Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942009000400002
Brazilian Journal of Anesthesiology
Scientific Article

Avaliação da cetamina racêmica e do isômero S(+), associados ou não a baixas doses de fentanil, na balneoterapia do grande queimado

Assessment of the use of racemic ketamine and its S(+) isomer, associated or not with low doses of fentanyl, in balneotherapy for major burn patients

Fernando Antônio de Freitas Cantinho; Antonio Carlos Pereira da Silva

http://dx.doi.org/10.1590/S0034-70942009000400002 Braz J Anesthesiol, vol.59, n4, p.396-408, 2009
PDF Português
PDF English
Downloads: 0
Views: 1410

Resumo

JUSTIFICATIVA E OBJETIVOS: O cuidado da ferida do grande-queimado desencadeia estímulo doloroso muito intenso. Este estudo teve por objetivo avaliar a segurança e efetividade de diferentes combinações de fármacos na anestesia para balneoterapia. MÉTODO: Com a aprovação do Comitê de Ética, foram estudados 200 procedimentos de balneoterapia em 87 grandes queimados adultos. Em todos os casos foi empregado o midazolam. Foram utilizados frascos numerados da cetamina, não se conhecendo no momento do uso se era racêmica ou S(+). A cada manhã era sorteado se os procedimentos daquele dia seriam conduzidos com ou sem fentanil. Formaram-se quatro grupos: ISO/sf (isômero S(+) sem o fentanil), ISO/cf (isômero S(+) com o fentanil), RAC/sf (cetamina racêmica sem o fentanil) e RAC/cf (cetamina racêmica com o fentanil). As doses iniciais propostas foram: midazolam 0,06 mg.kg-1, cetamina 1,0 a 1,1 mg.kg-1, fentanil 0,8 ¼g.kg-1; as doses adicionais eram administradas conforme necessário. RESULTADOS: Em apenas um caso houve lembrança de dor durante a balneoterapia. No grupo que recebeu a cetamina S(+), o acréscimo do fentanil não evidenciou vantagens; associado à forma racêmica, o fentanil reduziu a dose total e o número de bolus da cetamina. A extensão da superfície corporal queimada foi a principal determinante da intensidade de dor pós-procedimento. A menor intensidade de dor pós-procedimento foi o principal fator considerado pelo paciente para sua satisfação pela anestesia recebida. CONCLUSÕES: As quatro diferentes combinações de fármacos mostraram-se seguras e permitiram ausência de dor durante a balneoterapia. Características não ligadas diretamente aos anestésicos mostraram-se de maior importância na definição da dor pós-procedimento, que foi a principal característica considerada pelo grande queimado para definir sua satisfação com a anestesia recebida.

Palavras-chave

ANALGÉSICOS, DOENÇAS, TERAPÊUTICA

Abstract

BACKGROUND AND OBJECTIVES: The care of the wounds of major burn patients triggers severe painful stimuli. The objective of this study was to assess the safety and efficacy of different drug combinations in anesthesia for balneotherapy. METHODS: After approval by the Ethics Commission, 200 procedures of balneotherapy in 87 major burn adult patients were evaluated. Midazolam was used in all cases. The vials of ketamine were numbered and, therefore, at the time of the use, one did not know whether racemic or S(+)ketamine was being used. Each morning it was decided by drawing lots whether fentanyl would be used or not in the procedures of that day. Patients were included in one of four groups: ISO/sf (S(+) isomer without fentanyl), ISO/cf (S(+) isomer with fentanyl), RAC/sf (racemic ketamine without fentanyl), and RAC/cf (racemic ketamine with fentanyl). The initial doses proposed were as follows: midazolam, 0.06 mg.kg-1; ketamine, 1.0 to 1.1 mg.kg-1; and fentanyl, 0.8 ¼g.kg1-1; additional doses were administered as needed. RESULTS: Only one patient recalled the pain of balneotherapy. In the group that received S(+)ketamine, the use of fentanyl did not bring additional advantages; however, when associated with racemic ketamine, fentanyl reduced the total dose and the number of ketamine boluses. The extension of body surface burned was the main determinant of the severity of post-procedure pain. Reduced pain severity was the main factor considered by patients when grading their satisfaction with the anesthesia. CONCLUSIONS: The four different drug combinations proved to be safe and guaranteed the absence of pain during balneotherapy. Characteristics not directly related to the anesthetics proved to be more important in the incidence of post-procedure pain, which was the main factor considered by major burn patient to define their satisfaction with the anesthesia used.

Keywords

ANALGESICS, DISEASES, THERAPY

Referencias

Blot S. Development and validation of a model for prediction of mortality in patients with acute burn injury. Br J Surg. 2009;96:111-117.

Gomez M, Wong DT, Stewart TE. The FLAMES score accurately predicts mortality risk in burn patients. J Trauma. 2008;65:636-645.

Lorente JA, Vallejo A, Galeiras R. Organ dysfunction as estimated by the sequential organ failure assessment score is related to outcome in critically ill burn patients. Shock. 2009;31:125-131.

Fry C, Edelman LS, Cochran A. Response to a nursing-driven protocol for sedation and analgesia in a burn-trauma ICU. J Burn Care Res. 2009;30:112-118.

MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology. 1998;89:749-770.

Dyster-Aas J, Willebrand M, Wikehult B. Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. J Trauma. 2008;64:1349-1356.

Raymond I, Ancoli-Israel S, Choiniere M. Sleep disturbances, pain and analgesia in adults hospitalized for burn injuries. Sleep Med. 2004;5:551-559.

Jaffe SE, Patterson DR. Treating sleep problems in patients with burn injuries: practical considerations. J Burn Care Rehabil. 2004;25:294-305.

Cantinho FAF, Santos FG, Silva ACP. Conduta anestésica em balneoterapia de pacientes queimados: avaliação prospectiva de 2852 procedimentos. Rev Bras Anestesiol. 2004;54:229-238.

Lewis SM, Clelland JA, Knowles CJ. Effects of auricular acupuncture-like transcutaneous electric nerve stimulation on pain levels following wound care in patients with burns: a pilot study. J Burn Care Rehabil. 1990;11:322-329.

Hernandez-Reif M, Field T, Largie S. Childrens' distress during burn treatment is reduced by massage therapy. J Burn Care Rehabil. 2001;22:191-195.

Das DA, Grimmer KA, Sparnon AL. The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries: a randomized controlled trial. BMC Pediatr. 2005;5:1.

Landolt MA, Marti D, Widmer J. Does cartoon movie distraction decrease burned children's pain behavior?. J Burn Care Rehabil. 2002;23:61-65.

Patterson DR, Questad KA, Lateur BJ. Hypnotherapy as an adjunct to narcotic analgesia for the treatment of pain for burn debridement. Am J Clin Hypn. 1989;31:156-163.

Foertsch CE, O'Hara MW, Stoddard FJ. Parent participation during burn debridement in relation to behavioral distress. J Burn Care Rehabil. 1996;17:372-377.

Frenay MC, Faymonville ME, Devlieger S. Psychological approaches during dressing changes of burned patients: a prospective randomised study comparing hypnosis against stress reducing strategy. Burns. 2001;27:793-799.

Gallagher G, Rae CP, Kenny GNC. The use of a target-controlled infusion of alfentanil to provide analgesia for burn dressing changes: A dose finding study. Anaesthesia. 2000;55:1159-1163.

Prakash S, Fatima T, Pawar M. Patient-controlled analgesia with fentanyl for burn dressing changes. Anesth Analg. 2004;99:552-555.

Hansen SL, Voigt DW, Paul CN. A retrospective study on the effectiveness of intranasal midazolam in pediatric burn patients. J Burn Care Rehabil. 2001;22:6-8.

Santos RA, Oliveira ASN, Serra MCVS. Associação propofol/ cetamina para banho/curativo em queimado. Rev Bras Anestesiol. 1997;47(^s22):14.

Coimbra C, Choinière M, Hemmerling T. Patient-controlled sedation using propofol for dressing changes in burn patients: a dose-finding study. Anesth Analg. 2003;97:839-842.

Malek J, Simankova E, Kurzova A. Sevoflurane vs. ketamine in adult burn patients: a controlled study. Eur J Anaesthesiol. 2001;18(^s21):11.

Heinrich M, Wetzstein V, Muensterer OJ. Conscious sedation: off-label use of rectal S(+)-ketamine and midazolam for wound dressing changes in paediatric heat injuries. Eur J Pediatr Surg. 2004;14:235-239.

Owens VF, Palmieri TL, Comroe CM. Ketamine: a safe and effective agent for painful procedures in the pediatric burn patient. J Burn Care Res. 2006;27:211-216.

Tosun Z, Esmaoglu A, Coruh A. Propofol-ketamine vs propofol-fentanyl combinations for deep sedation and analgesia in pediatric patients undergoing burn dressing changes. Pediatr Anesth. 2008;18:43-47.

Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104:570-587.

Rossi LA, Camargo C, Santos CMNM. A dor da queimadura: terrível para quem sente, estressante para quem cuida. Rev Latino-Am Enfermagem. 2000;8:18-26.

Jeschke MG, Chinkes DL, Finnerty CC. Pathophysiologic response to severe burn injury. Ann Surg. 2008;248:387-401.

Blanchet B, Jullien V, Vinsonneau C. Influence of burns on pharmacokinetics and pharmacodynamics of drugs used in the care of burn patients. Clin Pharmacokinet. 2008;47:635-654.

5dd677dd0e8825531bc8fca6 rba Articles
Links & Downloads
2352-2291 (Electrónico) 0104-0014 (Impreso)
Braz J Anesthesiol ©2024 Todos los derechos reservados.

Braz J Anesthesiol

Share this page
Page Sections