Muerte Súbita e Inesperada en el Dolor Crónico y Pacientes con Fibromialgia

La muerte súbita e inesperada puede ocurrir en un paciente con dolor crónico grave, y el evento terminal puede no estar relacionado con la terapia médica. Afortunadamente, la muerte súbita no es tan comúnmente observada en pacientes con dolor como en los últimos años, probablemente debido a un mejor acceso a por lo menos algún tratamiento. La muerte súbita aún ocurre, sin embargo, y los profesionales necesitan saber cómo identificar a un paciente “en riesgo”.

La inesperada muerte súbita debido al dolor severo es poco apreciada, ya que muchos observadores todavía ven el dolor severo como una incómoda inofensiva, en vez de una potencial calamidad fisiológica. En muchos casos, poco antes de la muerte, el paciente le informa a la familia que se siente más enferma de lo habitual y busca alivio en la cama o en el sofá. Desafortunadamente, algunos de estos pacientes no despiertan. Otros pacientes mueren, sin aviso, durante el sueño o se encuentran colapsados ​​en el suelo. La toxicología agresiva de la medicina moderna y los procedimientos forenses después de la muerte contribuyeron a la mala comprensión de la amenaza de muerte del dolor. En algunos casos, un paciente con dolor que estaba siendo tratado adecuadamente con un opioide u otro agente con sobredosis o potencial de abuso murió repentina e inesperadamente.

Este artículo se destina en parte a llamar la atención sobre el hecho de que el mero descubrimiento de drogas susceptibles de abuso en la autopsia no significa necesariamente que las drogas hayan causado la muerte. De hecho, las drogas pueden haber retrasado la muerte. Algunos médicos fueron falsamente acusados ​​de causar muertes debido al tratamiento excesivo de drogas cuando, en realidad, el tratamiento insuficiente del dolor puede haber causado la muerte. Además, los niveles sanguíneos opioides evaluados en la autopsia de un paciente que murió repentinamente son erróneamente considerados sobredosis accidental porque el patólogo no sabe que los pacientes con dolor crónico en una dosis estable de opioides pueden ser totalmente funcionales con niveles séricos de sus opioides prescritos tan lejos excede los niveles letales en pacientes sin tratamiento previo con opiáceos. 1

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Se dan aquí los mecanismos de muerte repentina e inesperada en pacientes con dolor y algunas medidas de protección que los practicantes deben tomar para evitar ser falsamente acusados ​​de causar una muerte súbita e inesperada. Más importante, dado aquí son algunos consejos clínicos para ayudar a identificar al paciente con dolor crónico que está en alto riesgo de muerte súbita e inesperada para que el tratamiento del dolor más agresivo puede ser procesado.

Una breve historia anecdótica
Como estudiante de medicina de alto nivel en la Universidad de Kansas en la década de 1960, que se vio obligado a tomar un preceptoria rural con un médico rural. Al hacer las rondas un día para la casa de reposo del condado, oí a la esposa de un granjero declarar: “El dolor mató a mi madre la noche pasada”. Desde entonces he escuchado repetidamente que el dolor mató a un ser querido. El folclore frecuentemente menciona que las personas mueren “de”, así como “en” dolor. Hay, sin embargo, pocos detalles escritos de estos eventos.

En los primeros años de mi práctica de dolor, que empecé en 1975, tuve varios pacientes que murieron repentina e inesperadamente. Esto rara vez ocurre conmigo hoy, ya que aprendí a “esperar lo inesperado” ya identificar qué pacientes están en alto riesgo de muerte súbita. En los últimos años, he examinado varios casos de litigio y negligencia de muerte súbita e inesperada en pacientes con dolor crónico. En algunos de estos casos, los médicos fueron acusados ​​de over- o misprescribing y causando una muerte súbita e inesperada, aunque el paciente tomara dosis estabilizadas de opioides y otras drogas por largos períodos. Además, la autopsia no mostró evidencia de edema pulmonar (un signo definidor de sobredosis y depresión respiratoria). En los casos en que el médico fue falsamente acusado,

Configuración y causar
muertes inesperadas en pacientes con dolor crónico a menudo se producen en el hogar. A veces la muerte es en un hospital o centro de desintoxicación. La historia de estos pacientes es bastante típica. La mayoría está muy enferma para salir de casa y pasar mucho tiempo en la cama o en el sofá. La muerte generalmente ocurre durante el sueño o cuando el paciente se levanta para ir al baño. En algunos casos, la familia relata que el paciente pasó una cantidad extraordinaria de tiempo en el baño poco antes del colapso y de la muerte. La muerte súbita e inesperada, sin embargo, puede ocurrir en cualquier lugar en cualquier momento, como pacientes con dolor que murieron inesperadamente y de repente se encontraron en el trabajo o en un coche.

El espasmo coronario y / o arritmia cardiaca que conduce al paro cardíaco o asistolia es la causa aparente de muerte en la mayoría de estos casos, ya que no se ha encontrado patología macroscópica consistente en la autopsia. 2-5  El paro cardíaco instantánea parece ser responsable del colapso súbito o muerte durante el sueño. Tal vez el estreñimiento y el esfuerzo para pasar en las heces pueden ser factores de tensión cardiaca, ya que algunos pacientes con dolor mueren durante la defecación. La sepsis aguda debido a la insuficiencia adrenal ya la inmunosupresión puede ser responsable de algunas muertes súbitas.

Resultado de la Imagen para Muerte Súbita e Inesperada en Pacientes con Dolor Crónico

Dos mecanismos de muerte cardiaca
El dolor severo es un terrible estrés. 6.7  Los ataques agudos de dolor, agudas o crónicas, provocan que el eje hipotálamo-pituitaria-adrenal produce glucocorticoides (cortisol, pregnenolona) , y catecolaminas (adrenalina y noradrenalina), en un esfuerzo para contener el estrés biológicamente. 8.9  Las catecolaminas tienen un efecto estimulante directo y potente sobre el sistema cardiovascular y los resultados en la hipertensión grave y taquicardia. 10 A menudo, las frecuencias de pulso pueden subir a más de 100 latidos por minuto y hasta llegar a más de 130 latidos por minuto. La presión arterial puede alcanzar más de 200 mmHg sistólica y más de 120 mmHg diastólica. Además de la liberación de catecolaminas adrenales, las exacerbaciones del dolor causan hiperactividad del sistema nervioso autónomo y simpático, que añade estímulo adicional a la taquicardia inducida por catecolaminas y la hipertensión. Los signos físicos de hiperactividad autonómica y simpática, además de taquicardia e hipertensión, pueden incluir midriasis (pupila dilatada), sudoración, vasoconstricción con extremidades frías, hiperreflexia, hipertermia, náuseas, diarrea y vómitos.

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