«Normalización» de la perfusión tisular en el choque séptico: Rivers, Jones y el enfoque multimodal

Abstract

Initial resuscitation in patients with severe sepsis and septic shock is one of the cornerstones in the management of these patients. Rivers et al demonstrated that the application of a resuscitation protocol within the first six hours of entering the Emergency Department decreased in-hospital mortality in this group of patients. This protocol established a number of pre-defined resuscitation objectives for central venous pressure, mean blood pressure, and central venous saturation. The usefulness of these parameters has been questioned as objectives. Recently, Jones demonstrated that using lactate clearance as an initial resuscitation objective was not inferior to the use of venous oxygen saturation. Although these studies have demonstrated that the application of these protocols decreases mortality, a number of authors have questioned their usefulness. In this respect, Hernández states that a protocol with several objectives to assess tissue perfusion is more useful during resuscitation. However, these protocols are proposed to be applied on all patients in the same way without considering the individual physiological variability and their underlying health conditions. It is important to take into consideration that the usefulness of a number of these measurements arises from physiological models that have limitations, and that the concept of “normalisation” of physiological parameters should be analysed in the light of the concept of normality in physiology. Therefore, resuscitation with the same “predefined physiological objectives» for all patients is a limited concept in the light of the physiological reality.