Miller Anestesia

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pacientes sometidos a cirugía vascular. En un ensayo aleatorizado
prospectivo, el riesgo relativo de morbilidad cardíaca en el período
postoperatorio inmediato se redujo un 55% cuando se mantuvo la
normotermia con sistemas de calentamiento mediante aire for­
zad . En el postoperatorio inmediato, los pacientes sometidos
a cirugía vascular muestran el doble o el triple de incidencia de
isquemia miocárdica cuando la temperatura central es inferior a
35 ° Incluso una hipotermia leve de unos 35 °C se asocia a un
incremento del 200-700% de las concentraciones de norepin-
efrin , vasoconstricción generalizad y elevación de la
presión arterial en el postoperatori Los escalofríos son habitua-
les y aumentan el consumo de oxígeno corporal total, pero sólo en
un 40% en el paciente vascular anciano típic
Es importante controlar la respuesta al estrés en el postope-
ratorio. Esto incluye la prevención de posibles factores desenca­
denantes de isquemia miocárdica (dolor, anemia, hipotermia,
extremos hemodinámicos e insuficiencia ventilatoria). En los
pacientes sometidos a ventilación mecánica, el período de destete
resulta especialmente estresante y es frecuente que se produzca
isquemia miocárdica durante el mism Lo deseable sería sedar
cuidadosamente al paciente y destetarlo con rapidez. Cuando sea
posible, la extubación dentro del quirófano resulta menos estre-
sante y es preferible para los pacientes sometidos a cirugía vascular
carotídea o de la extremidad inferior. Cuando la cirugía es más
cruenta (AAT o aneurismas de aorta abdominal), suele ser precisa
una ventilación mecánica postoperatoria.
La cirugía vascular sigue representando un reto para el anes-
tesista dado el notable estrés fisiológico que se produce en una pobla-
ciónrelativamenteancianaconunaelevadaincidenciadeenfermedades
concomitantes. Los estudios clínicos proporcionan una perspectiva
sobre la valoración preoperatoria y la optimización del riesgo car-
díaco, las implicaciones de la técnica anestésica y el diagnóstico, pre-
vención y tratamiento de la isquemia miocárdica en pacientes que
van a someterse a cirugía vascular. Estos estudios han mejorado
nuestra capacidad de tratamiento de los pacientes de cirugía vascular,
reduciendo la morbilidad y mejorando el pronóstico global.
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Anestesia para la cirugía vascular 1801 52
Sección IV
Anestesia por subespecialidades en el adulto
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