Queda do VO2 e Lactato normal, vou confiar em quem?

vo2 ou lactato 1

J. L. Vincent e D. De Backer publicaram um artigo clássico em terapia intensiva sobre as fases dependente e independente do choque séptico em 1998. Foi o primeiro artigo que caracterizou em seres humanos, as relações entre VO2 (consumo de Oxigênio) e DO2 (oferta de Oxigênio) no choque séptico. Até essa publicação, existiam apenas trabalhos experimentais.

Esse artigo completou 20 anos mas a discussão que ele traz ainda é atual, não pela conclusão em si, que todos já conhecem (talvez não soubessem o quão recente é esse entendimento), mas sim pelos questionamentos que faz sobre a transição da fase dependente (instável, descompensada) para a fase independente (compensada, estável).

Antes de prosseguir, vou revisar esses conceitos começando pelo conceito de choque que é um quadro de falência circulatória associada à utilização inadequada de oxigênio pelas células. Esse uso inadequado de oxigênio é o ponto crítico que o mundo todo tenta prever, diagnosticar e tratar. As fases do choque que estamos discutindo são definidas pela relação entre oferta e consumo de O2, recebem vários nomes que tentam associar conceitos a fim de facilitar o entendimento:

 

Dependência patológica DO2/VO2 ou Anaeróbica ou Choque descompensado 

e

Dependência fisiológica DO2/VO2 ou Aeróbica ou Choque compensado

 

vo2 ou lactato

Na figura 1 nota-se um ponto destacado que é chamado de DO2 crítica, que é o ponto de inflexão determinante entre as duas fases do choque.  Observa-se também a DO2 crítica marca mudanças também no lactato, na SvO2 (Saturação venosa mista de O2) e na TEO2 (Taxa de extração de O2), seria muito fácil se os pacientes se comportassem assim, com essa interface clara e bem definida, mas a prática não é tão claro.

O artigo traz dúvida: o VO2 pode ser dependente na fase inicial mas independente na fase seguinte? Ou seja as relações entre VO2 e DO2 podem diferenciar as fases do choque em humanos? (Isso já havia sido provado em animais.) A resposta foi sim e como isso é regra há muito tempo, minha intenção aqui não é comentar isso e sim, evidenciar os questionamentos secundários. 

Será que o lactato, a TEO2 e a SvO2 também diferenciam as fases do choque séptico?

Se o VO2 cair juntamente com a DO2, mas ao mesmo tempo existir lactato normal e SvO2 normal, em que fase do choque o paciente se encontra?

Se você não entendeu essas duas últimas perguntas, perceba que no gráfico da figura 1, todos os parâmetros indicam a mesma coisa para um lado ou para o outro, não há divergência de informações. Se estamos na fase de dependência patológica, o lactato estará elevado, a SvO2 estará baixa e a TEO2 estará elevada, o oposto vale para a fase de dependência fisiológica. 

Na prática clínica encontramos justamente isso! Variáveis indicando sentidos opostos. Tudo fica mais fácil quando avaliamos o choque retrospectivamente, fica clara qual era a tendência e os indicadores discordantes são ignorados ou se atribui algum erro de aferição… Na verdade, na transição entre as fases pode haver informações discordantes pois o organismo ainda não atingiu um equilíbrio que irá conduzir à recuperação nem um estado refratário que irá conduzir à falência total. Porém, saber disso não resolve a o problema, a dúvida continua, vamos confiar mais em quem para saber se estamos indo para a dependência patológica ou para a dependência fisiológica?

O artigo traz na discussão que a TEO2 tem variações de magnitude limitadas para se correlacionar com a VO2, traz também que lactato não é confiável pois exitem pacientes na fase compensada do choque, independência fisiológica com lactato elevado, e paciente na fase descompensada, dependência patológica, com lactato normal. O artigo não comentou sobre o comportamento da SvO2, mas sabemos por outros estudos que não é um bom marcador para predizer anaerobiose.

Portanto o principal cuidado é cometer o erro de considerar que a ressuscitação do choque séptico foi concluído com êxito, sem que a falência circulatória esteja resolvida juntamente com a melhor utilização de oxigênio pelas células. Ou seja Índice cardíaco adequado à demanda metabólica (VO2 estável), com TEO2, lactato, SvO2 (ou SvcO2) normais.

 

Referências

Oxygen supply dependency can characterize septic shock. Intensive Care Med. 1998 Feb;24(2):118-23.

Como escolher os alvos terapêuticos para melhorar a perfusão tecidual no choque séptico. einstein. 2015;13(3):441-7

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014; 40(12): 1795–1815.

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