Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942009000400003
Brazilian Journal of Anesthesiology
Scientific Article

Incidência de depressão respiratória no pós-operatório em pacientes submetidos à analgesia venosa ou peridural com opioides

The incidence of postoperative respiratory depression in patients undergoing intravenous or epidural analgesia with opioids

Leonardo Teixeira Domingues Duarte; Maria do Carmo Barretto de Carvalho Fernandes; Verônica Vieira da Costa; Renato Ângelo Saraiva

http://dx.doi.org/10.1590/S0034-70942009000400003 Braz J Anesthesiol, vol.59, n4, p.409-420, 2009
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Resumo

JUSTIFICATIVA E OBJETIVOS: A analgesia controlada pelo paciente (PCA), por via venosa ou peridural, é técnica segura e eficaz no tratamento da dor pós-operatória. Todavia, o uso de opioides não é isento de risco, e a depressão respiratória é a complicação mais temida. Os objetivos deste estudo foram descrever a incidência de depressão respiratória associada à analgesia pós-operatória com opioides administrados por via peridural ou venosa e as características dos pacientes que apresentaram a complicação. MÉTODO: Estudo de incidência, retrospectivo, em pacientes operados no Hospital SARAH Brasília entre dezembro de 1999 e dezembro de 2007 e tratados com PCA com opioides por via venosa ou peridural. Foram definidos como casos de depressão respiratória: frequência respiratória < 8 irpm, necessidade do uso de naloxona ou saturação periférica de oxigênio abaixo de 90%. RESULTADOS: Foram avaliados 2790 pacientes, dos quais 635 pacientes receberam PCA venosa e 2155, analgesia peridural. Ocorreram sete casos de depressão respiratória pós-operatória (incidência de 0,25%). Destes, seis pacientes foram tratados com PCA venosa com morfina, enquanto o último recebeu analgesia peridural com fentanil. A média de idade foi de 30,5 ± 24,7 anos; o tempo médio entre o término da anestesia até a ocorrência da depressão respiratória foi de 18,1 ± 26,3 horas. A ocorrência de depressão respiratória foi significativamente mais frequente na PCA venosa com morfina (p = 0,001) e idade menor que 16 anos (p < 0,05). CONCLUSÕES: A incidência de depressão respiratória encontrada foi semelhante à descrita na literatura, sendo mais frequente em crianças e adolescentes, e com PCA venosa.

Palavras-chave

ANALGESIA, ANALGESIA, ANALGÉSICOS, COMPLICAÇÕES

Abstract

BACKGROUND AND OBJECTIVES: Intravenous or epidural patient-controlled analgesia (PCA) is a safe and effective technique in the treatment of postoperative pain. However, the use of opioids is not devoid of risks,and respiratory depression represents the most feared complication. The objective of the present study was to describe the incidence of respiratory depression associated with postoperative analgesia with the intravenous or epidural administration of opioids and the characteristics of the patients who developed this complication. METHODS: This is a retrospective, incidence study in patients who underwent surgeries at the Hospital SARAH Brasília from December 1999 to December 2007 and treated with intravenous or epidural PCA with opioids. Respiratory depression was defined as: respiratory rate < 8 bpm, need to use naloxone, or peripheral oxygen saturation below 90%. RESULTS: Two thousand seven hundred and ninety patients were evaluated; 635 of those patients received intravenous PCA and 2155 epidural analgesia. Seven patients developed postoperative respiratory depression (0.25%). Six of those patients were treated with intravenous PCA with morphine, while the last one received epidural analgesia with fentanyl. Patients had a mean age of 30.5 ± 24.7 years; the mean time between the end of anesthesia and the development of respiratory depression was 18.1 ± 26.3 hours. The incidence of respiratory depression was significantly higher in PCA with intravenous morphine (p = 0.001) and age below 16 years (p < 0.05). CONCLUSIONS: The incidence of respiratory depression was similar to that described in the literature; it is more frequent in children and adolescents, and with intravenous PCA.

Keywords

ANALGESIA, ANALGESIA, ANALGESICS, COMPLICATIONS

References

Walder B, Schafer M, Henzi I. Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain: A quantitative systematic review. Acta Anaesthesiol Scand. 2001;45:795-804.

Cashman JN, Dolin SJ. Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data. Br J Anaesth. 2004;93:212-223.

Ko S, Goldstein DH, VanDenKerkhof EG. Definitions of "respiratory depression" with intrathecal morphine postoperative analgesia: a review of the literature. Can J Anaesth. 2003;50:679-688.

Shapiro A, Zohar E, Zaslansky R. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. J Clin Anesth. 2005;17:537-542.

Ballantyne JC, Carr DB, Chalmers TC. Postoperative patient-controlled analgesia: meta-analyses of initial randomized control trials. J Clin Anesth. 1993;5:182-193.

Ramsay MA, Savege TM, Simpson BR. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974;2:656-659.

Momeni M, Crucitti M, De Kock M. Patient-controlled analgesia in the management of postoperative pain. Drugs. 2006;66:2321-2337.

Baxter AD. Respiratory depression with patient-controlled analgesia. Can J Anaesth. 1994;41:87-90.

Fleming BM, Coombs DW. A survey of complications documented in a quality-control analysis of patient-controlled analgesia in the postoperative patient. J Pain Symptom Manage. 1992;7:463-469.

Lotsch J, Dudziak R, Freynhagen R. Fatal respiratory depression after multiple intravenous morphine injections. Clin Pharmacokinet. 2006;45:1051-1060.

Aubrun F, Monsel S, Langeron O. Postoperative titration of intravenous morphine in the elderly patient. Anesthesiology. 2002;96:17-23.

Gagliese L, Jackson M, Ritvo P. Age is not an impediment to effective use of patient-controlled analgesia by surgical patients. Anesthesiology. 2000;93:601-610.

Weightman WM. Respiratory arrest during epidural infusion of bupivacaine and fentanyl. Anaesth Intensive Care. 1991;19:282-284.

Grass J. Patient-controlled analgesia. Anesth Analg. 2005;101:S44-S61.

Mann C, Pouzeratte Y, Eledjam JJ. Postoperative patient-controlled analgesia in the elderly: risks and benefits of epidural versus intravenous administration. Drugs Aging. 2003;20:337-345.

Scott DA, Beilby DS, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine: A prospective analysis of 1,014 patients. Anesthesiology. 1995;83:727-737.

Macintyre PE. Safety and efficacy of patient-controlled analgesia. Br J Anaesth. 2001;87:36-46.

Sidebotham D, Dijkhuizen MR, Schug SA. The safety and utilization of patient-controlled analgesia. J Pain Symptom Manage. 1997;14:202-209.

Kopka A, Wallace E, Reilly G. Observational study of perioperative PtcCO2 and SpO2 in non-ventilated patients receiving epidural infusion or patient-controlled analgesia using a single earlobe monitor (TOSCA). Br J Anaesth. 2007;99:567-571.

Overdyk FJ, Carter R, Maddox RR. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg. 2007;105:412-418.

Hagle ME, Lehr VT, Brubakken K. Respiratory depression in adult patients with intravenous patient-controlled analgesia. Orthop Nurs. 2004;23:18-27.

Taylor S, Kirton OC, Staff I. Postoperative day one: a high risk period for respiratory events. Am J Surg. 2005;190:752-756.

Gagliese L, Katz J. Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain. 2003;103:11-20.

Stone JG, Cozine KA, Wald A. Nocturnal oxygenation during patient-controlled analgesia. Anesth Analg. 1999;89:104-110.

Wheatley RG, Schug SA, Watson D. Safety and efficacy of postoperative epidural analgesia. Br J Anaesth. 2001;87:47-61.

Inturrisi CE. Clinical pharmacology of opioids for pain. Clin J Pain. 2002;18(4^sSuppl):S3-S13.

Bernards CM, Shen DD, Sterling ES. Epidural, cerebrospinal fluid, and plasma pharmacokinetics of epidural opioids (part 2): effect of epinephrine. Anesthesiology. 2003;99:466-475.

Bouillon T, Bruhn J, Roepcke H. Opioid-induced respiratory depression is associated with increased tidal volume variability. Eur J Anaesthesiol. 2003;20:127-133.

Assad SA, Isaacson SA, Wu CL. Update on patient-controlled epidural analgesia. Techn Reg Anesth Pain Manag. 2003;7:127-132.

van der Vyver M, Halpern S, Joseph G. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis. Br J Anaesth. 2002;89:459-465.

Silvasti M, Pitkanen M. Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty. Acta Anaesthesiol Scand. 2001;45:471-476.

Liu SS, Allen HW, Olsson GL. Patient-controlled epidural analgesia with bupivacaine and fentanyl on hospital wards: prospective experience with 1,030 surgical patients. Anesthesiology. 1998;88:688-695.

de Leon-Casasola OA, Parker B, Lema MJ. Postoperative epidural bupivacaine-morphine therapy: Experience with 4,227 surgical cancer patients. Anesthesiology. 1994;81:368-375.

Guinard JP, Mavrocordatos P, Chiolero R. A randomized comparison of intravenous versus lumbar and thoracic epidural fentanyl for analgesia after thoracotomy. Anesthesiology. 1992;77:1108-1115.

Tsui SL, Irwin MG, Wong CM. An audit of the safety of an acute pain service. Anaesthesia. 1997;52:1042-1047.

Parker RK, Holtmann B, White PF. Patient-controlled analgesia: Does a concurrent opioid infusion improve pain management after surgery?. JAMA. 1991;266:1947-1952.

Wheatley RG, Madej TH, Jackson IJ. The first year's experience of an acute pain service. Br J Anaesth. 1991;67:353-359.

Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth. 2002;89:409-423.

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