Article

lock Open Access lock Peer-Reviewed

3

Views

ARTIGO ORIGINAL

Síndrome vasoplégica: nova forma de síndrome pós perfusão

Walter José GomesI; Marcelo Grandini SilasI; Marly Garcia LopesI; José Honório PalmaI; Carlos Alberto TelesI; João Nelson R BrancoI; Antônio Carlos CarvalhoII; Ênio BuffoloI

DOI: 10.1590/S0102-76381996000100008

RESUMO

Uma nova forma de síndrome pós perfusão, denominada síndrome vasoplégica, aparecendo no período pós-operatório imediato de cirurgias cardíacas com circulação extracorpórea (CEC) é apresentada. As manifestações dessa síndrome incluem hipotensão, débito cardíaco normal ou aumentado, resistência vascular sistêmica diminuída e pressões de enchimento baixas. O exame físico mostra que, mesmo com hipotensão, os pacientes apresentam bom enchimento capilar de extremidades, mas com oligúria. Há necessidade de uso de vasoconstrictores potentes para manutenção da pressão arterial e, mesmo com altas doses de noradrenalina, não há o quadro clássico de extremidades frias. Doze pacientes que apresentaram sinais e sintomas compatíveis com a síndrome vasoplégica são mostrados. O quadro da síndrome vasoplégica mostra semelhança com o observado no choque séptico. Na sepse, as alterações são mediadas pelas citocinas, entre elas o TNF-a, que também já foi demonstrado serem ativadas pela CEC. O aparecimento da síndrome vasoplégica eleva a morbidade operatória, com conseqüente aumento de risco para o paciente.

ABSTRACT

A new form of postperfusion syndrome, termed vasoplegic syndrome and presenting in the postoperative period of heart surgery with cardiopulmonary bypass (CPB) is described. The patients exhibit hipotension, normal or elevated cardiac output, low systemic vascular resistance and decreased filling pressures. Physical examination revealed normal capillary filling atthe extremities, but oliguria and hipotension. These patients needed a high dosage of vasoconstrictor drugs (norepinephrine) for blood pressure control and even high dose of norepinephrine did not produce the classical situation of cool extremities. Twelve patients who presented signals and symptoms of vasoplegic syndrome are shown. The characteristics of vasoplegic syndrome are similar to those observed in the septic shock. In sepsis, the alterations are mediated by cytokines and TNF-a. The appearance of vasoplegic syndrome augments operative morbidity, with an increased risk to the patient.
Texto completo disponível apenas em PDF.

REFERÊNCIAS

1. ALLARDYCE, D. B.; YOSHIDA, S. H.; ASHMORE, P. G. - The importance of microembolism in the pathogenesis of organ disfunction caused by prolonged use of pump oxygenator. J. Thorac. Cardiovasc. Surg., 52: 706-712, 1996.

2. BELLOMO, R. - The cytokine network in the critically ill. Anaesth. Intens. Care, 20: 288-302, 1992.

3. BERNARDI, C. & TEDGUI, A. - Cytokine network and the vessel wall: insights into septic shock pathogenesis. Eur. Cytokine Netw., 3: 19-33, 1992. [MedLine]

4. BUTLER, J.; ROCKER, G. M.; WESTABY, S. - Inflammatory response to cardiopulmonary bypass. Ann. Thorac. Surg., 55: 552-559, 1993. [MedLine]

5. CHENOWETH, D. E.; COOPER, S. W.; HUGLI, T. E.; STEWART, R.; BLACKSTONE, E. H.; KIRKLIN, J. W. - Complement activation during cardiopulmonary bypass: evidence for generation of C3a and C5a anaphylatoxins. N. Engl. J. Med., 304: 497-503, 1981. [MedLine]

6. DOWNING, S. W. & EDMUNDS Jr., L. H. - Release of vasoactive substances during cardiopulmonary bypass. Ann. Thorac. Surg., 54: 1236-1248, 1992.

7. FINN, A.; NAIK, S.; KLEIN, N.; LEVINSKY, R. J.; STROBEL, S.; ELLIOTT, M. - lnterleukin-8 release and neutrophil degranulation after pediatric cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., 105: 234-241, 1993. [MedLine]

8. FONG, Y.; MOLDAWER, L. L.; SHIMS, G. T.; LOWRY, S. F. - The biological characteristics of cytokines and their implication in surgical injury. Surg. Gynecol. Obstet., 170: 363-378, 1990. [MedLine]

9. GOMES, W. J.; CARVALHO, A. C.; PALMA, J. H.; GONÇALVES, I.; BUFFOLO, E. - Vasoplegic syndrome: a new dilemma. J. Thorac. Cardiovasc. Surg., 107: 942-943, 1994. [MedLine]

10. HENNEIN, H. A.; EBBA, H.; RODRIGUEZ, J. L.; MERRICK, S. H.; KEITH, F. M.; BRONSTEIN, M. H.; LEUNG, J. M.; MANGANO, D. T.; GREENFIELD, L. J.; RANKIN, J. C. - Relationship of the proinflammatory cytokines to myocardial ischemia and dysfunction after uncomplicated coronary revascularization. J. Thorac. Cardiovasc. Surg., 108: 626-635, 1994. [MedLine]

11. JANSEN, N. J. G.; van OEVEREN, W.; GU, Y. J.; van VLIET, M. H.; EIJSMAN, L.; WILDEVUUR, C. R. H. - Endotoxin release and tumor necrosis factor formation during cardiopulmonary bypass. Ann. Thorac. Surg., 54: 744-748, 1992.

12. KIRKLIN, J. K. - The postperfusion syndrome: inflammation and the damaging effects of cardiopulmonary bypass. In: TINKER, J. H. Cardiopulmonary bypass: current concepts and controversies. Philadelphia, W. B. Saunders, 1989, p. 131-146.

13. KIRKLIN, J. K.; WESTABY, S.; BLACKSTONE, E. H.; KIRKLIN, J. W.; PACIFICO, A. D.; CHENOWETH, D. E. - Complement and the damaging effects of cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., 86: 845-857, 1983. [MedLine]

14. LAMAS, S.; MICHEL, T.; BRENNER, B. M.; MARSDEN, P. A. - Nitric oxidein endothelial cells: evidence for a pathway inducible by TNF-alpha. Am. J. Physiol., 261: C634-C641, 1991. [MedLine]

15. MANTOVANI, A & DEJANA, E. - Cytokines as communication signals between leukocytes and endothelial cells. Immunol. Today, 10: 370-5, 1989. [MedLine]

16. MORRISON, D. C. & RYAN, J. L. - Endotoxins and disease mechanisms. Am. Rev. Med., 38: 417-432, 1987.

17. RIGATO Jr., O - Avaliação dos níveis séricos de fator de necrose de tumor alfa (TNF-a) em pacientes com diagnóstico clínico de sepse. Relevancia da doença de base e associação com evolução. São Paulo, 1993. [Tese. Mestrado. Escola Paulista de Medicina].

18. ROCKE, D. A.; GRAFFIN, S. L.; WELLS, M. T.; KOEN, Y.; BROCK-UTINE, J. G. - Endotoxemia associated with cardiopulmonary bypass, J. Thorac. Cardiovasc. Surg., 93: 832-837, 1987. [MedLine]

19. STARNES Jr., H. F.; WARREN, R. S.; JEEVANANDAM, M. - Tumor necrosis factor and the acute metabolic response to tissue injury in man. J. Clin. Invest., 82: 1321-1325, 1988. [MedLine]

20. WATARIDA, S.; MPRI, A.; ONOE, M.; TABATA, R.; SHIRAISHI, S.; SUGITA, T.; NOJIMA, T.; NAKAJIMA, Y.; MATSUNO, S. - A clinical study on the effects of pulsatile cardiopulmonary bypass on the blood endotoxin levels. J. Thorac. Cardiovasc. Surg., 108: 620-625, 1994. [MedLine]

21. WESTABY, S. - Organ disfunction after cardiopulmonary bypass: a sistemic inflammatory reaction initiated by the extracorporeal circuit. Int. Care Med., 13: 89-95, 1987.

22. YOUNG, L. S. - Endotoxins and mediators: an introduction. In: STURK, A. Bacterial endotoxins: citokine mediators and new therapies for sepsis. New York, Wiley-Liss, 1991, p. 1-7.

CCBY All scientific articles published at rbccv.org.br are licensed under a Creative Commons license

Indexes

All rights reserved 2017 / © 2021 Brazilian Society of Cardiovascular Surgery DEVELOPMENT BY