a way that they are guidelines for achieving successful laryngoscopy and intubation. However, the repercussions of context and the necessity to intubate a patient have been disregarded. Many studies have defined the concept of a physiologically difficult airway as the set of the following elements: fragility and functional reserve of the patient, the physiological and pathophysiological conditions, and the pathologies that lead to the definition of intubation. Clinically, this concept is made up of a spectrum of entities, for example: post-intubation hypotension, refractory hypoxemia, cardiogenic shock, hemodynamic changes during mechanical ventilation, abdominal hypertension, and death. Methodology: it is based on the review of indexed scientific articles, airway management guidelines and their analysis to define management guidelines for patients with physiologically difficult airway. Results and conclusions: the analysis of the collected texts allows the structuring of the physiologically difficult airway concept. Three profiles are defined: cardiovascular, metabolic and pulmonary. Measures must be taken to optimize each of them before and after intubation. At the cardiovascular level, hypotension, a cardiac output diminution should be avoided, vital signs and intravascular volume status should be monitored. At the pulmonary level, pre-oxygenation must be optimized, assessing cardiopulmonary shunts and the oxygen delivery to tissue capacity. The metabolic profile is based on assessing the damage to specific organs and those that are susceptible: hyperlactatemia, intra-abdominal hypertension, renal failure and liver failure. The structured management of these variables decreases the risk of the frail patient collapsing after intubation.
Introduction and justification: airway management has classically been only managed from anatomical point of view. International guidelines and publications have been written in such a way that they are guidelines for achieving successful laryngoscopy and intubation. However, the repercussions of context and the necessity to intubate a patient have been disregarded. Many studies have defined the concept of a physiologically difficult airway as the set of the following elements: fragility and functional reserve of the patient, the physiological and pathophysiological conditions, and the pathologies that lead to the definition of intubation. Clinically, this concept is made up of a spectrum of entities, for example: post-intubation hypotension, refractory hypoxemia, cardiogenic shock, hemodynamic changes during mechanical ventilation, abdominal hypertension, and death. Methodology: it is based on the review of indexed scientific articles, airway management guidelines and their analysis to define management guidelines for patients with physiologically difficult airway. Results and conclusions: the analysis of the collected texts allows the structuring of the physiologically difficult airway concept. Three profiles are defined: cardiovascular, metabolic and pulmonary. Measures must be taken to optimize each of them before and after intubation. At the cardiovascular level, hypotension, a cardiac output diminution should be avoided, vital signs and intravascular volume status should be monitored. At the pulmonary level, pre-oxygenation must be optimized, assessing cardiopulmonary shunts and the oxygen delivery to tissue capacity. The metabolic profile is based on assessing the damage to specific organs and those that are susceptible: hyperlactatemia, intra-abdominal hypertension, renal failure and liver failure. The structured management of these variables decreases the risk of the frail patient collapsing after intubation.
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hipotensión post intubación, fallo renal, fallo hepático, ANESTESIOLOGÍA, hiperlactatemia