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

http://dx.doi.org/10.1590/S0034-70942002000500005 Braz J Anesthesiol, vol.52, n5, p.549-561, 2002
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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

References

Kavanag BP. Pain control after thoracic surgery: a review of current techniques. Anesthesiology. 1994;81:737-759.

Giles BE, Walker JS. Gender differences in pain. Curr Opin Anaesthesiol. 1999;12:591-595.

Eisenkraft JB, Cohen E, Neustein SM. Anesthesia for thoracic surgery. Clinical Anesthesia. 1977:769-803.

Stoelting RK, Miller RD. Basis of Anesthesia. 2000:425-434.

Moores DWO, Foster ED, McKneally MF. Incisions. Thoracic Surgery. 1995:113-129.

Kruger M, Sandler AM. Post-thoracotomy pain control. Curr Opin Anaesthesiol. 1999;12:55-58.

Mulder DS. Pain management principles and anesthesia techniques for thoracoscopy. Annals of Thoracic Surgery. 1993;56:630-632.

Bachiocco V, Scesi M, Morselli AM. Individual pain history and familial pain tolerance models: relationships to post-surgical pain. Clinical Journal of Pain. 1993;9:266-271.

Shulman M, Sandler NA, Bradley JW. Posthoracotomy pain and pulmonary following epidural and systemic morphine. Anesthesiology. 1984;61:569-575.

Defalque RJ, Boyd GL. Long-term posthoracotomy pain. Chest. 1992;101:884.

Lubenow TR, Faber LP, McCarthy RJ. Posthoracotomy pain management using continuous epidural analgesia in 1,324 patients. Annals of Thoracic Surgery. 1994;58:924-930.

Hu JS, Lui PW, Wang H. Thoracic epidural analgesia with morphine does not prevent posthoracotomy pain syndrome: a survey of 159 patients. Acta Anaesthesiol Sinica. 2000;38:195-200.

Behar M, Magora F, Olshawang D. Epidural morphine in treatment of pain. 1979:52-528.

Chayen MS, Rudick V, Borvine A. Pain control with epidural injection of morphine. Anesthesiology. 1988;53:338-339.

Benzon HT, Wong HY, Belavic Jr AM. A randomized double-blind comparison of epidural fentanyl infusion versus patient-controlled analgesia with morphine for posthoracotomy pain. Anesth Analg. 1993;76:316-322.

Liu N, Kuhlman G, Dalibon N. A randomized, double-blinded comparison of intrathecal morphine, sufentanil and their combination versus IV morphine patient-controlled analgesia for posthoracotomy pain. Anesth Analg. 2001;92:31-36.

Sandler NA, Stringer D, Panos L. A randomized, double-blind comparison of lumbar epidural and intravenous fentanyl infusions for posthoracotomy pain relief: Analgesic, pharmacokinetic, and respiratory effects. Anesthesiology. 1992;77:626-634.

Benzon HT, Wong HY, Belavic AM. A randomized double-blind comparison of epidural fentanyl infusion versus patient-controlled analgesia with morphine for posthoracotomy pain. Anesth Analg. 1993;76:316-322.

Sokal RR, Rohlf FJ. Biometry. 1969:776.

Siegel S. Estadística no Paramétrica Aplicada a las Ciencias de la Conducta. 1975:346.

Hollander M, Wolfe DA. Nonparametric Statistical Methods. 1973:503.

Brodner G. Pain management in patients undergoing thoracic surgery. Curr Opin Anaesthesiol. 1997;10:54-59.

Sullivan E, Grannis Jr FW, Ferrell B. Continuous extrapleural intercostal nerve block with continuous infusion of lidocaine after thoracotomy: A descriptive pilot study. Chest. 1995;108:1718-1723.

Silomon M, Claus T, Huwer H. Interpleural analgesia does not influence posthoracotomy pain. Anesth Analg. 2000;91:44-50.

Mann LJ, Young GR, Williams JK. Intrapleural bupivacaine in the control of posthoracotomy pain. Ann Thorac Surg. 1992;53:449-454.

McIlvaine WB. Intrapleural anesthesia is useful for thoracic analgesia: Pro: intrapleural anesthesia is useful for thoracic analgesia. J Cardiothorac Vasc Anesth. 1996;10:425-428.

Murphy DF. Interpleural analgesia. Br J Anaesth. 1993;71:426-434.

Bromage PR, Camporesi E, Chestnut D. Epidural narcosis for postoperative analgesia. Anesth Analg. 1980;59:473-480.

Klinck JR, Lindap JM. Epidural morphine in elderly. Anaesthesia. 1982;37:907-912.

Crespo AS, Carvalho AF. Insuficiência Respiratória Aguda. Ventilação Mecânica. 2000;8:31-55.

Hu JS, Lui PW, Wang H. Thoracic epidural analgesia with morphine does not prevent posthoracotomy pain syndrome: a survey of 159 patients. Acta Anaesth Sinica. 2000;38:195-200.

Carvalho WA, Vianna PTG, Braz JRC. Náuseas e vômitos em anestesia: fisiopatologia e tratamento. Rev Bras Anestesiol. 1999;49:65-79.

Apfel CC, Creim CA, Haubitz I. A risk score to predict the probability of postoperative vomiting in adults. Acta Anaes- thesiol Scand. 1998;42:495-501.

Palazzo MGA, Strunin L. Anaesthesia and emesis I: etiology. Can Anaesth Soc J. 1984;31:178-187.

Korttila K. Can we predict who will vomit after surgery?. Acta Anaesthesiol Scand. 1998;42:493-494.

Morris RW, Aune H, Feiss P. International, multicentre, placebo-controlled study to evaluate the effectiveness of ondansetron vs. metoclopramide in the prevention of post- operative nausea and vomiting. Eur J Anaesth. 1998;15:69-79.

Raphael JH, Norton AC. Antiemetic efficacy of prophylactic ondansetron in laparoscopic surgery: randomized, double-blind comparison with metoclopramide. Br J Anaesth. 1993;71:845-848.

Rust M. Intravenous ondansetron versus metoclopramide for the prophylaxis of postoperative nausea and vomiting. Anaesthesist. 1995;44:288-290.

Alon E, Himmelseher S. Ondansetron in the treatment of postoperative vominting: a randomized, double-blind comparison with droperidol and metoclopramide. Anesth Analg. 1992;75:561-565.

Pugh SC, Jones NC, Barsoum LZ. A comparison of prophylactic ondansetron and metoclopramide administration in patients undergoing major neurosurgical procedures. Anaesthesia. 1996;51:1162-1164.

Riegler FX. Intrapleural anesthesia is useful for thoracic analgesia: Con: unreliable benefit after thoracotomy-epidural is a better choice. J Cardiothorac Vasc Anesth. 1996;10:429-431.

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