Morfina subaracnóide em pós-operatório de revascularizaçao do miocárdio
Resumo
Resumo: Um numero significante de pacientes ainda experimenta nfveis inaceitaveis de dor
no perfodo p6s-operat6rio, apesar dos diversos avangos que ocorreram no controle
da dor nas ultimas decadas, causando efeitos indesejaveis em diversos sistemas. A
partir da descoberta dos receptores opi6ides, 0 uso de drogas opi6ides por via subaracn6ide vem sendo amplamente utilizado para 0 controle da dor. Este trabalho tem 0 objetivo estudar 0 efeito do sulfato de morfina administrado no espago subaracn6ide antes do infcio da operagao, em diferentes momentos do perfodo p6soperat6rio de revascularizagao do miocardio, quanta ao grau de analgesia, a incidencia de efeitos colaterais, a necessidade de analgesico, antiemetico e antipruriginoso, as medidas do volume minuto e 0 tempo entre 0 final da operagao e a extubagao traqueal. Foram estudados 41 pacientes do sexo masculino, com idade de 40 a 75 anos, admitidos no Departamento de Cirurgia Cardfaca da Santa Casa de Miseric6rdia de Curitiba, para revascularizagao do miocardio, no perfodo compreendido entre janeiro e setembro de 2002. Os pacientes foram submetidos a anestesia geral, com a utilizagao de fentanil e alfentanil venosos, e divididos aleatoriamente em tres grupos; um grupo recebeu 2,5mcg.kg-1 (Grupo 2,5) de morfina subaracn6ide, 0 outro 5mcg.kg-1 (Grupo 5), enquanto no outro nao se administrou morfina (Grupo C). A analise estatlstica foi realizada pelos metodos Kruskal-Wallis, ANOVA e Qui-Quadrado. Todos os grupos foram semelhantes quanta ao grau de analgesia por meio da Escala Visual Anal6gica (EVA), 24 horas ap6s 0 termino da operagao, nao apresentando diferenga estatlstica nos momentos de 60 minutos (3,8:f:1,4 vs 4,4:f:2,1 vs 5,2 :f:2,0, p= 0,1), 6 horas (2,0 :f:1,9 vs 2,7:f:1,8 vs 2,9 :f:2,1, p= 0,431), 12 horas (2,3:f:1,9 vs 2,5:f:2,1 vs 2,8 :f:1,3, p= 0,646) e 24 horas (2,9:f:1,7 vs 2,8:f:2,5 vs 3,2 :f:1,5, p= 0,686). Na verificagao intragrupo, constatou-se que 0 maior valor da EVA foi aos 60 minutos ap6s 0 termino da operagao (p= 0,048 vs 0,027 vs 0,001). Quanto a incidencia de efeitos colaterais, nao foi observada diferenga ao se comparar os tres grupos, embora nausea e vomito tenham side os efeitos colaterais mais frequentes. Na analise da necessidade de analgesico, antiemetico e antipruriginoso, nao foi observada diferenga entre os grupos estudados, ainda que os pacientes do grupo C tenham necessitado mais analgesico no perfodo compreendido entre 1 e 6 horas e os do grupo 5, mais antiemetico no mesmo perfodo. No estudo comparativo da ventilometria (frequencia respirat6ria, volume corrente e volume minuto), nao foi observada diferenga nos tres grupos nos momentos pre-operat6rio, 1 hora e 6 horas ap6s 0 termino da operagao. o tempo entre 0 final da operagao e a extubagao traqueal foi similar em todos os grupos. Conclui-se que a administragao de 2,5 ou 5mcg.kg-1 de sulfato de morfina no espago subaracn6ide, antes da anestesia geral, nao promove alteragao na analgesia p6s-operat6ria e no tempo para extubagao traqueal de pacientes submetidos a revascularizagao do miocardio com anestesia geral. Abstract: A significant number of patients still experience unacceptable levels of pain in the
post-op period, in spite of the many advances of pain control in the past decades, resulting in adverse effects on other systems. After opioid receptors were discovered, the practice of injecting opioid drugs in the subarachnoid space for pain control has been widely used. This paper shows the results of a study on the effects of injecting morphine sulfate in the subarachnoid space before surgery, at different post-op times after cardiac bypass surgery, addressing analgesia levels, possible side effects, need for analgesic, antiemetic and antipruriginous drugs, volume/minute measurements, and time between the end of surgery and tracheal tube removal. Forty-one male patients were studied, aged 40 to 75, admitted in the Cardiac Surgery Department of Santa Casa de Misericordia, in Curitiba, for cardiac bypass, between January and September 2002. The patients were submitted to general anesthesia with intravenous fentanyl and alfentanyl, and randomized to three groups. One group was
given 2.5mcg/k~ -1 (Group 2.5) of morphine in the subarachnoid space; the second group 5mcg.kg- (Group 5); and the third group was not given morphine (Group C). Statistical analysis was performed by the Kruskal-Wallis, ANOV A and Chi-Square methods. All the groups were considered to have similar analgesia levels (assessed by a Visual Analogical Scale), 24 hours after surgery, and showed no statistical difference at 60 minutes (3.8:t:1,4 vs 4.4:t:2,1 vs 5.2 :t:2.0, p= 0.1), 6 hours (2.0 :t:1.9 vs 2.7:t:1.8 vs 2.9 :t:2.1, p= 0.431), 12 hours (2.3:t:1.9 vs 2.5:t:2.1 vs 2.8 :t:1.3, p= 0.646) and 24 hours (2.9:t:1.7 vs 2.8:t:2.5 vs 3.2 :t:1.5, p= 0.686). Between groups, we noticed that the highest VAS value was at 60 minutes after surgery (p= 0.048 vs 0.027 vs 0.001). As for side effects, there was no difference among the groups, although nausea and vomiting were found to be the most frequent side effects. Analyzing the need for analgesic, antiemetic and antipruriginous drugs, no difference was observed among the groups studied, although patients in group C required more analgesic
drugs between 1 and 6 hours post-surgery, and patients in group 5, more antiemetic drugs in the same period of time. With the ventilometry comparative analysis (respiratory rate, current volume and volume/minute) no difference was observed among the three groups at pre-op, 1 hours and 6 hours post-op. The time between the end of surgery and tracheal tube removal was similar for all groups. We concluded that administering 2.5 or 5mcg.kg-1 of morphine sulfate into the subarachnoid space, before general anesthesia, does not affect post-op analgesia or tracheal tube removal time in patients submitted to cardiac bypass under general
anesthesia.
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