Neurocirugía Neurocirugía
Neurocirugia.2001;12:23-35 - Vol. 12 Núm.1 DOI: 10.1016/S1130-1473(01)70714-2
Reflexiones sobre el uso de la hipotermia moderada en el tratamiento del paciente con un traumatismo craneoencefálico grave
Reflections on the use of moderate hypothermia in the management of severely head injured patients
J. Sahuquillo, A. Biestro**, S. Amorós***, M.A. Poca, M. Báguena****, J. Ibáñez, M. Noguer*****, A. Garnacho****
* Servicio de Neurocirugía. Hospital Universitario Vall d’Hebron. Barcelona
** Unidad de Cuidados Intensivos. Hospital de Clinicas de Montevideo. Uruguay
*** Unidad de Investigación de Neurotraumatología. Hospital Universitario Vall d’Hebron. Barcelona
**** Unidad de Cuidados Intensivos de Neurotraumatología. Hospital Universitario Vall d’Hebron. Barcelona
***** Servicio de Anestesiología y Reanimación. Hospital General. Hospital Universitario Vall d’Hebron. Barcelona
Resumen

En los traumatismos craneoencefálicos se desencadenan una serie de alteraciones metabólicas que incrementan las lesiones primarias sufridas de forma inmediata al impacto. Es un hecho suficientemente demostrado que en los traumatismos craneoencefálicos graves, los insultos postraumáticos intra o extracraneales tales como la hipoxia cerebral, la hipotensión arterial o la anemia, exacerban la lesión neuronal y condicionan un peor pronóstico de aquellos pacientes que los sufren. La evidencia, tanto experimental como clínica, sugiere que la hipotermia moderada (32–34°C) puede limitar el efecto nocivo de estas anomalías metabólicas. Estudios experimentales y estudios clínicos controlados de hipotermia moderada, inducida durante periodos relativamente cortos de tiempo (24–48h), demuestran que esta es efectiva en el control de la hipertensión intracraneal y en mejorar el pronóstico cuando se comparan los resultados con grupos control en los que se utilizó la normotermia y las medidas terapéuticas convencionales. A pesar del probado efecto neuroprotector de la hipotermia, los trabajos clínicos sobre el tema han sido desarrollados, estudiados y seguidos de una forma inconstante por diversas razones. En este trabajo, revisamos los mecanismos neuroprotectores de la hipotermia, así como la evidencia clínica y experimental que demuestra su efecto neuroprotector en los pacientes con un TCE grave o en aquéllos que presentan hipertensión intracraneal refractaria a medidas de primer nivel. Se discuten también los resultados negativos del estudio multicéntrico de la hipotermia moderada profiláctica en TCE graves efectuado en EEUU y cuyos resultados no han sido todavía publicados. El principal problema que persiste en la aplicación terapéutica de la hipotermia moderada es la falta de una metodología sistemática para su inducción y mantenimiento. Del mismo modo, la duración óptima de la fase hipotérmica, el momento más adecuado y la metodología para iniciar el recalentamiento no han sido homogéneos en los diferentes estudios analizados. Por ello, los resultados entre diferentes centros son difíciles de comparar y analizar. Sin embargo, la mayor parte de datos disponibles sugieren que la hipotermia es altamente efectiva como neuroprotector contra los efectos adversos de la lesión neuronal traumática y en el tratamiento de las lesiones secundarias. Sin embargo, es necesario la realización de estudios clínicos prospectivos con una metodología homogénea y bien definida antes de implementar esta medida en la práctica clínica diaria. El esfuerzo más importante en los próximos años debe dirigirse a refinar la metodología, a definir el momento y el método óptimo de enfriamiento y recalentamiento, y a tratar de optimizar la metodología consiguiendo tiempos de inducción más rápidos. También es fundamental, definir el momento más apropiado y la velocidad de recalentamiento, ya que es en esta fase del tratamiento donde muchos de los pacientes adecuadamente controlados, deterioran clínicamente y en algunos casos, mueren.

Abstract

Traumatic brain injury initiates several metabolic processes that can increase the primary injury. It is well established that in severe head injuries, posttraumatic secondary insults, such as brain hypoxia, hypotension or anemia, exacerbate neuronal injury and lead to a poorer outcome. Experimental and clinical evidence suggests that moderate hypothermia (32–34°C), may limit some of these deleterious secondary metabolic responses. Recent laboratory studies and prospective controlled clinical trials of induced moderate hypothermia for relatively short periods (24–48h) in patients with severe head injury, have demonstrated good intracranial pressure control and better outcome when compared with patients maintained in normothermia and given conventional treatment. Despite its proven clinical role in neuroprotection, hypothermia research has been inconstantly followed for various reasons. In this paper we review the mechanisms of neuroprotection in hypothermia, the different preclinical and clinical studies that favor its use as a neuroprotector in severe head injury or in patients in whom high intracranial pressure is refractory to first tier measures. The evidence that favors hypothermia is discussed. We also discuss the negative results of the still unpublished multicentre trial on prophylactic moderate hypothermia developed in the USA. The main problem with moderate hypothermia is the lack of a systematic methodology to induce and maintain it. Also, optimal duration of its use and the methodology and timing for rewarming have not been determined. Consequently, the results of different trials are difficult to analyze and compare. However, most evidence suggests that hypothermia provides remarkable protection against the adverse effects of neuronal damage that is exacerbated by secondary injury. Further prospective controlled trials with clearly defined methodology are needed before this method is implemented in daily clinical practice. The most important task for the years to come may be to focus on refining this procedure, defining the optimal time of cooling and rewarming and to optimize the methods of rapidly inducing and maintaining Iow temperature. It is also essential to define the most appropriate method and velocity of the rewarming phase, in which many successfully controlled patients deteriorate and die.

Palabras clave
Hipotermia moderada, Traumatismo craneoencefálico grave, Revisión, Neuroprotección
Keywords
Moderate hypothermia, Severe head injury, Review, Neuroprotection
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Sahuquillo, J.; Biestro, A.; Amorós, S.; Poca, M.A.; Báguena, M.; Ibáñez, J.; Noguer, M.; Garnacho, A.: Reflexiones sobre el uso de la hipotermia moderada en el tratamiento del paciente con un traumatismo craneoencefálico grave. Neurocirugía 2001; 12: 23–35.

Copyright © 2001. Sociedad Española de Neurocirugía
Neurocirugia.2001;12:23-35 - Vol. 12 Núm.1 DOI: 10.1016/S1130-1473(01)70714-2