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Manejo de la analgesia postoperatoria en las primeras 24 horas en un Hospital de segundo nivel: Estudio observacional

2006; Q106299148; Volume: 13; Issue: 1 Linguagem: Espanhol

2254-6189

Dolores Fernández, Federico Gordo, Sandra María Calderón López, H. Méndez, J. Real,

Anesthesia and Sedative Agents

espanolObjetivo: Evaluar el cumplimiento y eficacia de la medicacion analgesica no protocolizada y utilizada en un hospital de segundo nivel en las 24 h posteriores a cirugia, donde la intensidad del dolor esta catalogada como moderada severa. Metodo: Estudio prospectivo y observacional. Se incluyeron 119 pacientes mayores de 18 anos, intervenidos de cirugia traumatologica: protesis total de cadera, rodilla, artrodesis vertebral, cirugia de hombro y laparotomias. Ante la falta de protocolos, la medicacion analgesica postoperatoria de base y de rescate fue prescrita segun criterio del anestesiologo responsable. La administracion de cloruro morfico y el empleo de los dispositivos de administracion: cateteres peridurales, PCA (analgesia controlada por el paciente) quedaron restringidos a la unidad de recuperacion anestesica (URPA) y al area critica. En planta de hospitalizacion los opiaceos prescritos fueron la meperidina por via intramuscular y el tramadol endovenoso. Los opiaceos siempre se asociaron a analgesicos parenterales como metamizol, diclofenaco o paracetamol Se valoro la intensidad del dolor (VAS 0-100 mm y escala verbal EV 1-4) 24 h despues de la cirugia (24) y se registro la maxima intensidad de dolor percibida en el primer dia de postoperatorio (Max). Se considero el porcentaje de pacientes con dolor no controlado (DNC): VAS >30 y EV >2 para los momentos 24 y Max. Se consignaron las dosis de farmacos analgesicos de base y rescate, prescritos y consumidos. Para cada analgesico prescrito como base, se calculo la diferencia porcentual entre la dosis media prescrita y la dosis media consumida, indicador que se denomino grado de cumplimiento (GC). Resultados: Intensidad de dolor 24: VAS 27.8 ± 22.6, EV 2; porcentaje de pacientes con DNC segun VAS /EV: 36.1/ 42.8%, respectivamente. Max: VAS 58.4 ± 28.9, EV 4; DNC segun VAS/EV : 79.8 / 82.3 %, respectivamente. Prescripcion de opiaceos (No pacientes, X ± DE) y GC (%): morfina: 28, 11.7 ± 12.6 mg/dia, 100%; meperidina: 58, 333.4 ± 108.7 mg/dia, 35.2%; tramadol: 13, 218.9 ± 80.2 mg/dia, 59.3%. Consumo de analgesicos antiinflamatorios no esteroideos (No pacientes, X ± DE): diclofenaco ( 39, 223.1 ± 52.5 mg/dia); metamizol (74, 6.86 ± 1.8 mg/dia) ambos superiores a las dosis recomendadas. Conclusiones: Como conclusion pensamos que los resultados expuestos demuestran la ineficacia de la medicacion analgesica empleada en el postoperatorio, debida a fallos en la prescripcion y en el cumplimiento de la misma. La formacion continuada, la implicacion de los anestesiologos y del personal de enfermeria y el compromiso institucional son elementos fundamentales para corregir los errores observados en el tratamiento del dolor postoperatorio. EnglishObjective: We carried out this study in our second level hospital to evaluate the fulfillment and effectiveness of postoperative analgesics administered without appropriate guidelines during the first 24 h after surgical procedures where the intensity of pain is considered moderate-severe. Method: We included 119 patients above 18 years of age, who underwent orthopedic surgery: total knee or hip replacement, vertebral arthrodesis, shoulder surgery and laparotomies. Postoperative analgesics (base and rescue) were prescribed according to criterion of the responsible anesthesiologist through lack of appropriate protocols. The use of morphine, epidural analgesia and PCA (patient controlled analgesia) devices were restricted to recovery room and critical care unit. In hospitalized patients the prescribed opiates were meperidine and tramadol by intramuscular and intravenouse route, respectively. The opiates were always associated to nonsteroidal antiinflammatory drugs (NSAIDs) as metamizol or diclofenac and analgesics as paracetamol. Intensity of pain was measured by VAS 0-100 mm and verbal scale (VS) 1-4, 24 h after surgery (24) and we registered the maxim intensity of pain (Max) perceived during the first postoperative day, in both moments the percentages of patients with non controlled pain (NCP): VAS >30 and VS >2 were considered. Prescribed and administered doses of analgesic drugs (base and rescue) were registered. The proportion between prescribed and administered doses of analgesics was considered as a fulfillment indicator and expressed by percentage (GC).≠ Results: Pain intensity 24: VAS 27.8 ± 22.6, VS 2 (1-4); percentage of patients with NCP measured by VAS/VS: 36.1 and 42.8%, respectively . Max: VAS 58.4 ± 28.9, VS 4 (1-4); NCP by VAS/VS: 79.8 / 82.3 %, respectively. Prescribed opiates (No patients, X± SD and GC %): morphine : 28, 11.7 ± 12.6 mg /day, 100%; meperidine: 58, 333.4 ± 108.7 mg/day, 35.2%; tramadol: 13, 218.9 ± 80.2 mg/day, 59.3%. Administered NSAIDs ( No patients, X ± SD): diclofenac : 39, 223.1 ± 52.5 mg /day; metamizol : 74, 6.86 ± 1.8 mg /day. Conclusions: We observed medical inframetering prescription of opiates and lack of fulfillment in the administration from the infirmary staff. On the contrary NSAIDs were prescribed and administered at higher doses than the recommended ones. These results suggest that postoperative pain is not well controlled in our hospital. The continuing education and involvement of anesthesiologists, nurses and surgeons are essential factors to improve the quality of pain relief.