Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942002000500005
Brazilian Journal of Anesthesiology
Scientific Article

Analgesia pós-toracotomia com associação de morfina por via peridural e venosa

Comparison of intravenous and epidural morphine analgesia after thoracotomy

Neuber Martins Fonseca; Beatriz Lemos da S. Mandim; Célio Gomes de Amorim

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Resumo

JUSTIFICATIVA E OBJETIVOS: Analgesia após cirurgia de tórax é feita por diferentes métodos. O objetivo do estudo foi avaliar a analgesia pós-operatória com associação de morfina por via venosa e peridural, comparada ao uso por via isolada. MÉTODO: Foram estudados 20 pacientes submetidos à cirurgia de tórax, ambos os sexos, estado físico ASA I a III. Foi feita medicação pré-anestésica com midazolam por via venosa (3 a 3,5 mg) na SO. A monitorização constou de ECG contínuo, pressão arterial invasiva, oximetria de pulso, capnografia, PVC, diurese e temperatura. Primeiramente foi realizada anestesia peridural contínua, T7-T8 com 10 ml de bupivacaína a 0,25% e, em seguida, indução com fentanil (5 µg.kg-1), etomidato (0,2 a 0,3 mg.kg-1) e succinilcolina (1 mg.kg-1). Foi feita IOT com tubo de duplo lume, complementação com pancurônio (0,08 a 0,1 mg.kg-1) e ventilação controlada mecânica. Os pacientes foram então distribuídos aleatoriamente em três grupos. Ao Grupo I, administrou-se pelo cateter peridural, 2 mg de morfina 0,1% na indução da anestesia (M1), após 12 horas (M2) e 24 horas (M3) do final da cirurgia, ao Grupo II, morfina por via venosa em bomba de infusão (15 µg.kg.h-1) precedida de bolus de 50 µg.kg-1, durante 30 horas e ao Grupo III, morfina por via peridural na dose de 0,5 mg em M1, M2 e M3, associada com morfina venosa em bomba de infusão (8 µg.kg.h-1) precedida de bolus de 25 µg.kg-1, por 30 horas. Análise de gases arteriais, freqüências cardíaca e respiratória, presença de prurido, náuseas, vômitos e analgesia pós-operatória foram avaliados a cada 6 horas, até um total de 30 horas do pós-operatório. A analgesia foi avaliada por escala de graduação numérica (EGN) de 0 a 10. RESULTADOS: A EGN apresentou redução no grupo I apenas no momento M2 não ocorrendo nos demais intervalos. Nos grupos II e III ocorreu redução da dor a partir de 18 horas em relação aos valores iniciais e em relação ao grupo I. Houve maior necessidade de analgesia complementar no grupo I do que nos outros grupos. CONCLUSÕES: Observou-se melhor efeito analgésico com morfina venosa ou com a associação de vias venosa e peridural utilizando-se menores doses de morfina. Esta diferença foi expressiva quando menores quantidades de analgésicos complementares foram utilizados nestes grupos, oferecendo um efetivo método de analgesia para o pós-operatório de cirurgia de tórax com menores efeitos depressores respiratórios e emetogênicos.

Palavras-chave

ANALGESIA, CIRURGIA, DOR, TÉCNICAS ANESTÉSICAS, TÉCNICAS ANESTÉSICAS

Abstract

BACKGROUND AND OBJECTIVES: Patients undergoing thoracotomy experience severe postoperative pain. This study aimed at evaluating postoperative analgesia with the association of intravenous and epidural morphine as compared to a single route. METHODS: Participated in this study 20 patients of both genders, physical status ASA I, II or III, scheduled for thoracotomy. Patients were premedicated with intravenous midazolam (3 to 3.5 mg) in the OR. Monitoring consisted of continuous ECG, invasive blood pressure, pulse oximetry, capnography, CVP, diuresis and temperature. Continuous epidural anesthesia was induced in T7-T8 with 10 ml of 0.25% bupivacaine followed by fentanyl (5 µg.kg-1), etomidate(0.2 to 0.3 mg.kg-1) and succinylcholine (1 mg.kg-1). Tracheal intubation was performed with a double lumen tube and complemented with pancuronium(0.08 to 0.1 mg.kg-1) and mechanically controlled ventilation. Patients were then randomly distributed in three groups. Group I received 2 mg of 0.1% morphine by epidural catheter at anesthetic induction (M1), 12 h (M2) and 24 h (M3) after surgery. Group II received intravenous morphine by infusion pump (15 µg.kg.h-1) preceded by a 50 µg.kg-1 bolus, for 30 hours. Group III received 0.5 mg epidural morphine in M1, M2 and M3, associated to intravenous morphine by infusion pump (8 µg.kg.h-1), preceded by a 25 µg.kg-1 bolus, for 30 hours. Blood gas analysis, heart and respiratory rate, incidence of pruritus, nausea, vomiting and postoperative analgesia were evaluated at 6-hour intervals for 30 postoperative hours. Analgesia was evaluated by a numeric gradual scale (NGS) from 0 to 10. RESULTS: NGS was lower in Group I in M2, without differences in remaining intervals. Pain decreased in Groups II and III as from 18 hours as compared to baseline and to Group I. Group I needed more additional analgesia as compared to other groups. CONCLUSIONS: There has been a better analgesic effect with intravenous morphine or the association of intravenous and epidural morphine, with lower drug doses. This difference was significant when lower analgesic doses were used in these groups and represented an effective postoperative analgesic method for thoracotomy, with lower respiratory depression and emetic effects.

Keywords

ANALGESIA, ANESTHETIC TECNIQUES, ANESTHETIC TECNIQUES, PAIN, SURGERY

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