Revisión clínica de opioides intravenosos en cuidado agudo
Clinical review of intravenous opioids in acute care
Mark J. McKeen and Sadeq A. Quraishi
Journal of Anesthesiology and Clinical Science 2013,
Abstract
Opioids are routinely used in the management of moderate to severe pain. However, in the acute care setting, consistently undertreated and suboptimally managed pain continues to be a problem. Given the potential for opioids to result in lifethreatening situations, and the increasing complexity of the patients that are cared for in acute care facilities, a thorough understanding of intravenous opioid therapy is a necessity for hospital-based clinicians. Opioids can be classified by chemical structure and/or drug effect (i.e. action on Mu, Kappa, and Delta opioid receptors throughout the body). Endogenous opioids include endorphins, enkephalins, and dynorphins, which moderate the body's natural response to pain. Commonly used exogenous intravenous opioids include morphine, hydromorphone, fentanyl, meperidine, methadone, buprenorphine, butorphanol, and nalbuphine, which vary greatly in potency, duration of action, metabolism, and in their adverse effect profile. A growing body of evidence suggests that patient controlled analgesia may be superior to conventional methods (need for analgesia determined by clinicians) of treating pain in the acute care setting. Newer pump delivery systems may also decrease the risks of human and equipment errors as well as enhance patient safety and satisfaction. The purpose of this review is to help guide clinicians in the safe and effective management of pain in patients requiring intravenous opioid therapy in the acute care setting. Keywords: Acute pain, acute care, opioid, PCA
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Impacto de la edad, sexo y ruta de administración sobre los eventos adversos de los opioides en el departamento de emergencias. Estudio retrospectivo
Impact of age, sex and route of administration on adverse events after opioid treatment in the emergency department: a retrospective study.
Daoust R, Paquet J, Lavigne G, Piette É, Chauny JM.
Pain Res Manag. 2015 Jan-Feb;20(1):23-8.
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Estudio clínico aleatorizado de un protocolo con hidromorfona intravenosa versus el cuidado habitual en el dolor agudo de los ancianos en el departamento de urgencias.
Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients.
Chang AK, Bijur PE, Davitt M, Gallagher EJ.
Drugs Aging. 2013 Sep;30(9):747-54. doi: 10.1007/s40266-013-0103-y.
Abstract
BACKGROUND AND OBJECTIVES: Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. METHODS: This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED withacute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. RESULTS: 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. CONCLUSIONS: Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with lessopioid over 60 min.
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Comparación de nalbufina con morfina en sus efectos analgésicos y seguridad. Meta-análisis de estudios aleatorizados controlados
A comparision of nalbuphine with morphine for analgesic effects and safety : meta-analysis of randomized controlled trials.
Zeng Z, Lu J, Shu C, Chen Y, Guo T, Wu QP, Yao SL, Yin P.
Sci Rep. 2015 Jun 3;5:10927. doi: 10.1038/srep10927.
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