Terapie Mediche Associate - Ospedale di Circolo e Fondazione

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Terapie Mediche Associate
IL CONTROLLO DEL DOLORE
Alessandro Bacuzzi
U.O. Anestesia, Rianimazione e Cure Palliative
Direttore: Salvatore Cuffari
Azienda Ospedaliero Universitaria Ospedale di Circolo e Fondazione Macchi - Varese
Sommario
•Definizione del dolore
•Perché trattare il dolore nel trauma
•Analisi terapia del dolore nei DEA (letteratura)
•Strumenti di valutazione del dolore nel trauma
•Terapia farmacologica
•Conclusioni
Definizione del dolore
“Il dolore è un’esperienza personale e soggettiva, influenzata
dall’educazione, dalle circostanze, dall’attenzione nonché da un certo numero
di altri parametri psicologici.”
Melzack R., Wall P.D. – The challenge of pain (2nd ed.)
London, 1988
“Un’esperienza sgradevole, sensoriale ed emotiva, associata ad un
danno tessutale in atto o potenziale, o descritto in termini di tale danno”
“The experience of pain can be defined only in terms of human consciousness. As with all sensory
experience, there is no way of being certain that one person’s experience of pain is the same as
another’s. There is therefore no absolute qualification of pain experience; it can only be estimated
by verbal or magnitude scaling methods. “
Perchè trattare il dolore nel trauma
Crit Care Med 2002 Vol. 30, No. 1
Crit Care Med 2008 Vol. 36, No. 7 (Suppl.)
Table 1. Negative outcomes associated with
inadequate analgesia
Outcome
Thromboembolic events
++
Increased agitation
++
Pulmonary complications
++
Catabolic stress response
++
Immunosuppression
++
Needless suffering
++
Posttraumatic stress disorder
+
Chronic pain
+
Increased length of stay
+
Increased mortality
+
Perkins FM, Kehlet H. Anesthesiology 2000;
93:1123–1133
Tuman KJ, McCarthy RJ, March RJ, et al.
Anesth Analg 1991; 73: 696–704
Sorenson RM, Pace NL. Anesthesiology
1992; 77:1095–1104
Wu CL, Sapirstein A, Herbert R, et al. J Clin
Anesth 2006; 18: 515–520
Liu SS, Carpenter RL, Mackey DC, et al.
Anesthesiology 1995; 83:757–765
Kress JP, Hall JB. Crit Care Med
2006; 34:2541–2546
Kress JP, Pohlman AS, O’Connor MF, et al.
N Engl J Med 2000; 342: 1471–1477
+ moderate correlation; ++ good correlation.
Il trattamento del dolore nei DEA: ?
An observational prospective study
The study was conducted in the ED of the
S. Croce and Carle Cuneo Hospital,
The study was conducted during three
consecutive weeks, from 7 July 2008 to 1
August 2008.
Oligoanalgesia in Emergency Departments (ED) is known to be common
The Joint Commission and the Veterans Health Administration show that an inaccurate
or a
missing assessment of patients’ pain is a major predictor of insufficient pain treatment
In conclusion, the underuse of analgesics in the ED continues to represent a problem and our study
demonstrates that half of all ED patients in pain desire analgesics and that only half of those
wanting analgesics receive them.
in the Netherlands.
Prospective cohort study of 450 trauma patients
The prevalence of pain was high, both on admission (91%) and at discharge (86%)
The most effective pain treatment given was a combination of injury treatment and supplementary
pharmacological interventions, however this treatment was given to a small group of patients.
Several studies have described the administration of analgesics in the ED and have concluded that
there is an undertreatment of acute pain in the ED, even though it is known that acute pain can often
be simply alleviated and reduced.
Eur J Anaesthesiol 2011;28:97–105
Conclusion: this multicentre study conducted on a nationwide scale shows that pain relief can be
improved in the ED. Pain intensity is not sufficiently reassessed, analgesics are underutilised,
morphine sulfate is rarely used and delay in treatment is common.
Ann Emerg Med. 2011;xx:xxx.
Prospective interventional study in the
emergency department (ED) of an adult
tertiary referral hospital and major trauma
center. Australia
The delivery of timely analgesia is not only expected by patients but also linked to improved biological
outcomes and reduced anxiety.
It has been demonstrated that time to analgesia can be reduced if pain is formally rated and
recorded at triage.
Conclusion: The simple act of altering our ED computerized information system to require pain
scoring at triage led to substantially faster provision of initial analgesia, with the effect sustained at
12 months.
Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department.
Am J Emerg Med. Nov 1989;7(6):620-623. (Review, 198 patients)
La misurazione del dolore
“Underassessment of pain is a major cause of inadequate
pain management. In fact, the most common reason for the
undertreatment of pain in U.S. hospitals is the failure of
clinicians to assess pain and pain relief.”
Max MB, Payne R, Edwards WT, et al. American Pain Society; 1999.
In 1996, the American Pain Society (APS) introduced the
phrase “pain as the 5th vital sign.”
Campbell J. Pain as the 5th vital sign [presidential address].
American Pain Society, November 11, 1996.
http://www.ampainsoc.org/education/enduring/
“…la rilevazione del dolore divenga costante al pari di altri
segni vitali … nella valutazione clinica della persona. “
Misura # valutazione
Scale soggettive (self-report) e Scale oggettive
Scale soggettive: unidimensionali o multidimensionali
NRS (Numeric Rating Scale o Numeric Pain
Intensity Scale)
Visual Analogue Scale (VAS
Il trattamento farmacologico del dolore
The ATLS® Subcommittee and International ATLS® Subcommittee of the American College of
Surgeons Committee on Trauma
ATLS 8th Edition
Chapter 01: Initial Assessment and
Management
Secondary
Survey
Pain
Management
Relief
of pain / anxiety as appropriate
Administer intravenously
Careful monitoring is essential
Pain in trauma patients:
paracetamol
Acute
Nociceptive: somatic
visceral
Acetaminofene (Paracetamolo)
NSAIDs (FANS)
Oppioidi:
Morfina
Fentanyl
Paracetamolo: blocco COX3 a livello centrale
Inibizione selettiva sintesi prostaglandine a livello del SNC (COX 3)
Attivazione e potenziamento via serotoninergica bulbo-spinale
No effetti collaterali centrali (sedazione, nausea, vomito, depressione respiratoria)
Nessun effetto sull’aggregazione piastrinica
Nessun effetto collaterale gastrointestinale
Buona sicurezza renale ed epatica
Può essere usato in gravidanza (attenta valutazione del rapporto rischio/beneficio), bambini e
anziani
Paracetamolo: posologia (Infusione 15’)
Adolescenti e adulti > 50 kg:
1 gr fino a 4 volte/die, intervallo almeno 4 ore. Dose max 4 gr
Adolescenti e adulti < 50 kg, bambini > 33 kg (circa 11 anni)
15 mg/kg di paracetamolo per somministrazione fino a 4 volte/die.
Intervallo 4 ore. Dose max 60 mg/kg senza superare i 2 gr
Bambini > 10 kg e < 33 kg (circa 11 anni)
15 mg/kg di paracetamolo per somministrazione fino a 4 volte/die. Intervallo 4
ore. Dose max 60 mg/kg senza superare i 2 gr
Bambini < 10 kg, neonati
7,5 mg/kg di paracetamolo per somministrazione fino a 4 volte/die.
Intervallo 4 ore. Dose max 30 mg/kg.
Paracetamolo: metabolismo epatico
Paracetamolo
Coniugazione acido
glucuronico
60% - 80%
Coniugazione acido
solforico
20% - 30%
Paracetamolo immodificato
4%
Citocromo
P450
N-acetil-p-benzochinone-amina (NAPQI) metabolita tox
Coniugazione del glutatione
urine
Paracetamolo: profilo di sicurezza
Il Paracetamolo fino a 4 g/die evidenzia un buon profilo di sicurezza renale
Non vi sono evidenze dell’insorgenza di nefropatia cronica nel trattamento con il ParacetamolO
Raccomandato dalla National Kidney Foundation come analgesico non narcotico di elezione nei
pazienti con patologia renale sottostante
Dosi tossiche (circa 10 grammi nell’adulto - 150 mg/Kg nel bambino): epatotossicità in caso di
iperdosaggio acuto (accidentale o intenzionale).
Trattamento intosssicazione: N-acetilcisteina ( rilascio di glutatione)
Fattori che aumentano il rischio: disidratazione, malnutrizione cronica, epatopatie.
NSAIDs (FANS)
NSAIDs (FANS)
COX-1 inhibitors:
SALICYLATES
Other NASAIDs: diclofenac
ibuprofen
indomethacin
Ketorolac
Naproxen
Selective COX-2 inhibitors
NSAIDs (FANS)
Efficaci
Possibile l’associazione con
paracetamolo ed oppioidi
NON associarli tra loro
Effetto “tetto” tipico
NSAIDs (FANS): effetti collaterali inibitori COX-1
•Effetti gastrointestinali
•Effetti ematologici:
lucopenia, agranulocitosi
•Effetti emocoagulativi: inibizione dell’aggregabilità piastrinica
aumento del tempo di sanguinamento,
potenziamento delgi anti coagulanti
•Effetti renali:
ridotta escrezione di Na, iperazotemia
•Effetti epatici:
aumento delle transaminasi, epatite colestatica
•Effetti respiratori:
broncospasmo
NSAIDs (FANS):
Studio su FANS per via orale - insorgenza di effetti indesiderati a livello
del tratto gastrointestinale:
- l’ibuprofene è il meglio tollerato
- Ketoprofene, indometacina, naprosse e diclofenac hanno un rischio intermedio
- Piroxicam e ketorolac hanno dimostrato un maggior rischio gastrolesivo
Hernández-Díaz S, García Rodríguez LA - Arch Intern Med 2000; 160: 2093-99
NSAIDs (FANS): KETOROLAC
IV/IM analgesia comparabile a 10 mg di morfina
G.U. n.119 del 23/05/2002
•indicato nel trattamento a breve termine (max 48 H) del dolore acuto postoperatorio di grado moderato-severo.
•nel caso di chirurgia maggiore o dolore intenso può essere usato quale
complemento ad analgesico oppiaceo.
•per os 10 mg ogni 4-6 h fino ad un max di 40 mg/die
•nell’anziano ridurre la dose
•non indicato sotto 16 anni di età
•IM/EV 30 mg ogni 4-6 h senza superare 90 mg/die e per 48 h
NSAIDs (FANS):
Even though there has not been the same evidence on celecoxib increasing
cardiovascular risk as has been publicized on refocoxib – the potential risks
should still be strongly considered. Patients may be better served by taking a
traditional NSAID and either a proton-pump inhibitor or H2-blocker for
gastrointestinal protection.
OPPIOIDI:
Sistema Oppioide
OPPIOIDI:
OPPIOIDI:
OPPIOIDI:
The ideal analgesic for emergency use would be highly effective, have rapid
onset, be easily used, and titratable.
This fabled agent would have a reliable duration of action, lack hemodynamic
effects, have minimal to no side effects, and would not mask signs or symptoms
of serious disease.
Although this agent obviously does not exist, the opioid analgesics are the
most effective drugs for rapidly controlling pain in the ED.
OPPIOIDI:
iv
100
OPPIOIDI:
Morphine sulfate is the analgesic to which all others are compared.
The major advantages to morphine are its low cost and its half-life of 3-4
hours—longer than most other parenteral agents. The major disadvantage to
morphine is its potential to release histamine, resulting in vasodilation or
localized inflammatory reactions.
In addition to sedation and respiratory depression in high doses, other
common side effects include nausea and dysphoria.
OPPIOIDI:
Fentanyl
has several advantages in the ED. It is short-acting, and
therefore useful in procedural sedation or in patients who require serial
examinations.
It causes little histamine release and no significant myocardial depression;
therefore, it is safer than many other opioids when used in patients at risk for
hemodynamic instability.
In higher doses, it may cause apnea before sedation. Fentanyl can cause
muscular rigidity when given by the parenteral route. However, this typically
occurs with rapid administration at the very high doses used for induction of
anesthesia (10 mcg/kg or more).
OPPIOIDI:
Fentanyl
J Trauma. 2007;63:819–
826.
The choice of fentanyl as the analgesic was based on its relatively short halflife, minimal effect on hemodynamic parameters, and rare central nervous
system effects.
We found no adverse events attributable to the analgesia protocol despite
cumulative doses of fentanyl up to 150 µg.
OPPIOIDI:
Route Of Administration
Crit Care Med 2008 Vol. 36, No. 7 (Suppl.)
Multimodal Pain Control
The rationale for multimodal therapy is to capitalize on the synergistic action
between pharmacologic agents and different techniques.
Multimodal therapy helps avoid the complications of opioid-centered analgesia,
which include physical dependence, addiction, ileus, respiratory depression,
and opioid-induced hyperalgesia. These problems with opioid- centered
postoperative pain management occur regardless of the opioid used (for
example, fentanyl versus morphine) or the route of administration (for example,
intermittent dosing vs. PCA)
Conclusioni
Conclusioni
La gestione del paziente traumatizzato risulta spesso complessa,
svolta in un contesto difficile e con la necessità di coinvolgere più
competenze professionali. Il rischio è quello di sottovalutare il trattamento del
dolore, aspetto importante per le sue implicazioni fisiopatologiche.
Il trattamento del dolore inizia con la sua valutazione e misurazione.
L’utilizzo di semplici scale unidimensionali - nella prima valutazione ed in itinere quantifica il dolore e permette di valutare l’effetto della terapia.
I farmaci disponibili sono numerosi. Il concetto di associazione tra
classi di farmaci diverse è razionale ed estremamente efficace.
Nel traumatizzato la somministrazione di oppioidi è sicura con semplici
accorgimenti: individualizzare la dose e “titrare” il farmaco.
Il problema dell’OLIGOANALGESIA è purtroppo ancora diffuso a livello
internazionale
Conclusioni
The compassionate relief of pain and suffering is a principal goal of
medicine, but there are other compelling reasons to treat pain as well.
There is, for example, growing evidence that pain may have significant
adverse physiologic consequences.
Recent studies further suggest that acute pain causes alterations in central
nervous system functions that may lead to hyperalgesia and allodynia and that
may affect subsequent pain experiences.
Furthermore, aggressive treatment of pain, even in unconscious patients, has
been shown to result in improved clinical outcomes.
Conclusioni
“Pain is inevitable; suffering is optional”
GRAZIE

Terapie Mediche Associate - Ospedale di Circolo e Fondazione

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