Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942003000600011
Brazilian Journal of Anesthesiology
Clinical Information

Clonidina como droga adjuvante no tratamento da síndrome de abstinência alcoólica em unidade de terapia intensiva: relato de caso

Clonidine as adjuvant therapy for alcohol withdrawal syndrome in intensive care unit: case report

Leandro Gobbo Braz; Lais Helena Camacho Navarro; José Reinaldo Cerqueira Braz; Ubirajara Teixeira da Silva; Fábio Akio Yamaguti; José Carlos Cristovan

http://dx.doi.org/10.1590/S0034-70942003000600011 Braz J Anesthesiol, vol.53, n6, p.802-807, 2003
PDF
Downloads: 0
Views: 1849

Resumo

JUSTIFICATIVA E OBJETIVOS: A sedação de dependentes de álcool e drogas em Unidades de Terapia Intensiva (UTI) é um desafio pela elevada incidência de tolerância às drogas sedativas e da elevada freqüência de síndromes de abstinência. O objetivo deste relato é mostrar um caso de paciente jovem admitido na UTI que desenvolveu síndrome de abstinência alcoólica e tolerância às drogas sedativas, solucionadas somente após o uso de clonidina. RELATO DO CASO: Paciente do sexo masculino, 18 anos, dependente de álcool, tabaco, cocaína e maconha, vítima de acidente por arma de fogo, foi admitido na UTI no 1º dia de pós-operatório de enterectomia, após aspiração de conteúdo gástrico durante reintubação traqueal. Evolução clínica: drogas vasoativas até o 4º dia de internação e broncopneumonia bilateral com derrame pleural e necessidade de ventilação artificial até o 15º dia. O esquema de sedação inicial utilizado foi a associação de midazolam e fentanil. A partir do 4º dia, o paciente apresentou vários episódios de agitação psicomotora, mesmo com a associação de lorazepam no 6° dia. No 9° dia, o paciente recebeu as maiores doses dos fármacos, mas permanecia agitado. Optou-se pela associação de dexmedetomidina, que reduziu as doses das outras drogas em 35% e diminuiu a agitação. No 12° dia, o midazolam e a dexmedetomidina foram substituídos pela infusão de propofol, com piora do quadro. No 13° dia, foi associada clonidina ao esquema de sedação, com resolução do quadro de agitação. No 14° dia, o propofol foi suspenso, sendo mantida a infusão de fentanil e reintroduzida a infusão de midazolam, com doses respectivamente 75% e 65% menores em relação ao pico de uso destas drogas. No 15° dia, o paciente foi extubado e teve alta da UTI. CONCLUSÕES: A droga de escolha para o tratamento da síndrome de abstinência alcoólica é o benzodiazepínico. Entretanto, no presente relato, somente o uso adjuvante de clonidina conseguiu proporcionar tratamento adequado ao paciente.

Palavras-chave

DOENÇAS, DROGAS, DROGAS

Abstract

BACKGROUND AND OBJECTIVES: Sedation of patients with past history of alcohol and drug abuse in Intensive Care Units (ICU) is a challenge due to the high incidence of sedative drugs tolerance and withdrawal syndromes. This report aimed at describing a case of a young patient admitted to the ICU who developed alcohol withdrawal syndrome and tolerance to sedatives, resolved only after clonidine administration. CASE REPORT: Male patient, 18 years old, alcohol, tobacco, cocaine and marijuana abuser, victim of firearm accident, who was admitted to the ICU in the first post-enterectomy day, after gastric content aspiration during tracheal re-intubation. Clinical evolution was: vasoactive drugs up to the 4th day; bilateral bronchopneumonia with pleural effusion and need for artificial ventilation up to the 15th day. Initial sedation scheme was the association of midazolam and fentanyl. As from the 4th day, patient presented with several psychomotor agitation episodes, even after the association of lorazepam in the 6th day. In the 9th day, patient received the largest doses but remained agitated. Dexmedetomidine was associated, which has decreased other drug doses in 35% and has improved agitation. In the 12th day, midazolam and dexmedetomidine were replaced by propofol infusion with worsening of agitation. In the 13th day, clonidine was associated to the sedation scheme with total resolution of agitation. Propofol was withdrawn in the 14th day, fentanyl was maintained and midazolam infusion was restarted, with doses 75% and 65% lower as compared to peak doses of such drugs. Patient was extubated in the 15th day and was discharged from ICU. CONCLUSIONS: Benzodiazepines should remain the drugs of choice for the treatment of acute alcohol withdrawal syndrome. However in this report, only adjuvant clonidine was able to adequately treat the patient.

Keywords

DISEASES, DRUGS, DRUGS

References

Robinson BJ, Robinson GM, Maling TJ. Is clonidine useful in treatment of alcohol withdrawal?. Alcoholism: Clinical & Experimental Research. 1989;13:95-98.

Moyo-Smith MF. Pharmacological management of alcohol withdrawal: A meta analysis and evidence based practice guideline. JAMA. 1997;278:144-151.

Braz JRC, Koguti ES, Braz LG. Efeitos da Associação da Clonidina à Bupivacaína Hiperbárica na Anestesia Subaracnóidea Alta. Rev Bras Anestesiol. 2003;53:561-572.

Braz LG, Vianna PTG, Braz JRC et al. Níveis de sedação determinados pela clonidina e midazolam na medicação pré-anestésica: Avaliação clínica e eletroencefalográfica bispectral. Rev Bras Anestesiol. 2002;52:9-18.

Kahn A, Munford JP. Double-blind study of lofexedine and clonidine in the detoxification of opiate addicts in hospital. Drug&Alcohol Dependence. 1997;44:57-61.

Bjorkqvist SE. Clonidine in alcohol withdrawal. Acta Psych Scand. 1975;52:256-263.

Davison R, Kaplan K, Fintel D. The effect of clonidine on the cessation of cigarettes smoking. Clin Pharmacol. 1988;44:265.

Ramsay MAE, Savege TM, Simpson BRJ. Controlled sedation with alphaxalene-alphadolone. Br Med J. 1974;2:656-659.

Wolf KM, Shaughness AF, Middleton DB. Prolonged delirium tremens requiring massive doses of medication. J Am Board Farm Pract. 1993;6:502-504.

Cohen IL, Gallagher TJ, Pohlman AS. Management of the agitated intensive care unit patient. Crit Care Med. 2002;30:97-123.

McCowan C, Marik P. Refractory delirium tremens treated with propofol. A case series. Crit Care Med. 2000;28:1781-1784.

Cusman Jr P. Clonidine and alcohol withdrawal. Advances Alcohol&SubstanceAbuse. 1987;7:17-28.

Reis DJ, Regunanthan S, Meeley MP. Imidazole receptor and clonidine displacing sustance in the relationship to control blood pressure, neuroprotection and adrenomedullary secretion. Am J Hipertens. 1992;5:51-57.

Stieger DS, Cantieni R, Frutiger A. Acute colonic pseudobstruction in two patients receiving high dose clonidine for delirium tremens. Intens Care Med. 1997;23:780-782.

Spies CD, Rommelspacher H. Alcohol withdrawal in the surgical patient prevention and treatment. Anesth Analg. 1999;88:946-954.

Mondavio M, Ghizza GF. Use of clonidine in the prevention of alcohol withdrawal syndrome. Minerva Medica. 1989;80:1233-1235.

Aparici M, Fernandez AL, Alegria E. Clonidine in the treatment of tobacco withdrawal. A comparison with nicotine chewing gum. Rev Clin Esp. 1994;194:453-456.

Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. Cochrane Database of Systematic Reviews. 2000.

Cousin DB. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119-141.

5ddc3f590e88258b1bf2c91e rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections