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este tiene importantes limitaciones&#58; es explorador dependiente&#44; requiere equipos dedicados y necesita de entrenamiento para su utilizaci&#243;n&#46; Se ha propuesto como alternativa el uso de c&#225;maras t&#233;rmicas como m&#233;todo predictor de flujo y maduraci&#243;n&#44; por su f&#225;cil utilizaci&#243;n&#44; reproducci&#243;n y bajo coste&#46; Podr&#237;a ayudar a cambiar la estrategia quir&#250;rgica en el mismo periodo intraoperatorio&#44; y evitar que pacientes salieran del &#225;rea quir&#250;rgica con accesos destinados al fracaso&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo de nuestro estudio fue demostrar una disminuci&#243;n en la temperatura distal posterior a la creaci&#243;n de una FAV durante el postoperatorio inmediato&#44; y una correlaci&#243;n negativa entre este cambio de temperatura y el flujo de esta&#46; Realizamos un estudio observacional prospectivo en un periodo de 6 meses&#44; incluyendo pacientes con enfermedad renal cr&#243;nica etapa IV-V que fueran candidatos a la creaci&#243;n de una FAV nativa en nuestro centro&#44; 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Se realiz&#243; un an&#225;lisis univariado usando test param&#233;tricos&#58; Chi-cuadrado y T-test para muestras apareadas para el estudio de cambio de temperaturas y flujos pre-post de cada brazo&#46; Para la comparaci&#243;n de los cambios relativos de temperatura entre ambos brazos se utiliz&#243; T-test para muestras independientes&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Se obtuvieron un total de 52 pacientes&#44; cuyas caracter&#237;sticas se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La temperatura en la mano intervenida disminuy&#243; 0&#44;91<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;34&#41; posterior a la intervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#44; y el cambio relativo de temperatura entre ambas manos fue de &#8722;1&#44;15<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;015&#41;&#46; El flujo en la arteria humeral proximal aument&#243; en 621&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;&#177;<span class="elsevierStyleHsp" style=""></span>548&#44;5&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Se evidenci&#243; una tendencia a mayor velocidad de flujo en la FAV a menor temperatura postoperatoria en la mano&#44; sin embargo&#44; esta correlaci&#243;n no fue estad&#237;sticamente significativa &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;117&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;418&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">El resto de variables analizadas&#44; tanto demogr&#225;ficas&#44; comorbilidades y las caracter&#237;sticas de la f&#237;stula realizada&#44; no se relacionaron de manera estad&#237;sticamente significativa con el cambio relativo de temperatura&#46; Se realiz&#243; tambi&#233;n una regresi&#243;n lineal con las variables analizadas&#44; para identificar factores pron&#243;sticos independientes que pudieran ser predictores del flujo de la FAV&#44; quedando los cambios de temperatura excluidos como factor predictor del mismo&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A modo de discusi&#243;n&#44; sabemos que al crear una FAV se distribuye de forma preferente el flujo arterial al territorio venoso de baja resistencia en lugar del sistema arterial distal de la extremidad&#44; debido a la mayor resistencia perif&#233;rica distal&#44; y esto podr&#237;a traducirse en una disminuci&#243;n en la temperatura de la mano ipsilateral por hipoperfusi&#243;n&#46; Nuestros resultados tanto en la comparaci&#243;n de las temperaturas pre y poscirug&#237;a&#44; como en el cambio relativo de temperatura en la mano intervenida constataron que estos cambios ya se producen de forma inmediata tras su creaci&#243;n&#46; Sin embargo&#44; no encontramos una relaci&#243;n entre esta disminuci&#243;n de temperatura y el aumento del flujo postoperatorio de la f&#237;stula que nos permitiera asociarlos y recomendar su uso como predictor de este flujo o su posterior maduraci&#243;n&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En un estudio previo<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#44; tambi&#233;n se utiliz&#243; una c&#225;mara t&#233;rmica para medir la temperatura distal a la FAV &#40;como factor binario de enfriamiento o no de la extremidad&#41;&#44; y encontraron de forma significativa que predec&#237;an una correcta maduraci&#243;n y permeabilidad de la FAV con una sensibilidad del 96 y 96&#37; y una especificidad del 68 y 69&#37;&#44; respectivamente&#46; Sin embargo&#44; no se compar&#243; el cambio de temperatura con el flujo postoperatorio&#46; Nuestros resultados&#44; incluso al rehacer un an&#225;lisis secundario por grupos binarios &#40;enfriamiento o no&#41; no apoyan esta relaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;331&#41;&#44; por lo que creemos dif&#237;cil su uso como predictor de maduraci&#243;n&#44; si no se relaciona de forma significativa con el flujo intraoperatorio de la f&#237;stula&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; comprobamos que existe una disminuci&#243;n de la temperatura distal posterior a la creaci&#243;n de la f&#237;stula en la mano intervenida&#46; Sin embargo&#44; seg&#250;n nuestros resultados&#44; este cambio no se relaciona de forma significativa en el flujo de la FAV y&#44; por lo tanto&#44; los cambios de temperatura son poco fiables como factor pron&#243;stico de maduraci&#243;n&#46;</p></span>"
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Carta al Director
Predicción del flujo intraoperatorio de fístulas arteriovenosas mediante el uso de imágenes térmicas infrarrojas
Prediction of intraoperative arteriovenous fistula flow using infrared thermal imaging
Victoria Gaméa,
Autor para correspondencia
vgame@clinic.cat

Autor para correspondencia.
, Regina Callejóna, Nestor Fontseréb, Gaspar Mestresa
a Unidad Funcional de Accesos Vasculares, Servicio de Cirugía Vascular, Instituto de Enfermedades Cardiovasculares, Hospital Clínic, Barcelona, España
b Unidad Funcional de Accesos Vasculares, Servicio de Nefrología, Instituto de Nefrología y Urología, Hospital Clínic, Barcelona, España
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este tiene importantes limitaciones&#58; es explorador dependiente&#44; requiere equipos dedicados y necesita de entrenamiento para su utilizaci&#243;n&#46; Se ha propuesto como alternativa el uso de c&#225;maras t&#233;rmicas como m&#233;todo predictor de flujo y maduraci&#243;n&#44; por su f&#225;cil utilizaci&#243;n&#44; reproducci&#243;n y bajo coste&#46; Podr&#237;a ayudar a cambiar la estrategia quir&#250;rgica en el mismo periodo intraoperatorio&#44; y evitar que pacientes salieran del &#225;rea quir&#250;rgica con accesos destinados al fracaso&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo de nuestro estudio fue demostrar una disminuci&#243;n en la temperatura distal posterior a la creaci&#243;n de una FAV durante el postoperatorio inmediato&#44; y una correlaci&#243;n negativa entre este cambio de temperatura y el flujo de esta&#46; Realizamos un estudio observacional prospectivo en un periodo de 6 meses&#44; incluyendo pacientes con enfermedad renal cr&#243;nica etapa IV-V que fueran candidatos a la creaci&#243;n de una FAV nativa en nuestro centro&#44; bajo anestesia local y sin accesos previos&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Se midi&#243; la temperatura mediante una c&#225;mara t&#233;rmica port&#225;til &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41; y el flujo de la f&#237;stula mediante ecograf&#237;a doppler&#44; en el pre y postoperatorio inmediato&#44; utilizando como control la mano no intervenida&#46; Para el c&#225;lculo de flujo se utiliz&#243; la f&#243;rmula&#58; Qa&#40;ml&#47;min&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#193;rea en cm<span class="elsevierStyleSup">2</span> &#40;0&#44;785<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>D<span class="elsevierStyleSup">2</span>&#44; en cm<span class="elsevierStyleSup">2</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>velocidad media &#40;cm &#47;s&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>factor de conversi&#243;n &#40;0&#44;06&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; Se realiz&#243; un an&#225;lisis univariado usando test param&#233;tricos&#58; Chi-cuadrado y T-test para muestras apareadas para el estudio de cambio de temperaturas y flujos pre-post de cada brazo&#46; Para la comparaci&#243;n de los cambios relativos de temperatura entre ambos brazos se utiliz&#243; T-test para muestras independientes&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Se obtuvieron un total de 52 pacientes&#44; cuyas caracter&#237;sticas se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La temperatura en la mano intervenida disminuy&#243; 0&#44;91<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;34&#41; posterior a la intervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#44; y el cambio relativo de temperatura entre ambas manos fue de &#8722;1&#44;15<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;015&#41;&#46; El flujo en la arteria humeral proximal aument&#243; en 621&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;&#177;<span class="elsevierStyleHsp" style=""></span>548&#44;5&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Se evidenci&#243; una tendencia a mayor velocidad de flujo en la FAV a menor temperatura postoperatoria en la mano&#44; sin embargo&#44; esta correlaci&#243;n no fue estad&#237;sticamente significativa &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;117&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;418&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">El resto de variables analizadas&#44; tanto demogr&#225;ficas&#44; comorbilidades y las caracter&#237;sticas de la f&#237;stula realizada&#44; no se relacionaron de manera estad&#237;sticamente significativa con el cambio relativo de temperatura&#46; Se realiz&#243; tambi&#233;n una regresi&#243;n lineal con las variables analizadas&#44; para identificar factores pron&#243;sticos independientes que pudieran ser predictores del flujo de la FAV&#44; quedando los cambios de temperatura excluidos como factor predictor del mismo&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A modo de discusi&#243;n&#44; sabemos que al crear una FAV se distribuye de forma preferente el flujo arterial al territorio venoso de baja resistencia en lugar del sistema arterial distal de la extremidad&#44; debido a la mayor resistencia perif&#233;rica distal&#44; y esto podr&#237;a traducirse en una disminuci&#243;n en la temperatura de la mano ipsilateral por hipoperfusi&#243;n&#46; Nuestros resultados tanto en la comparaci&#243;n de las temperaturas pre y poscirug&#237;a&#44; como en el cambio relativo de temperatura en la mano intervenida constataron que estos cambios ya se producen de forma inmediata tras su creaci&#243;n&#46; Sin embargo&#44; no encontramos una relaci&#243;n entre esta disminuci&#243;n de temperatura y el aumento del flujo postoperatorio de la f&#237;stula que nos permitiera asociarlos y recomendar su uso como predictor de este flujo o su posterior maduraci&#243;n&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En un estudio previo<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#44; tambi&#233;n se utiliz&#243; una c&#225;mara t&#233;rmica para medir la temperatura distal a la FAV &#40;como factor binario de enfriamiento o no de la extremidad&#41;&#44; y encontraron de forma significativa que predec&#237;an una correcta maduraci&#243;n y permeabilidad de la FAV con una sensibilidad del 96 y 96&#37; y una especificidad del 68 y 69&#37;&#44; respectivamente&#46; Sin embargo&#44; no se compar&#243; el cambio de temperatura con el flujo postoperatorio&#46; Nuestros resultados&#44; incluso al rehacer un an&#225;lisis secundario por grupos binarios &#40;enfriamiento o no&#41; no apoyan esta relaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;331&#41;&#44; por lo que creemos dif&#237;cil su uso como predictor de maduraci&#243;n&#44; si no se relaciona de forma significativa con el flujo intraoperatorio de la f&#237;stula&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; comprobamos que existe una disminuci&#243;n de la temperatura distal posterior a la creaci&#243;n de la f&#237;stula en la mano intervenida&#46; Sin embargo&#44; seg&#250;n nuestros resultados&#44; este cambio no se relaciona de forma significativa en el flujo de la FAV y&#44; por lo tanto&#44; los cambios de temperatura son poco fiables como factor pron&#243;stico de maduraci&#243;n&#46;</p></span>"
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Información del artículo
ISSN: 02116995
Idioma original: Español
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