Morte abrupta de pacientes com dor crônica. Você deve estar ciente

Dor severa, independente da terapia médica, pode causar morte súbita e inesperada. A parada cardíaca é a causa, e os profissionais precisam saber como detectar um paciente de alto risco.
Resultado da imagem para Patient on ICU Bed

A morte repentina e inesperada pode ocorrer em um paciente com dor crônica grave e o evento terminal pode não estar relacionado com a terapêutica médica. Felizmente, a morte súbita não é tão comumente observada em pacientes com dor como nos últimos anos, provavelmente devido a melhor acesso a pelo menos algum tratamento. A morte súbita ainda ocorre, no entanto, e os profissionais precisam saber como detectar um paciente “em risco”.

Inesperado, a morte súbita devido a dor severa é pouco apreciada, já que muitos observadores ainda vêem dor intensa como um incômodo inofensivo em vez de uma potencial calamidade fisiológica. Em muitos casos, apenas antes da morte, o paciente informa a família de que se sentem mais doen do que de costume e buscam alívio na cama ou no sofá. Infelizmente, alguns desses pacientes não despertam. Outros pacientes morrem, sem aviso prévio, em seu sono ou são encontrados colapsados ​​no chão. A toxicologia agressiva da medicina moderna e os procedimentos forenses após a morte contribuíram para a má compreensão da ameaça de morte da dor. Em alguns casos, um paciente doente que estava sendo tratado adequadamente com um opióide ou outro agente com overdose ou potencial de abuso morreu de forma repentina e inesperada. Drogas foram encontradas em fluidos corporais após a morte,

Este artigo destina-se parcialmente a chamar a atenção para o fato de que a mera descoberta de drogas abusivas na autópsia não significa necessariamente que as drogas causaram a morte. Na verdade, as drogas podem ter adiado a morte. Alguns médicos foram falsamente acusados ​​de causar mortes devido ao tratamento excessivo da droga quando, de fato, o tratamento insuficiente da dor pode ter causado a morte. Além disso, os níveis sanguíneos de opióides avaliados na autópsia de um paciente que morreu de repente são muitas vezes negligentemente considerados overdoses acidentais, porque o patologista ignora que os pacientes com dor crônica em uma dose estável de opióides podem ser totalmente funcionais com os níveis séricos de seus opióides prescritos excede os níveis letais em pacientes com óxidos opiáceos. 1

Dado aqui estão os mecanismos de morte súbita e inesperada em pacientes com dor e algumas medidas de proteção que os profissionais devem tomar para evitar ser falsamente acusado de causar uma morte súbita e inesperada. Mais importante, dado aqui estão algumas dicas clínicas para ajudar a identificar o paciente com dor crônica que está em alto risco de morte súbita e inesperada para que o tratamento da dor mais agressivo possa ser processado.

Uma breve história anedótica
Como estudante de medicina sênior da Universidade de Kansas, no início da década de 1960, eu era obrigado a receber uma preceptoria rural com um médico do país. Ao fazer nossas rodadas um dia para o lar de idosos do condado, eu ouvi a esposa de um fazendeiro declarar: “a dor matou minha mãe na noite passada.” Desde então, eu ouvi repetidamente que a dor matou um ente querido. O folclore freqüentemente menciona que as pessoas morrem “de”, bem como “em” a dor. Há, no entanto, pequenos detalhes escritos desses eventos.

Nos primeiros anos de minha prática de dor, que comecei em 1975, vários pacientes morreram de repente e inesperadamente. Isso raramente acontece comigo hoje, já que aprendi a “esperar o inesperado” e identificar quais pacientes correm alto risco de morte súbita. Nos últimos anos, revisei uma série de litígios e casos de negligência de morte súbita e inesperada em pacientes com dor crônica. Em alguns desses casos, os médicos foram acusados ​​de excesso ou má prescrição e causaram uma morte súbita e inesperada, embora o paciente tenha tomado doses estabilizadas de opióides e outras drogas por longos períodos. Além disso, a autópsia não mostrou evidência de edema pulmonar (um sinal definidor de sobredosagem e depressão respiratória). Nos casos em que o médico foi acusado falsamente, o achado pós-morte de drogas abusivas em fluidos corporais causou um membro da família,

Definição e Causa
Mortes inesperadas em pacientes com dor crônica geralmente ocorrem em casa. Às vezes, a morte está em um hospital ou centro de desintoxicação. A história desses pacientes é bastante típica. A maioria está doente demais para sair de casa e passar muito tempo na cama ou em um sofá. A morte ocorre frequentemente durante o sono ou quando o paciente se levanta para ir ao banheiro. Em alguns casos, a família relata que o paciente passou uma quantidade extraordinária de tempo no banheiro apenas antes do colapso e da morte. A morte repentina e inesperada, no entanto, pode ocorrer a qualquer momento, como pacientes com dor que morreram inesperadamente e de repente foram encontrados no trabalho ou em um carro.

O espasmo coronariano e / ou a arritmia cardíaca levando a parada cardíaca ou asistolia é a aparente causa de morte na maioria desses casos, uma vez que nenhuma patologia grosseira consistente foi encontrada na autópsia. 2-5  A parada cardíaca imediata parece explicar o colapso súbito ou a morte durante o sono. Talvez constipação e esforço para passar fezes podem ser fatores de tensão cardíaca, pois alguns pacientes com dor morrem durante a defecação. A sepsis aguda por insuficiência adrenal e imunossupressão pode representar algumas mortes repentinas.

Dois mecanismos de morte cardíaca
A dor severa é um estresse horrível. 6,7  As inflamações da dor severa, agudas ou crônicas, causam o eixo hipotálamo-hipófise-adrenal para produzir glicocorticóides (cortisol, pregnenolona) e catecolaminas (adrenalina e noradrenalina) em um esforço para conter o estresse biologicamente. 8,9  As catecolaminas têm um efeito de estimulação direta e potente no sistema cardiovascular e taquicardia severa e resultado de hipertensão. 10 As taxas de pulso geralmente podem aumentar para mais de 100 batimentos por minuto e até subir para mais de 130 batimentos por minuto. A pressão arterial pode atingir mais de 200 mmHg sistólica e mais de 120 mmHg diastólica. Além da liberação de catecolaminas adrenais, as inflamações da dor causam hiperatividade do sistema nervoso autônomo e simpático, que adicionam estimulação adicional à taquicardia e hipertensão induzidas por catecolaminas. Os sinais físicos de hiperatividade autônoma e simpática, além de taquicardia e hipertensão, podem incluir midríase (pupila dilatada), sudação, vasoconstrição com extremidades frias, hiperreflexia, hipertermia, náuseas, diarréia e vômitos

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