DOR EM CUIDADOS
INTENSIVOS
ou “O que sempre quis saber sobre Dor mas teve medo de perguntar...”
DILEMAS DA DOR EM UCI
• Subvalorizada
/ Subtratada
• Desconhecimento
• Desnorteamento
• ...”Chapa
5”
de fármacos/ Vias de administração
terapêutico
Alfen
tanil e
m
perfu
são
1º PROBLEMA
Melhorar a selecção dos Analgésicos
Adequar os analgésicos às rotinas do doente
CURSO SUPERINTENSIVO DE
DOR EM 8 MINUTOS
DOR
“A dor é uma experiência multidimensional desagradável, envolvendo não só um componente sensorial mas também um componente emocional, e que se associa a uma lesão tecidular concreta ou potencial, ou é descrita em função dessa lesão”
TIPOS DE DOR
Nocicep'va* Neuropá'ca* Psicogénica*
Somá'ca*
Periférica*
Visceral*
Central*
TIPOS DE DOR
TERAPÊUTICA UNIVERSAL DA
DOR - OMS
(1986)
• By
the Mouth
• By
the Ladder
• By
the Clock
• For
the Individual
• Attention
to detail (follow-up)
ESCADA DOR OMS
ESCADA DOR OMS (2003)
A l t e r i n g I n t e n s i v e C a re
Sedation Paradigms to
I m p ro v e P a t i e n t
Outcomes
666
Richard R.
Riker,
666
Riker & Fraser
a,b,
*, Fraser
Gilles L.
MD, Riker
FCCM &
Fraser,
PharmD, FCCM
a,c
been validated. Although the Critical Care Pain Observation Tool54 and the Behavioral
55
Pain
Scale
represent
for monitoring
in these
chal! Sedation ! Critical care
! Adults
! Analgesia
been
validated.
Althoughsignificant
the Criticalimprovements
Care Pain Observation
Tool54 pain
and the
Behavioral
! Delirium ! Outcomes
lenging
patients,
data linking
these improvements
scores with patient
self-report pain
of pain
and
55
Pain
Scale
represent
significant
for monitoring
in severity
these chalimproved
outcomes
yetthese
to bescores
published.
Of noteself-report
however, of
patients
with doculenging
patients,
datahave
linking
with patient
pain severity
and
mented
assessment
of
the
presence
or
absence
of
pain
on
day
2
of
their
ICU
stay
improved
outcomes
have
yet
to
be
published.
Of
note
however,
patients
with
docuSEDATION ALGORITHMS: A HISTORY
59
appear to
have shorter
and be
mechanical
faster.
mented
assessment
ofICU
the stays
presence
or liberated
absencefrom
of pain
on day 2ventilation
of their ICU
stay
The clinical approach to Several
sedation for
intensivehave
care unit
(ICU) patients
has evolved the approach to ICU sedation by
59
papers
focused
onbeimproving
appear
to
have
shorter
ICU
stays
and
liberated
from
mechanical
ventilation
faster.
significantly during the last 30 years, as new medications have emerged, and clinicians
31–35,60
employing
a strategy
wefocused
call “analgesia-first”
or the
“A1.”
This
in which
Several
papers
have
on
improving
approach
to strategy,
ICU sedation
by
have embraced systematic and evidence-based approaches to care. One of the first
31–35,60
sedating
medications
areRamsay
given
only
after aggressive
strategies
been
studies to address thisemploying
issue was published
in 1974we
by
and
colleagues;
it was
a strategy
call
“analgesia-first”
or “A1.”analgesic
This
strategy,have
in which
a report ahead of its time
in many
ways: sedation
was titrated
to a scale, a propofol
subset of or benzodiazepine-based regimens
used,
compares
favorably
to traditional
sedating
medications
are
given
only
after
aggressive
analgesic strategies have been
patients was monitored
with
electroencephalography,
sedation
medication
was
interfor sedation.
Patients
receiving
A1 therapy consistently
achieve comfort goals, and
used,
compares
favorably
to traditional
rupted, and a relatively
light level
of sedation
was targeted
(Ramsay scalepropofol
of 2–4).1 or benzodiazepine-based regimens
lesssedation.
than
50%
require
sedating
no overwhelming
data
to
Reports describing different
approaches
to
ICU sedation
began
totherapy
appear inconsistently
the There are
for
Patients
receiving
A1medications.
achieve
comfort goals,
and
1980s and early 1990s.
Althoughuse
they generally
reported
deepbut
levels
support
ofvariable,
one
analgesic
over
another,
the
extremely
half-life of remifenless
thanhighly
50%
require
sedating
medications.
There
are noshort
overwhelming
data to
of sedation, frequent use
of may
neuromuscular
blockade,for
andpatients
no standard
approach frequent
to
tanil
be
beneficial
requiring
neurologic
evaluations.
Breen
2
3 the extremely short half-life of remifenof one
analgesic
over
another,
but
medication selection support
or strategyuse
for administration.
Simpson
and
colleagues
re31
and
colleagues
randomized
patients
to either
remifentanil
first evaluations.
(supplemented
by
ported the advantages
of lorazepam
to
the lasting
effects
of requiring
diazepam,
and
tanil
may
berelative
beneficial
for patients
frequent
neurologic
Breen
31 popularity,
midazolam
needed:
an A1
approach)
or either
midazolam
first, supplemented
by fentanyl
continuous infusion etomidate
initiallyas
gained
until
it was recognized
not remifentanil
and
colleagues
randomized
patients
to
first (supplemented
by
4,5
to be as safe as originally
believed.
Patient
perceptions
and
recall
of
the
ICU
expeor morphine.
The A1 approach reduced the time of mechanical ventilation by 54 hours
midazolam
6 as needed: an A1 approach) or midazolam first, supplemented by fentanyl
and the impact of organ dysfunction on drug and
rience were a novel consideration,
and
the time7 The
fromreports
start
ofcontinuous
weaning
to extubation
bymechanical
27 hours. An
open-label
study
by
morphine.
A1
approach
reduced
the
ventilation
by 54
hours
metabolite eliminationor
was
described.
Early
of
sedation
withtime
mid- of
34
8,9
Rozendaal
and
colleagues
randomized
medical
surgical
ICU patients
to
azolam and propofol and
appeared,
and
innovative
to to
avoid
prolonged
the time
from
start approaches
of weaning
extubation
by 27and
hours.
An open-label
study by
10
Reportspropofol
of lingering
sedation from continuous
infusions were proposed.
34 (with
remifentanil-based
sedation
as required)
versus ICU
a GABA-based
Rozendaal
and colleagues
randomized medical
and surgical
patients to
regimen
supplemented
with
fentanyl
or
morphine.
Patients
treated
with
the A1
remifentanil-based sedation (with propofol as required) versus a GABA-based
approach
weaned
mechanical
faster,Patients
and they
were almost
A version of this article regimen
appeared in the
25:3 issue offrom
Critical with
Care Clinics.
supplemented
fentanylventilation
or morphine.
treated
with thetwice
A1
a
Tufts University Schoolas
of Medicine,
Boston,
MA,
USA
likely toweaned
be extubated
and discharged
from thefaster,
ICU during
the first
3 days.
b
approach
from mechanical
ventilation
and they
were
almostDahaba
twice
Departments of Medicine
and Neurocritical
Care,
32 Maine Medical Center, 22 Bramhall Street,
and
colleagues
randomized
patients tofrom
two different
medications,
using
an A1
Portland, ME 04102, USA
as
likely
to be extubated
and discharged
the ICU during
the firstboth
3 days.
Dahaba
c
Departments of Medicine
and Pharmacy,
Maine
Center,
22 Bramhall Street,
Portland,
32 Medicalor
strategy
(remifentanil
morphine),
with
midazolam
needed
to
and
colleagues
randomized
patients
to two
differentsupplementation
medications, bothasusing
an A1
KEYWORDS
ME 04102, USA
NA UCI...
Prioridade à Analgesia!!!
PRINCÍPIOS GERAIS
1. Iniciar o controlo analgésico PRIMEIRO (Estratégia “A1”)
2. De acordo com a Escada Analgésica (OMS)
3. Antecipar a dor
4. Esquema analgésico multimodal (efeitos sinérgicos/aditivos com diminuição dos efeitos colaterais associados a cada fármaco)
5. Preferência a esquemas Qixos de administração em detrimento de prescrições em SOS. 6. Titulação medicamentosa
7. Gestão do desperdício
TRETAS DA FARMACOLOGIA
Mas que, infelizmente sem elas não vamos perceber como fazer bem...
• Analgésicos
Não Opióides
• Analgésicos
Opióides
• Anestésicos
Locais
NÃO OPIÓIDES
• Paracetamol, AINE’s
(Quetorolac, Metamizol...)
•
Quando associados aos opióides, diminuem a necessidade destes
fármacos – têm efeito “poupador de opióides”.
•
Paracetamol - hepatotoxicidade
•
AINE’s - CI: hipovolémia, insuficiência renal, cardíaca, hepática,
perturbações da hemostase, antecedentes de hemorragia
digestiva ou úlcera gastroduodenal, asma ... and so yon.
OPIÓIDES
•
Tramadol (minor), o fentanil, o Alfentanil, a morfina e meperidina (major)
•
Não têm efeito tecto
•
Devem ser iniciados apenas se houver manutenção da dor ou aumento
secundário a terapêutica com não-opiáceos (OMS)
•
Efeitos secundários incluem depressão respiratória, sedação, confusão,
obstipação, náuseas, vómitos e retenção urinária, agitação paradoxal, risco
de depressão respiratória...etc
DOR NEUROPÁTICA
PROTOCOLOS UCI
Obrigada!