Reposição Volêmica no Choque Hemorrágico. A Solução Empregada faz Diferença em Relação aos Efeitos Hemodinâmicos e Renais?
Hemorrhagic Shock Volume Replacement: Does the Solution Make a Difference in Hemodynamic and Renal Effects?
Leandro Gobbo Braz, Pedro Thadeu Galvão Vianna, Luiz Antonio Vane, José Reinaldo Cerqueira Braz
Resumo
Justificativa e Objetivos - O emprego de pequenos volumes de solução hipertônica (SH) isoladamente ou em associação à solução de dextran 70 a 6% (SHD), abre novas perspectivas no manuseio da reposição volêmica durante o choque hipovolêmico, em relação ao emprego de soluções cristalóides. A pesquisa experimental tem como objetivo verificar se o tipo de solução empregada na reposição do choque hemorrágico apresenta diferença em relação aos efeitos hemodinâmicos e renais. Método - Foram utilizados 24 cães anestesiados com pentobarbital sódico. Após retirada de 40% do volume sangüíneo, os cães foram distribuídos de forma aleatória em 3 grupos de 8 animais, de acordo com a solução empregada para a reposição volêmica: G1 - SH a 7,5% em volume de 4 ml.kg-1; G2 - solução de Ringer com lactato (RL) na proporção 2:1 em relação ao volume de sangue retirado; e G3 - SHD em volume de 4 ml.kg-1. Foram estudados os seguintes atributos: freqüência cardíaca (FC), pressão arterial média (PAM), pressão venosa central (PVC), fluxo sangüíneo aórtico (FAo), resistência vascular aórtica (RvAo), fluxo plasmático renal (FPR), ritmo de filtração glomerular (RFG), fluxo sangüíneo renal, débito urinário (DU), resistência vascular renal, excreção urinária de sódio (EUNa), excreção fracionária de sódio (EFNa), depuração osmolar (Dosm) e depuração de água livre (DH2O). Os atributos PAM, PVC e FAo foram estudados nos momentos: M1 (controle); M2 - após a retirada de 40% da volemia; M3, M4 e M5 -imediatamente e após 15 e 60 min da reposição volêmica, respectivamente. Os demais atributos foram estudados nos momentos: M1 (controle); M2 e M3 -15 e 60 min da reposição volêmica, respectivamente. Resultados - A reposição com RL (G2) aumentou o FAo e a PVC em M3 e M4, em níveis superiores aos determinados pela reposição com pequenos volumes (G1 e G3). Não houve diferença significante da PAM entre os grupos, que se elevou após a reposição, mas não retornou aos níveis do controle. O DU aumentou significantemente em G2 (RL), com aumento da DH2O nesse grupo e em G3 (SHD). Conclusões - A reposição com RL determina excessiva expansão volêmica, enquanto a reposição com SH e SHD determina boa expansão volêmica, sem diferença significante entre elas. Todas as soluções mantêm a hemodinâmica e função renais, com o RL provocando aumento do débito urinário.
Palavras-chave
Abstract
Background and Objectives - The use of low volumes of hypertonic (7.5%) NaCI solution (HS), alone or in combination with 6% dextran-70 solution (DHS) offers new perspectives for hemorrhagic shock volume replacement as compared to isotonic crystalloid solutions. This report evaluates whether the type of solution makes a difference in hemodynamic and renal effects after hemorrhagic shock. Methods - Twenty-four dogs previously anesthetized with sodium pentobarbital were studied. After 40% removal of blood volume, dogs were randomly distributed into three groups according to the volume replacement solution: G1 (n=8) - HS (hyperosmolar 7.5% NaCl solution) 4 ml.kg-1; G2 (n=8) - LR (lactated Ringer’s) solution at a 2:1 ratio to blood volume removed; and G3 (n=8) - SHD (hyperosmolar NaCl 7.5% solution associated to hyperoncotic 6% dextran 70) 4 ml.kg-1. The following parameters were studied: heart rate (HR), mean blood pressure (MBP), central venous pressure (CVP), aortic blood flow (AoBF), aortic vascular resistance (AoVR), renal plasma flow (RPF), glomerular filtration rate (GFR), renal blood flow, urinary output (UO), renal vascular resistance, sodium urinary excretion (UENa), sodium fractionary excretion (FENa), osmolar clearance (COsm) and free water clearance (CH2O). MBP, CVP and AoBF were studied at control (M1), after hemorrhagic shock (M2) and immediately (M3), 15 min (M4) and 60 min (M5) after volume replacement. Other parameters were studied at control (M1), 15 min (M2) and 60 min (M3) after volume replacement. Results - Replacement with LR (G2) increased AoBF and CVP in M3 and M4 to higher levels than those determined by the low volume replacement (G1 and G3). Volume replacement increased MBP, which did not return to baseline values in all groups. No significant differences were observed. UO increased significantly in G2 (LR) and CH2O increased in G2 and G3 (DHS). Conclusions - Volume replacement with LR determined excessive volume expansion. Volume replacement with HS and DHS determined good volume expansion without significant difference between them. All solutions maintained renal function, while only LR increased urinary output.
Keywords
Referencias
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