Rev. Soc. Esp. Dolor. 2021; 28(5): 264-265 / DOI: 10.20986/resed.2021.3942/2021
Adriana María Buriticá, Francisco Javier Vilá, Antonio Montero
RESUMEN
Introducción: A pesar de los esfuerzos y la evidencia disponible, el dolor agudo postoperatorio (DAP) moderado a intenso continúa teniendo una prevalencia elevada en nuestro medio. Como parte de una estrategia de analgesia balanceada o multimodal, las técnicas de analgesia regional ofrecen un adecuado control analgésico con menores efectos indeseables (que el uso exclusivo de opioides), aunque no están exentas de complicaciones y no son aplicables a todas las cirugías. El objetivo de este trabajo fue valorar la eficacia de las técnicas analgésicas para el tratamiento del DAP moderado a intenso, la incidencia de complicaciones asociadas a estas técnicas y la relación entre DAP y el antecedente de dolor crónico.
Pacientes y métodos: Estudio retrospectivo que incluyó 728 pacientes en los que se indicaron técnicas analgésicas, como analgesia epidural, analgesia perineural continua y analgesia controlada por el paciente (PCA) con morfina intravenosa, para el tratamiento del DAP moderado a intenso entre octubre del 2018 y octubre del 2020. Los pacientes fueron valorados por la Unidad de Dolor Agudo Postoperatorio (UDAP) a las 24 y 48 horas, se registró el dolor con la ENV (Escala Numérica Verbal), la presencia de reacciones adversas y/o complicaciones, empleo de analgesia multimodal y consumo de morfina en equivalentes intravenosos. Los niveles de dolor se clasificaron en leve (ENV: 0-3), moderado (ENV: 4-6) e intenso (ENV mayor o igual a 7).
Resultados: Cerca del 60 % de los pacientes presentaron dolor leve a las 24 horas y del 70 % a las 48 horas. Un 71,8 % de los portadores de analgésica continua epidural presentaron dolor leve el primer día y un 83 % al segundo. Las cirugías con niveles más altos de dolor moderado e intenso fueron la cirugía espinal en la que se empleó la PCA de morfina y la artroplastia de rodilla en que se utilizó analgesia a través de bloqueo femoral continuo. El consumo de morfina registrado en las PCA fue de 25,8 mg (DE: 18,4) a las 24 horas y de 18,6 mg (DE: 14,6) a las 48 horas. No hubo complicaciones graves asociadas a ninguna de las técnicas, excepto las retiradas accidentales de catéteres epidurales (3,6 %). En los bloqueos periféricos continuos, las retiradas accidentales (13 %) y las fugas pericatéter (6,4 %) fueron las complicaciones más frecuentes. Hubo una relación significativa entre el antecedente de dolor crónico y la intensidad de dolor postoperatorio (p = 0,000).
Conclusiones: Las técnicas analgésicas evaluadas para el manejo del DAP moderado e intenso, se consideran eficaces. La analgesia epidural torácica fue la técnica más eficaz con los porcentajes más altos de dolor leve a las 24 y 48 horas. Los pacientes con antecedente de dolor crónico presentaron porcentajes más altos de dolor moderado e intenso a las 24 y 48 horas.
ABSTRACT
Introduction: Despite the efforts and the available evidence, moderate to severe acute postoperative pain (APP) continues to have a high prevalence in our setting. As part of a balanced or multimodal analgesia strategy, regional analgesia techniques offer adequate analgesic control with fewer undesirable effects (that the exclusive use of opioids), although they are not free of complications and do not apply to all surgeries. This study aimed to assess the efficacy of analgesic techniques for the treatment of moderate to intense APP, the incidence of complications associated with these techniques, and the relationship between APP and the presence of chronic pain.
Patients and methods: This retrospective study included 728 patients in which analgesic techniques such as epidural analgesia, continuous perineural analgesia, and morphine Patient Controlled Analgesia (PCA) were indicated to treat moderate to severe APP between October 2018 and October 2020. The patients were evaluated by the APP service at 24 and 48 hours, the pain was recorded with the NRS (Numerical Rating Scale), and the study also registered the presence of adverse reactions and/or complications, the use of multimodal analgesia, and the consumption of morphine in equivalent intravenous doses. Pain levels were classified as mild (NRS: 0-3), moderate (NRS: 4-6) and intense (NRS greater than or equal to 7).
Results: Approximately 60 % of all patients presented mild pain at 24 hours and 70 % at 48. Epidural opioianalgesia in abdominal surgery presented 71.8 % mild pain on the first day and 83 % on the second. The surgeries with the highest levels of moderate and severe pain were spinal surgery using morphine PCA and knee replacement with continuous femoral nerve block. The morphine consumption recorded in the PCA was 25.8 mg (SD 18.4) at 24 hours and 18.6 mg (SD: 14.6) at 48 hours. There were no serious complications associated with any of the techniques, except for accidental removal of epidural catheters (3.6 %). In continuous peripheral nerve blocks, accidental withdrawals (13 %), and leakage from the catheter insertion site (6.4 %) were the most frequent complications. There was a significant relationship between chronic pain and pain intensity (p = 0.000).
Conclusions: Analgesic techniques for the management of APP, achieve better analgesic levels with few complications. The role of effective and safe thoracic epidural analgesia in open abdominal surgery stands out. Patients with a history of chronic pain had higher percentages of moderate and severe pain at 24 and 48 hours.
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