Plotselinge en onverwachte sterfte kan voorkomen bij een patiënt met ernstige chronische pijn, en de terminale gebeurtenis kan mogelijk niet gerelateerd zijn aan medische therapie. Gelukkig is de plotselinge dood niet zo vaak gezien bij patiënten met pijn als in de afgelopen jaren, waarschijnlijk als gevolg van een betere toegang tot ten minste een behandeling. Plotselinge dood doet zich echter nog steeds voor en professionals moeten weten hoe ze een “at-risk” -patiënt kunnen identificeren.
Een onverwachte plotselinge dood door ernstige pijn wordt nauwelijks gewaardeerd, omdat veel waarnemers nog steeds ernstige pijn als een onschadelijke overlast zien in plaats van als een mogelijke fysiologische ramp. In veel gevallen, kort voor de dood, informeert de patiënt de familie dat ze zich zieker voelen dan gewoonlijk en zoeken ze verlichting bij het bed of de sofa. Helaas worden sommige van deze patiënten niet wakker. Andere patiënten sterven zonder waarschuwing tijdens de slaap of worden samengevouwen op de vloer aangetroffen. De agressieve toxicologie van de moderne geneeskunde en post-mortem forensische procedures droegen bij aan een slecht begrip van de dreiging van de dood van pijn. In sommige gevallen stierf een patiënt met pijn die goed werd behandeld met een opioïde of andere overdosis of potentiële misbruiker plotseling en onverwachts.
Dit artikel is bedoeld, voor een deel, om de aandacht te vestigen op het feit dat de loutere ontdekking waarschijnlijk drugsmisbruik bij de autopsie niet noodzakelijkerwijs betekent dat drugs dood hebben veroorzaakt. Sterker nog, medicijnen hebben de dood misschien uitgesteld. Sommige artsen zijn valselijk beschuldigd van het veroorzaken van sterfgevallen als gevolg van overmatige medicamenteuze behandeling, terwijl in feite onvoldoende behandeling van de pijn de dood tot gevolg had. Bovendien bloed opioide niveaus gemeten bij autopsie van een patiënt plotseling die ten onrechte accidentele overdosis gestorven door de patholoog niet weet dat chronische pijnpatiënten op een stabiele dosis van opioïden volledig functioneel kan zijn met serumconcentraties hun voorgeschreven opioïden die ver uitstijgt boven letale niveaus bij onbehandelde patiënten met opioïden. 1
Gegeven hier zijn de mechanismen van een plotselinge en onverwachte dood bij patiënten met pijn en enkele beschermende maatregelen die beoefenaars moeten nemen om vals beschuldigd te worden van het veroorzaken van een plotselinge en onverwachte dood. Belangrijker nog, hier gegeven zijn enkele klinische tips om de patiënt met chronische pijn te identificeren die een hoog risico op een plotselinge en onverwachte dood heeft, zodat de meest agressieve pijnbehandeling kan worden verwerkt.
Een korte geschiedenis Anekdotisch
Als een senior medische student aan de Universiteit van Kansas in de vroege jaren 1960, moest ik een landelijke preceptorate nemen met een arts uit het achterland. Toen we de ronde op een dag afsloten naar het verpleeghuis in de provincie, hoorde ik een boerin verklaren: “De pijn heeft mijn moeder gisteravond gedood.” Sindsdien heb ik herhaaldelijk gehoord dat de pijn een geliefde heeft gedood. Folklore vermeldt vaak dat mensen “van” evenals “in” pijn sterven. Er zijn echter weinig geschreven details van deze gebeurtenissen.
In de beginjaren van mijn pijnpraktijk, die begon in 1975, had ik verschillende patiënten die plotseling en onverwacht stierven. Dit gebeurt mij vandaag zelden, aangezien ik heb geleerd om te wachten op het onverwachte en te identificeren welke patiënten een hoog risico lopen op een plotselinge dood. In de afgelopen jaren heb ik verschillende gevallen van rechtszaken en verwaarlozing van plotselinge en onverwachte sterfgevallen bij patiënten met chronische pijn geanalyseerd. In sommige van deze gevallen zijn artsen beschuldigd van overdreven of verkeerd voorschrijven en het veroorzaken van een plotselinge en onverwachte dood, zelfs als de patiënt gestabiliseerde doses opioïden en andere medicijnen gedurende lange perioden heeft ingenomen. Bovendien toonde de autopsie geen tekenen van longoedeem (een signaal dat een overdosis en ademhalingsdepressie definieert). In gevallen waarin de dokter vals werd beschuldigd,
Scenario en oorzaak
Onverwachte sterfgevallen bij patiënten met chronische pijn komen meestal thuis voor. Soms ligt de dood in een ziekenhuis of detoxcentrum. De geschiedenis van deze patiënten is vrij typisch. De meesten zijn te ziek om hun huis te verlaten en veel tijd in bed of op de bank door te brengen. De dood treedt meestal op tijdens de slaap of wanneer de patiënt opstaat om naar de badkamer te gaan. In sommige gevallen meldt het gezin dat de patiënt een buitengewone hoeveelheid tijd doorbracht in de badkamer net voor de ineenstorting en de dood. Plotselinge en onverwachte dood kan echter overal op elk moment voorkomen, zoals pijnpatiënten die onverwacht stierven en plotseling werden gevonden op het werk of in een auto.
Coronaire spasmen en / of hartritmestoornissen die leiden tot hartstilstand of asystolie is de schijnbare doodsoorzaak in de meeste van deze gevallen, omdat macroscopische pathologie consistent met autopsie niet werd gevonden. 2-5 Instant hartstilstand lijkt verantwoordelijk te zijn voor plotselinge instorting of overlijden tijdens de slaap. Misschien zijn de constipatie en de inspanning om in de ontlasting te gaan mogelijk factoren van hartspanning, aangezien sommige patiënten met pijn tijdens de ontlasting sterven. Acute sepsis als gevolg van bijnierinsufficiëntie en immunosuppressie kan verantwoordelijk zijn voor sommige plotselinge sterfgevallen.
Twee mechanismen van cardiale dood
Ernstige pijn is een vreselijke stress. 6,7 acute aanvallen van pijn, acute of chronische, veroorzaken de hypothalamus-hypofyse-bijnier-as produceert glucocorticoïden (cortisol, pregnenolon) , en catecholaminen (epinefrine en norepinefrine) in een poging om het biologisch spanning bevatten. 8.9 Catecholamines hebben een direct en krachtig stimulerend effect op het cardiovasculaire systeem en resulteert in ernstige hypertensie en tachycardie. 10 Vaak kunnen polsslagen stijgen tot meer dan 100 slagen per minuut en meer dan 130 slagen per minuut bereiken. De bloeddruk kan meer dan 200 mmHg systolisch en meer dan 120 mmHg diastolisch zijn. In adrenale catecholamine vrijmaking pijn exacerbaties veroorzaken hyperactiviteit van het sympathetische autonome zenuwstelsel en die voegt extra stimulatie van catecholamine geïnduceerde tachycardie en hypertensie. De fysieke tekenen van autonome en sympathische hyperactiviteit in aanvulling op tachycardie en hypertensie, kunnen mydriasis (verwijde pupillen), zweten, vaatvernauwing, kou, hyperreflexie, koorts, misselijkheid, diarree en braken.
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