Introduo
Sedao, analgesia e sepse tm vrias interfaces a assinalar.
Analgsicos e sedativos alteram o estado funcional do sistema nervoso
central. Da mesma forma, a sepse o faz, caracterizando a encefalopatia
sptica, descrita por Hipcrates h mais de 2500 anos.
Em funo disso, os efeitos da administrao ou interrupo do uso
de analgsicos e sedativos em pacientes spticos poder ser
acentuadamente modificado. A depresso da conscincia, bem como do
controle neural da respirao e da atividade autonmica induzida por
analgsicos e sedativos agravar-se- na presena de sepse.
A avaliao do nvel de sedao e analgesia no raramente
prejudicada nesses casos. Assim, a oscilao clnica da encefalopatia
sptica dificulta o ajuste da posologia de analgsicos e sedativos. A melhora
da sepse, por exemplo, exige aumento das doses de sedativos durante a
ventilao artificial, e essa situao poderia ser equivocadamente
interpretada como induo de tolerncia, eventualidade comumente
associada ao uso prolongado de analgsicos e sedativos.
Analgsicos e sedativos podem dificultar o reconhecimento de
algumas manifestaes clnicas do quadro sptico. A abstinncia de
agentes usados em analgesia e sedao resulta em amplo espectro de
manifestaes clnicas, vrias delas compartilhadas com a sepse.
Assim, a interrupo ou o antagonismo de opiides expressa-se por
lacrimejamento, rinorria, sudorese e taquicardia. Progressivamente surgem
clicas abdominais, tremores, nuseas e vmitos, diarria, desidratao,
acidose metablica, midrase, torpor, agitao, agressividade e hipotenso
arterial.
A abstinncia de diazepnicos associa-se a nuseas, vmitos,
diarria, taquicardia, hipertenso arterial, agitao, angstia, insnia,
confuso e at crises convulsivas.
Alterando a resposta imunolgica, sedativos e analgsicos facilitariam
infeces contribuiriam para a ecloso da sepsePacifici et al, 2000; Casalinuovo, Gaziano,
Francesco, 2000
. Opiides afetam a proliferao, a diferenciao e a funo das
clulas imunolgicasSalo M, 1977; Roy, Charboneau, Barke, 1999, a resposta atividade
fagocitria e a ao de mediadores inflamatriosNuez, Urzua, 1999; McCarthy et al,
2001
. Os receptores opiides tm-se mostrado moduladores da liberao de
citocinasWetzel et al, 2000; os benzodiazepnicos afetam a funo linfocitriaMagro,
Crowson, 1996
; o propofol parece estimular, enquanto o midazolam suprime a
produo de interleucinas IL-1beta, IL-6 e TNF-alfa, ao mesmo tempo que
ambos suprimem a produo de IL-8Helmy, Al-Attiah, 2001. Atravs de
mecanismos diversos, o tiopental tambm afeta a resposta imunolgicaKress
et al, 1989; Rudd, Benestad, Opdahl, 1988; Salo, Pirttikangas, Pulkki, 1997
. A estimulao dos
receptores 2 pela dexmedetomidina pode, in vitro, induzir a agregao
plaquetriaCohen et al, 1980. Alm disso, in vivo, a dexmedetomidina promove liberao
do xido ntrico do endotlio vascular e diminuio da liberao de catecolaminas,
por retroalimentao negativa, ao estimular os adrenorreceptores 2 ps-
sinpticos Cohen et al, 1980. Alm do mais, foi observada diminuio da liberao de
ACTH, insulina e renina, assim como reduo da resposta inflamatria no
traumaKhan, 1999. Quando comparada ao propofol, a infuso contnua de
dexmedetomidina resultou em uma liberao menor de IL-6Venn, 2001.
O efeito in vitro do diazepam, propofol e etomidado sobre a atividade
de neutrfilos pode ainda depender do solvente em que so veiculados
esses agentesHeine et al, 2001. J a administrao parenteral de qualquer
frmaco constitui invaso das defesas orgnicas, permitindo acesso
circulao de microorganismos contaminantes. A adio de EDTA na
emulso lipdica que veicula o propofol visa reduzir a proliferao bacteriana
que pode acompanhar acidental contaminao do sistema de infuso.
Recomenda-se respeitar rgidas normas de preveno para contaminao
das solues, o que inclui seu descarte aps 6 horas de infusoBach, Motsch,
1996
.
Agentes bloqueadores neuromusculares so, em situaes
particulares, administrados a doentes graves. A fraqueza muscular aps uso
prolongado de bloqueadores neuromusculares tem sido objeto de grande
ateno e constitui um dos limitantes ao uso desses frmacos. A sepse e a
disfuno de mltiplos rgos tm sido, por sua vez, associada miopatia
Coakley et al, 1993; Giostra et al, 1994; Hanson et al, 1997; Helliwell et al, 1991; Lacomis et al, 1996; Lacomis,
Petrella, Giuliani, 1998; Ramsay et al, 1993
ou polineuropatia, denominada polineuropatia
Barat et al, 1987; Coronel et al, 1990; Lycklama, Nijeholt, Troost, 1987; Op
do doente grave ou crtico
De Coul et al, 1991; Waldhausen et al, 1989; Wijdicks et al, 1994; Witt et al, 1991
. Sepse e bloqueio
neuromuscular sobrepem-se no doente grave para produzir fraqueza
muscular em considervel nmero (29 a 72%) de pacientes internados por
perodo prolongado em Terapia IntensivaBerek et al, 1987; Coakley et al, 1993; Witt, Bolton
Sibbald, 1985; Witt et al, 1991; Hund et al, 1997
. Alteraes eletrolticas e outros agentes,
como corticides e aminoglicosdeos podem contribuir para miopatia,
polineuropatia ou prolongar a ao de bloqueadores neuromusculares.
Restrio ao uso prolongado de bloqueadores neuromusculares ou, quando
imprescindveis, ajustes prximos e peridicos da posologia, conforme
informaes obtidas da monitorao (estimulao de nervo perifrico)
minimizam as conseqncias do emprego desses agentes a doentes
spticos.
No desconsiderando evidentemente as interfaces acima
mencionadas, as disfunes orgnicas heptica, renal e circulatria que
acompanham a sepse modificam as intervenes destinadas a prover
sedao e analgesia ao paciente sptico.
Recomendaes
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