Mort subite et inattendue chez les patients souffrant de douleur chronique et de fibromyalgie

Une mort subite et inattendue peut survenir chez un patient souffrant de douleur chronique sévère, et l’événement terminal peut ne pas être lié au traitement médical. Heureusement, la mort subite n’est pas aussi fréquente chez les patients souffrant de douleur que ces dernières années, probablement en raison d’un meilleur accès à au moins certains traitements. Cependant, la mort subite persiste et les professionnels doivent savoir comment identifier un patient “à risque”.

Une mort subite imprévue due à une douleur intense est à peine perçue, car de nombreux observateurs considèrent encore la douleur intense comme une nuisance inoffensive, plutôt qu’une calamité physiologique potentielle. Dans de nombreux cas, peu de temps avant le décès, le patient informe la famille qu’il se sent plus malade que d’habitude et cherche à obtenir un soulagement du lit ou du canapé. Malheureusement, certains de ces patients ne se réveillent pas. D’autres patients décèdent sans prévenir pendant leur sommeil ou se retrouvent effondrés sur le sol. La toxicologie agressive de la médecine moderne et des procédures médico-légales post-mortem a contribué à une mauvaise compréhension de la menace de mort par douleur. Dans certains cas, un patient souffrant de douleur qui était traité correctement avec un opioïde ou une autre surdose ou un abuseur potentiel est décédé subitement et inopinément.

Cet article vise en partie à attirer l’attention sur le fait que la simple découverte de drogues susceptibles d’abus à l’autopsie ne signifie pas nécessairement que ces drogues ont causé la mort. En fait, la drogue pourrait avoir retardé la mort. Certains médecins ont été faussement accusés d’avoir provoqué des décès dus à un traitement médicamenteux excessif alors qu’en réalité, un traitement insuffisant de la douleur pouvait avoir entraîné la mort. En outre, les taux sanguins d’opioïdes évalués lors de l’autopsie d’un patient décédé subitement sont considérés à tort comme des surdoses accidentelles, car le pathologiste ignore que les patients présentant une douleur chronique associée à une dose stable d’opioïdes peuvent être entièrement fonctionnels avec des taux sériques d’opioïdes prescrits dépassant jusqu’à présent. taux mortels chez les patients non traités avec des opioïdes. 1

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Nous présentons ici les mécanismes de la mort subite et inattendue chez les patients souffrant de douleur et certaines mesures de protection que les praticiens doivent prendre pour éviter d’être faussement accusés de causer une mort subite et inattendue. Plus important encore, voici quelques conseils cliniques pour aider à identifier le patient souffrant de douleur chronique présentant un risque élevé de mort subite et inattendue, afin que le traitement de la douleur le plus agressif puisse être traité.

Une brève histoire anecdotique
En tant qu’étudiant en médecine à l’Université du Kansas au début des années 1960, je devais suivre un précepte rural avec un médecin de l’arrière-pays. Alors que nous nous rendions un jour dans la maison de retraite du comté, j’ai entendu la femme d’un fermier déclarer: “La douleur a tué ma mère la nuit dernière”. Depuis lors, j’ai entendu à plusieurs reprises que la douleur avait tué un être cher. Le folklore mentionne souvent que les gens meurent “de” ou “dans” la douleur. Il existe toutefois peu de détails écrits sur ces événements.

Dans les premières années de ma pratique de la douleur, qui a débuté en 1975, plusieurs de mes patients sont décédés subitement et inopinément. Cela m’est rarement arrivé aujourd’hui, puisque j’ai appris à “attendre l’imprévu” et à identifier les patients présentant un risque élevé de mort subite. Au cours des dernières années, j’ai analysé plusieurs cas de litige et de négligence concernant la mort subite et inattendue chez des patients souffrant de douleur chronique. Dans certains de ces cas, les médecins ont été accusés d’avoir surcrit ou prescrit incorrectement et d’avoir causé une mort soudaine et inattendue, même si le patient avait pris des doses stabilisées d’opioïdes et d’autres médicaments pendant de longues périodes. En outre, l’autopsie n’a mis en évidence aucun œdème pulmonaire (signal définissant le surdosage et la dépression respiratoire). Dans les cas où le médecin a été faussement accusé,

Scénario et cause
Des décès inattendus chez les patients souffrant de douleur chronique surviennent généralement à la maison. Parfois, la mort est dans un hôpital ou un centre de désintoxication. L’histoire de ces patients est assez typique. La plupart sont trop malades pour quitter leur domicile et passent beaucoup de temps au lit ou sur le canapé. La mort survient généralement pendant le sommeil ou lorsque le patient se lève pour aller aux toilettes. Dans certains cas, la famille rapporte que le patient a passé énormément de temps dans les toilettes juste avant l’effondrement et la mort. Une mort soudaine et inattendue, cependant, peut survenir n’importe où, à n’importe quel moment, comme des patients souffrant de douleur décédés inopinément et retrouvés subitement au travail ou dans une voiture.

Les spasmes coronaires et / ou les arythmies cardiaques conduisant à un arrêt cardiaque ou à une asystolie constituent la cause apparente du décès dans la plupart des cas, car aucune pathologie macroscopique compatible avec l’autopsie n’a été constatée. 2-5  Un arrêt cardiaque instantané semble être responsable d’un collapsus soudain ou de la mort pendant le sommeil. Peut-être que la constipation et l’effort de passer dans les selles peuvent être des facteurs de tension cardiaque car certains patients souffrant de douleur décèdent pendant la défécation. Une septicémie aiguë due à une insuffisance surrénalienne et à une immunosuppression peut être responsable de certaines morts subites.

Résultat de l'image pour la mort subite et inattendue chez les patients souffrant de douleur chronique

Deux mécanismes de la mort cardiaque
La douleur intense est un stress horrible. 6,7  Les crises aiguës de douleur aiguë ou chronique incitent l’axe hypothalamo-hypophyso-surrénalien à produire des glucocorticoïdes (cortisol, prégnénolone) et des catécholamines (adrénaline et noradrénaline) dans le but de réduire biologiquement le stress. 8,9  Les catécholamines exercent un effet de stimulation direct et puissant sur le système cardiovasculaire et entraînent une tachycardie et une hypertension graves. 10 Souvent, les pulsations peuvent atteindre plus de 100 battements par minute et atteindre plus de 130 battements par minute. La tension artérielle peut atteindre plus de 200 mmHg systolique et plus de 120 mmHg diastolique. En plus de la libération de catécholamines surrénaliennes, des exacerbations de la douleur provoquent une hyperactivité du système nerveux autonome et sympathique, ce qui ajoute un stimulus supplémentaire à la tachycardie et à l’hypertension induites par la catécholamine. Les signes physiques d’hyperactivité autonome et sympathique, en plus de la tachycardie et de l’hypertension, peuvent inclure une mydriase (pupilles dilatées), une transpiration, une vasoconstriction aux extrémités froides, une hyperréflexie, une hyperthermie, des nausées, une diarrhée et des vomissements.

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