Pérdida de masa muscular en el paciente críticamente enfermo: ¿Caquexia, sarcopenia y/o atrofia? Impacto en la respuesta terapéutica y la supervivencia

Sebastián Chapela; Andrés Martinuzzi

Pérdida de masa muscular en el paciente críticamente enfermo: ¿Caquexia, sarcopenia y/o atrofia? Impacto en la respuesta terapéutica y la supervivencia

Sebastián Chapela, Andrés Martinuzzi

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Resumen

La pérdida de la masa muscular esquelética (PMM) en el paciente críticamente enfermo es la expresión final de eventos fisiopatológicos desencadenados por el trauma y la injuria, la inflamación y la hipercatabolia. La PMM pudiera responder también al aporte insuficiente de energía y nutrientes, lo que acentuaría la depleción de los tejidos magros. De no ser intervenida oportunamente, la PMM puede colocar al enfermo en riesgo de falla ventilatoria, y con ello, intubación y ventilación mecánica, prolongación de la estadía hospitalaria, y el encarecimiento de las prestaciones asistenciales. La PMM puede ser reconocida mediante la exploración funcional, la evaluación antropométrica, y la medición de la fuerza de contracción muscular mediante la dinamometría. Asimismo, el tamaño de las masas musculares se puede reconstruir mediante técnicas imagenológicas como la resonancia magnética nuclear (RMN) y el ultrasonido (US). La determinación del nitrógeno ureico urinario (NUU) permite examinar la intensidad de la hipercatabolia a la vez que trazar los cambios en la repleción tisular tras el inicio de la intervención nutricional. La paliación de la PMM y la repleción tisular suelen conseguirse mediante terapias multimodales que combinan el apoyo nutricional, el uso de nutrientes y fármacos orientados específicamente a la acreción muscular, y la promoción de la rehabilitación y el ejercicio físico. Se han concluido ensayos clínicos prometedores con agonistas de receptores a andrógenos y la grelina, e inhibidores de los factores de transcripción FOX. A medida que un número cada vez mayor de pacientes admitidos en las unidades de cuidados intensivos muestran ya PMM asociada al envejecimiento, se hace imperativo el establecimiento de pautas para el examen del tamaño de la masa muscular esquelética y la calidad de la fuerza de contracción, la cuantificación del estrés metabólico y la hipercatabolia, y la adopción de un programa multimodal efectivo que limite la PMM, haga posible la rehabilitación del enfermo, y asegure el éxito de la actuación médico-quirúrgica.

Palabras clave

Pérdida de masa muscular; Unidad de Cuidados Intensivos; Paciente críticamente enfermo; Caquexia; Sarcopenia

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