UTI - Cuidado humanizado do paciente crítico.

terça-feira, agosto 04, 2009

Etomidato X Ketamina na intubação rápida do paciente séptico

O etomidato é um agente hipinótico não barbitúrico utilizado para indução anestésica. Tem um início de ação rápido e meia vida curta. Sua principal vantagem é não causar hipotensão, além de ter efeitos de proteção cerebral no caso de intubação de pacientes com hipertensão intracraniana. Ele, entretanto, não é analgésico e não atenua a resposta pressórica associada à intubação. Seu uso em conjunto com o fentanil e a succinilcolina se difundiu para intubação de pacientes em sequência rápida. Alternativas ao seu uso são o midazolam, o propofol, a quetamina e o tiopental. Uma boa revisão sobre a intubação em sequência rápida foi publicada em 2005 no Chest. O receio de administrar o etomidato em pacientes sépticos advém do fato do etomidato inibir temporariamente a produção adrenal de cortisol através da supressão da 11beta-hidroxilase. Apesar disso, até o momento não se sabe se esse efeito colateral causa aumento da morbi-mortalidade.

Mes passado foi publicado no Lancet o trabalho “Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial”. É um estudo prospectivo, randomizado, controlado, cego (médico intensivista), realizado na França entre abril de 2007 e fevereiro de 2008. Foram incluídos pacientes acima de 18 anos de idade que necessitavam de intubação orotraqueal de emergência. Os critérios de exclusão eram: parada cardio-respiratória, contra-indicação ao uso de succinilcolina, quetamina ou etomidato e gravidez. Também foram excluídos pacientes que faleceram antes da chegada ao hospital e aqueles que permaneceram menos de 3 dias na UTI. Os pacientes foram randomizados para receberem etomidato (bolus IV de 0,3mg/kg) ou quetamina (bolus IV de 2 mg/kg). O médico emergencista estava ciente da droga a ser administrada, mas ele não participava do manejo desses doentes após a transferência para as UTIs. O desfecho primário foi o SOFA score máximo nos primeiros três dias de internação na UTI. Escolheu-se esse desfecho pois a insuficiência adrenal secundária ao etomidato tem duração máxima de 48 horas. Os desfechos secundários foram a variação do SOFA score (score máximo menos o basal), mortalidade em 28 dias, dias livres da UTI e dias livres de suporte de sistemas orgânicos (ventilação mecânica e vasopressores) durante os 28 dias de acompanhamento. Como havia interesse especial nos pacientes traumatizados e sépticos, a amostra foi calculada para que o estudo tivesse poder estatístico suficiente para analisar esses subgrupos. Insuficiência adrenal foi definida como um cortisol sérico menor que 275nmol/L ou uma diferença em relação ao basal de menos de 250 nmol/L em 30 e 60 minutos após a administração de adrenocorticotropina.

Foram incluídos na análise final 469 pacientes. Não houve diferença entre os grupos em relação às características basais. O principal motivo para a intubação orotraqueal foi coma. Haviam 104 pacientes com trauma (22%) e 76 com sepse (16%). O SOFA score máximo não diferiu entre os grupos, bem como todos os outros desfechos secundários. A função adrenal foi testada em 232 pacientes. A porcentagem de pacientes com insuficiência adrenal foi maior no grupo do etomidato em relação ao grupo da quetamina (OR 6,7; IC 3,5-12,7). Não houve também diferença significativa de mortalidade entre os pacientes respondedores e não-respondedores ao teste da adrenocorticotropina. Os subgrupos de pacientes sépticos ou traumatizados também não apresentaram diferenças no SOFA score máximo ou na mortalidade.

Esse estudo mostrou que o etomidato não foi associado à um aumento da morbi-mortalidade quando comparado à quetamina para intubação em sequência rápida em pacientes críticos. Entretanto, o número de pacientes sépticos foi pequeno, não permitindo uma conclusão definitiva sobre esse subgrupo. Apesar de o etomidato sabidamente causar supressão adrenal, a relevância clínica desse efeito colateral ainda é questionada. Não se sabe até mesmo se a insuficiência adrenal, que está associada à um aumento da mortalidade em pacientes críticos, é apenas um marcador de gravidade ou se tem efeito direto na morte desses doentes. De qualquer forma, o uso da quetamina como alternativa ao etomidato em pacientes sépticos parece seguro.


Fonte: Duplocego.com

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