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2026, Número 2

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Med Crit 2026; 40 (2)


Uso racional y basado en la evidencia de glucocorticoides y mineralocorticoides en pacientes con choque séptico en la Unidad de Cuidados Intensivos

Pérez I, Paredes MC, Tórra OL, Sánchez A

Idioma: Español
Referencias bibliográficas: 53
Paginas: 142-151
Archivo PDF: 667.84 Kb.


RESUMEN

Introducción: el choque séptico continúa siendo una de las principales causas de morbimortalidad en las unidades de cuidados intensivos. Los glucocorticoides han demostrado reducir la dependencia de vasopresores sin impacto en mortalidad; sin embargo, el uso combinado con mineralocorticoides permanece controvertido con respecto a este último desenlace. Estudios recientes han reabierto el debate sobre el beneficio de la combinación de hidrocortisona y fludrocortisona. Objetivo: analizar críticamente la evidencia histórica y contemporánea acerca del uso de esteroides, en particular la terapia combinada con glucocorticoides y mineralocorticoides, en el manejo del choque séptico. Material y métodos: se realizó una revisión narrativa de la literatura desde la década de 1930 hasta 2024, incluyendo ensayos clínicos controlados, estudios observacionales, metaanálisis y guías internacionales. Se evaluaron desenlaces clínicos relevantes como mortalidad, reversión del choque, duración del soporte vasopresor y complicaciones metabólicas. Resultados: ensayos posteriores a 2000, como APROCCHSS, demostraron reducción significativa de la mortalidad y reversión más rápida del choque con la combinación de hidrocortisona y fludrocortisona. La evidencia, al analizar la terapia solo con hidrocortisona, muestra beneficios en duración del choque sin beneficios en mortalidad. Estudios de cohorte a gran escala y metaanálisis recientes sugieren un beneficio adicional de la terapia combinada, especialmente en pacientes con mayor gravedad y en adultos mayores. Sin embargo, la heterogeneidad poblacional y la falta de ensayos comparativos directos limitan la solidez de las recomendaciones actuales. Conclusiones: los esteroides en choque séptico muestran un efecto consistente en la reversión del choque y, con el uso de terapia combinada, una posible reducción de la mortalidad, aunque la certeza de la evidencia es moderada. Además, los metaanálisis han mostrado una probabilidad posterior de superioridad con la terapia combinada para el desenlace de mortalidad. Se sugiere la utilización prudente de la terapia combinada por el perfil riesgo-beneficio, priorizando a pacientes con mayor riesgo y considerando la necesidad de estudios que definan subfenotipos de sepsis con mayor beneficio.


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