8/12/2019 El Manejo Agudo de La Hemorragia Por Trauma

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EL MANEJO AGUDO DE LA HEMORRAGIA POR TRAUMA:UNA REVISON SITEMATICA DE LAS PRUEBAS

ALEATORIASCONTROLADAS

Nicola Curry 1 *,

Sally Hopewell 2

3 , Carolyn Dore 2

, Chris Hyde 4

, KarimBrohi 5 y SimonStanworth 1

INTRODUCCION

El trauma es una de las principales causas mundiales de muerte y discapacidad. Alrededor del 40% de las muertes se deben a sangrados o sus consecuencias,estableciendo la hemorragia como la causa ms comn de muerte evitable en estegrupo clnico [1-3]. La relacin entre los resultados pobres y la hemorragia portrauma han sido bien reconocido por ms de 30 aos [ 4 ], y se aplica globalmente[ 5 , 6 ], en ambos escenarios civiles y militares [ 7 ]. Sin embargo, los resultadosde hemorragia gravepermanecen pobres, con tasas de mortalidad cercana al 50%para los pacientes que requieren transfusin masiva de sangre o que desarrollanuna coagulopata significativa [ 8 , 9 ]. Manejo de la hemorragia por traumadepende de un enfoque multifactorial de una intervencin quirrgica oportuna, lareanimacion de lquidos y la terapia de transfusin sangunea [ 10 ].

Los avances han tenido lugar en nuestra comprensin de la fisiopatologa de lacoagulopatia inducida por trauma[ 11 , 12 ], en la disponibilidad de modalidades dediagnstico rpido [ 13 ], y la introduccin de estrategias de reanimacinhemostticos [ 14 ]. Por el contrario, las revisiones de la evidencia han demostradoque algunos terapias aceptadas, como la sangre o la transfusin de plasma podraser ineficaz o asociado con peores resultados [ 15 , 16 ].

Revisiones existentes se han centrado sobre las intervenciones individuales, talescomo la razn de transfusiones[ 16 - 19 ], sustitutos de la sangre [ 20 ], o agentesfarmacuticos [ 21 , 22 ]. Nuestro objetivo fue llevar a cabo una revisinsistemtica de la literatura ms amplio de pruebas para todos lospruebasaleatorias controladas (RCTs) pertinente para el manejo temprano deltrauma de pacientes con sangrado. Especficamente nos dirigimos a evaluar lametodologa de las pruebas y valorar un ampliointervalo de resultados centradossobre el sangrado y los requisitos de transfusin, la correccin de la coagulopatay la mortalidad.

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Abstraccin de datos y evaluacin de la calidad

Los datos se resumieron en formularios especficos de estudio por un revisor yverificados por un segundo revisor. Esto incluy: pas de origen, contexto clnico,la poblacin de estudio, la estructura de la prueba, la calidad del estudio, la

naturaleza y la duracin de los grupos de intervencin y control, resultadosevaluados y conclusiones reportadas. Los desacuerdos se resolvieron porconsenso. La valoracin de la calidad metodolgica fue encargado por las pruebasaleatorias controladas elegibles. Se evalu la generacin de la secuenciaaleatoria, encubrimiento de la asignacin, el cegamiento de la asignacin y el datodel resultado incompleto [ 23 ].

Anlisis

Se ejecut un anlisis descriptivo, ya que no era posible encargar un metanlisisdebido a la heterogeneidad de las intervenciones. Las PACs se agruparon encuatro reas clnicas: estrategias de la sangre y ahorro de la sangre; el manejomecnico y quirrgico; el uso de lquidos intravenosos para la reanimacin; yagentes farmacuticos.