paul trigos

#pedsICU médico.. pediatra.. intensivista pediatra..bioeticista...
(｡◕‿◕｡)➜.. ser humano

[小谷祐樹 Yuki Kotani｜集中治療医 @YukiKotani5]

⑥敗血症のガイドライン（ICM & CCM）

129の推奨文から見て取れるように、広範なトピックを網羅しています。個人的な目玉は「In our practice」。エビデンスが不十分な時に、ガイドライン作成委員が自身のプラクティスを紹介していて、より実践的な構成になりました。
https://t.co/gaR2KB1Cub

[paul trigos @trigosP52]

La reducción de la exposición al oxígeno con objetivo (SpO2 ) del 90 % no reduce la mortalidad en pacientes adultos con VM
Conservative Oxygen Therapy in Mechanically Ventilated Critically Ill Adult Patients: The UK-ROX https://t.co/GH6QbE5hcY

[paul trigos @trigosP52]

No es perseguir es saber usar e incluso favorecer su uso adecuado y temprano

[paul trigos @trigosP52]

Los neonatologos lo habia establecido hace mucho tiempo ..El bicarbonato de sodio no mejora el retorno sostenido de la circulación espontánea, la supervivencia,ni los resultados neurológicos

[JAMA @JAMA_current]

🧵 Sodium bicarbonate did not improve sustained return of spontaneous circulation, survival, or neurologic outcomes in adults with in-hospital cardiac arrest compared to placebo.

#CCR26 @CritCareReviews

https://t.co/2KJGJOlyHu

[paul trigos @trigosP52]

La vitamina c en dosis altas es un prooxidante puede generar sobrecarga renal y daño renal y tiene efectos adversos en la respuesta inmunitaria a los procesos infecciosos .. https://t.co/LjvF0NbNbD

[paul trigos @trigosP52]

La administración de líquidos sin tener en cuenta el gasto cardiaco empeora la congestión venosa, (VExUS y PVC) la estrategia es valida en quienes pueden tolerarlo, gasto cardiaco y adaptabilidad cardiaca preservada o deficit de volumen intravascular https://t.co/LS4jfeNk2a

[Dr. Chacón-Lozsán F .'. @franciscojlk]

🫀 Septic Shock Is Not Just About Blood Pressure: It Is About Ventriculo-Arterial Coupling

For years, septic shock resuscitation has focused on restoring MAP, increasing cardiac output, and normalizing lactate.

But what if the real problem is not flow alone?

What if the heart and arterial system are no longer working together?

This is the concept of ventriculo-arterial coupling (VAC): the dynamic interaction between ventricular contractility (Ees) and arterial load (Ea). When coupling is preserved, the cardiovascular system operates efficiently, maximizing stroke work while minimizing myocardial energy expenditure.

Why VAC Matters in Septic Shock

Sepsis causes profound vasoplegia, myocardial depression, and alterations in vascular tone.

As a result, many patients develop ventriculo-arterial uncoupling, where ventricular contractility and arterial load become mismatched. This leads to:
✅ Reduced cardiovascular efficiency
✅ Increased myocardial energetic cost
✅ Impaired tissue perfusion despite apparently adequate cardiac output
✅ Variable responses to fluids, vasopressors, and inotropes

In other words:
Two patients may have the same MAP and cardiac output but completely different cardiovascular efficiency and energetic burden.

The Norepinephrine Paradox

One of the most interesting concepts highlighted by Pinsky and Guarracino is that increasing blood pressure does not always improve cardiovascular performance.

In some septic shock patients with depressed contractility:
🔹 Norepinephrine increases arterial elastance (Ea)
🔹 MAP rises
🔹 Left ventricular afterload increases
🔹 Stroke volume may fall
🔹 VAC worsens
🔹 Cardiac output may remain unchanged or even decrease

The monitor shows a better blood pressure.

The ventricle may actually be working less efficiently.

Why Some Patients Respond and Others Do Not

The review provides a physiological explanation for the heterogeneity we see every day in the ICU.

Patients with preserved contractile reserve may tolerate increased afterload and maintain efficient coupling.

Patients with septic cardiomyopathy may not.

This may explain why identical norepinephrine doses can produce dramatically different hemodynamic responses among seemingly similar septic shock patients.

Beyond Left Ventricular Function

The same principles apply to the right ventricle.

In septic patients with ARDS:
🔹 Pulmonary vascular resistance rises
🔹 RV afterload increases
🔹 RV-pulmonary artery coupling deteriorates
🔹 Venous congestion develops
🔹 Organ perfusion worsens despite acceptable systemic pressures

This reminds us that shock physiology extends far beyond MAP alone.

Clinical Takeaway

Perhaps the next evolution of septic shock management is not simply asking: "Did cardiovascular efficiency improve?"

Reference 📚
Pinsky MR, Guarracino F. Pathophysiological implications of ventriculoarterial coupling in septic shock. Intensive Care Medicine Experimental. 2023;11:87.
https://t.co/3bYkZ1G7wG

[paul trigos @trigosP52]

No todo es vasopresor ..hay mas que tension arterial ... mejor optimizar gasto cardiaco

[Dr. Chacón-Lozsán F .'. @franciscojlk]

🫀 Septic Shock Is Not Just About Blood Pressure: It Is About Ventriculo-Arterial Coupling

For years, septic shock resuscitation has focused on restoring MAP, increasing cardiac output, and normalizing lactate.

But what if the real problem is not flow alone?

What if the heart and arterial system are no longer working together?

This is the concept of ventriculo-arterial coupling (VAC): the dynamic interaction between ventricular contractility (Ees) and arterial load (Ea). When coupling is preserved, the cardiovascular system operates efficiently, maximizing stroke work while minimizing myocardial energy expenditure.

Why VAC Matters in Septic Shock

Sepsis causes profound vasoplegia, myocardial depression, and alterations in vascular tone.

As a result, many patients develop ventriculo-arterial uncoupling, where ventricular contractility and arterial load become mismatched. This leads to:
✅ Reduced cardiovascular efficiency
✅ Increased myocardial energetic cost
✅ Impaired tissue perfusion despite apparently adequate cardiac output
✅ Variable responses to fluids, vasopressors, and inotropes

In other words:
Two patients may have the same MAP and cardiac output but completely different cardiovascular efficiency and energetic burden.

The Norepinephrine Paradox

One of the most interesting concepts highlighted by Pinsky and Guarracino is that increasing blood pressure does not always improve cardiovascular performance.

In some septic shock patients with depressed contractility:
🔹 Norepinephrine increases arterial elastance (Ea)
🔹 MAP rises
🔹 Left ventricular afterload increases
🔹 Stroke volume may fall
🔹 VAC worsens
🔹 Cardiac output may remain unchanged or even decrease

The monitor shows a better blood pressure.

The ventricle may actually be working less efficiently.

Why Some Patients Respond and Others Do Not

The review provides a physiological explanation for the heterogeneity we see every day in the ICU.

Patients with preserved contractile reserve may tolerate increased afterload and maintain efficient coupling.

Patients with septic cardiomyopathy may not.

This may explain why identical norepinephrine doses can produce dramatically different hemodynamic responses among seemingly similar septic shock patients.

Beyond Left Ventricular Function

The same principles apply to the right ventricle.

In septic patients with ARDS:
🔹 Pulmonary vascular resistance rises
🔹 RV afterload increases
🔹 RV-pulmonary artery coupling deteriorates
🔹 Venous congestion develops
🔹 Organ perfusion worsens despite acceptable systemic pressures

This reminds us that shock physiology extends far beyond MAP alone.

Clinical Takeaway

Perhaps the next evolution of septic shock management is not simply asking: "Did cardiovascular efficiency improve?"

Reference 📚
Pinsky MR, Guarracino F. Pathophysiological implications of ventriculoarterial coupling in septic shock. Intensive Care Medicine Experimental. 2023;11:87.
https://t.co/3bYkZ1G7wG

[paul trigos @trigosP52]

Ni restrigir el volumen de líquidos y ni la administración temprana de vasopresores mejora la supervivencia o el alta hospitalaria ...por si solos no son una estrategia ganadora https://t.co/QqwQLLsFFn

[paul trigos @trigosP52]

Posponer la administración de vasopresores y optar por fluidos en pacientes tolerantes y depleción de volumen; limitar los bolos de fluidos en pacientes con insuficiencia respiratoria o enfermedad cardiorrenal significativa"reanimar con guia hemodinamica" https://t.co/ufvi9BMvag

[paul trigos @trigosP52]

Epinephrine Versus Dopamine in Children
Los datos disponibles demuestran un aparente beneficio en la mortalidad asociado al uso de epinefrina efecto que disminuye con la edad no diferencias en neonatos con efectis hemodinamicos comparables https://t.co/2wWo4hzGci

[paul trigos @trigosP52]

Norepinefrina versus dopamina neonatos ..tuvieron una eficacia comparable como agentes vasoactivos de primera línea
 Julio 2025 https://t.co/ex2ce2fOmB

[paul trigos @trigosP52]

En la UCI en sospecha o confirmación de infección bacteriana el uso de terapia antimicrobiana empírica apropiada se asoció con una menor mortalidad a los 28 días consistente en todos los niveles de certeza diagnóstica y gravedad mayor a mayor gravedad https://t.co/VO9ncclhvV

[paul trigos @trigosP52]

La pletismografia y sus indices como el PI "proporcionan información útil para la reanimación del shock, el manejo de líquidos, la terapia con vasopresores, la predicción de resultados, la estratificación del riesgo" ..🧐
https://t.co/MolfqMwaZ6

[paul trigos @trigosP52]

cambio de paradigma en la patobiología "el reconocimiento de que la supervivencia depende no solo de la eliminación de patógenos sino de la capacidad restaurar la homeostasis a través de la regulación dinámica de las respuestas inmunitarias y citotoxicas" https://t.co/QJ6BitkW8J

[paul trigos @trigosP52]

Para anagesia y sedacion 1 linea opiaceos para sedacion se prefiere propofol o dexmedetomidine (mejor perfil seguridad)sobre midazolam "Reserve midazolam for specific indications""consider dexmedetomidine in patients at high risk of delirium" https://t.co/p3a74uoYMB

[paul trigos @trigosP52]

la terapia combinada basada en macrólidos es el estandar de atencion la claritromicina es el agente preferido (Nac grave) "Su perfil farmacodinámico superior y la señal de reducción de la mortalidad favorecen su uso en el ámbito de cuidados intensivos https://t.co/aK0y7HBiI9

[paul trigos @trigosP52]

Es necesario añadir un macrólido en la neumonía adquirida en la comunidad (NAC) grave? La respuesta es un SÍ inequívoco. https://t.co/jNBQ5ggfeZ

[paul trigos @trigosP52]

"paracetamol es un antipirético seguro contra los síndromes convulsivos y tiene el potencial de prevenir la recurrencia de estos síndromes durante el mismo episodio febril"
https://t.co/hMmZ5Nxsly

[paul trigos @trigosP52]

Esta revisión proporciona un apoyo limitado para el uso de antipiréticos en la prevención de la recurrencia de convulsiones febriles dentro del mismo episodio de fiebre 🤒
https://t.co/RbuAwBO0q1