Mort brutale de patients souffrant de douleurs chroniques. Vous devez être conscient

Forest Tennant, MD, DrPH

Une douleur intense, indépendante du traitement médical, peut provoquer une mort soudaine et inattendue. L’arrêt cardiaque est la cause, et les praticiens doivent savoir comment repérer un patient à haut risque.
Résultat de l'image pour Patient sur le lit d'ICU

Une mort soudaine et inattendue peut survenir chez un patient souffrant de douleur chronique sévère, et l’événement terminal peut ne pas être lié à un traitement médical. Heureusement, la mort subite n’est pas aussi fréquemment observée chez les patients souffrant de douleur que les années précédentes, probablement en raison d’un meilleur accès à au moins certains traitements. Cependant, la mort subite se produit toujours, et les praticiens doivent savoir comment repérer un patient «à risque».

Inattendue, la mort subite due à une douleur intense est peu appréciée, car de nombreux observateurs considèrent toujours la douleur intense comme une nuisance inoffensive plutôt qu’une calamité physiologique potentielle. Dans de nombreux cas, juste avant la mort, le patient informe sa famille qu’il se sent plus malade que d’habitude et cherche à se soulager dans son lit ou sur son canapé. Malheureusement, certains de ces patients ne se réveillent pas. D’autres patients meurent, sans avertissement, dans leur sommeil ou se trouvent effondrés sur le sol. La toxicologie agressive de la médecine moderne et les procédures médico-légales après la mort ont contribué à la mauvaise compréhension de la menace de mort de la douleur. Dans certains cas, un patient souffrant de douleur qui a été traité de façon appropriée avec un opioïde ou un autre agent ayant un potentiel de surdose ou d’abus est mort subitement et de façon inattendue. Des médicaments ont été trouvés dans les fluides corporels après la mort,

Cet article vise en partie à attirer l’attention sur le fait que la simple découverte de drogues abusives à l’autopsie ne signifie pas nécessairement que les drogues ont causé la mort. En fait, les médicaments peuvent avoir retardé la mort. Certains médecins ont été faussement accusés d’avoir causé des décès en raison d’un abus de médicaments, alors qu’en fait, le traitement insuffisant de la douleur pourrait avoir causé la mort. De plus, les taux sanguins d’opioïdes mesurés à l’autopsie d’un patient décédé subitement sont trop souvent considérés à tort comme des surdoses accidentelles parce que le pathologiste ne sait pas que les patients souffrant de douleur chronique sous opiacés peuvent fonctionner pleinement avec des taux sériques d’opioïdes prescrits. dépasser les niveaux létaux chez les patients naïfs d’opioïdes. 1

Les mécanismes de la mort soudaine et inattendue chez les patients souffrant de douleur et les mesures de protection que les praticiens doivent prendre pour éviter d’être faussement accusés de causer une mort soudaine et inattendue sont donnés ici. Plus important encore, voici quelques conseils cliniques pour aider à identifier le patient souffrant de douleur chronique qui présente un risque élevé de mort subite et inattendue, afin qu’un traitement de la douleur plus agressif puisse être rendu.

Une brève histoire anecdotique
En tant qu’étudiant en médecine à l’Université du Kansas au début des années 1960, j’ai dû suivre un préceptorat en milieu rural avec un médecin de campagne. En faisant un tour à 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 dire que la douleur avait tué un être cher. Le folklore mentionne fréquemment que les gens meurent “de”, ainsi que “dans” la douleur. Il y a cependant peu de détails écrits sur ces événements.

Dans les premières années de ma pratique de la douleur, que j’ai commencé en 1975, j’ai fait mourir plusieurs patients soudainement et de façon inattendue. Cela m’arrive rarement aujourd’hui car j’ai appris à «m’attendre à l’inattendu» et à identifier les patients qui courent un risque élevé de mort subite. Au cours des dernières années, j’ai examiné un certain nombre de cas de litiges et de fautes professionnelles de mort subite et inattendue chez des patients souffrant de douleur chronique. Dans certains de ces cas, les médecins ont été accusés de surprescription ou de mauvaise lecture et d’avoir causé un décès soudain et inattendu, même si le patient avait pris des doses stabilisées d’opioïdes et d’autres médicaments pendant de longues périodes. De plus, l’autopsie n’a révélé aucun signe d’œdème pulmonaire (un signe de surdose et de dépression respiratoire). Dans les cas où le médecin a été faussement accusé, la découverte de drogues abusives dans les fluides corporels après la mort a causé la mort d’un membre de la famille.

Définition et cause Les
décès inattendus chez les patients souffrant de douleur chronique se produisent généralement à la maison. Parfois, la mort est dans un hôpital ou un centre de désintoxication. L’histoire de ces patients est plutôt typique. La plupart sont trop malades pour quitter la maison et passer beaucoup de temps au lit ou sur un canapé. La mort survient souvent pendant le sommeil ou lorsque le patient se lève pour aller aux toilettes. Dans certains cas, la famille rapporte que le patient a passé une quantité de temps extraordinaire sur les toilettes juste avant l’effondrement et la mort. Une mort soudaine et inattendue peut cependant se produire n’importe où et n’importe quand, lorsque des patients souffrant de douleur sont décédés de façon inattendue et ont soudainement été retrouvés au travail ou en voiture.

Les spasmes coronariens et / ou les arythmies cardiaques entraînant un arrêt cardiaque ou une asystolie sont la cause apparente du décès dans la majorité de ces cas, car aucune pathologie macroscopique conséquente n’a été retrouvée à l’autopsie. 2-5  Un arrêt cardiaque instantané semble expliquer un collapsus soudain ou la mort pendant le sommeil. Peut-être que la constipation et la tension pour passer les selles peuvent être des facteurs de contrainte cardiaque, car certains patients souffrant de douleur meurent pendant la défécation. Une septicémie aiguë due à une insuffisance surrénale et à une immunosuppression peut être à l’origine de certains décès soudains.

Deux mécanismes de mort cardiaque
La douleur intense est un stress horrible. 6,7  Les poussées douloureuses aiguës ou chroniques provoquent chez l’axe hypothalamo-hypophyso-surrénalien la production de glucocorticoïdes (cortisol, prégnénolone) et de catécholamines (adrénaline et noradrénaline) dans le but de contenir biologiquement le stress. 8,9  Les catécholamines ont un effet de stimulation puissant et direct sur le système cardiovasculaire et entraînent une tachycardie sévère et une hypertension. dix Les taux de pouls peuvent généralement atteindre plus de 100 battements par minute et même 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 surrénales, les poussées de douleur provoquent une hyperactivité du système nerveux autonome et sympathique, qui ajoute une stimulation supplémentaire à la tachycardie induite par les catécholamines et à l’hypertension. Les signes physiques d’hyperactivité sympathique autonome, en plus de la tachycardie et de l’hypertension, peuvent inclure mydriase (pupille dilatée), transpiration, vasoconstriction avec extrémités froides, hyperréflexie, hyperthermie, nausées, diarrhée et vomissements.

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