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Uso de analgésicos intravenosos en pacientes en diálisis. 

Charles J. Diskin , Selby Thomas

Trasplante de diálisis para nefrología , Volumen 14, Número 10, 1 de octubre de 1999, páginas 2530–2532,
https://bibliotecavirtual.unisinu.edu.co:2121/10.1093/ndt/14.10.25.2530
Publicado: 01 de octubre de 1999

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Señor,

Nos gustaría felicitar al Dr. Pauli-Magnus y sus colegas por su trabajo que aclara la farmacocinética y los riesgos del uso de mor na en la ESRD [
1 ]. Los opioides han sido un pilar del alivio del dolor durante siglos [ 2 ] (quizás hasta el período más remoto al que se extiende la historia) [ 3]],
sin embargo, siguen siendo una parte esencial de nuestro arsenal terapéutico actual. Se han identi cado más de 20 alcaloides distintos del opio
y se han desarrollado una variedad de agonistas y antagonistas sintéticos. Sin embargo, cuando realizamos una encuesta en febrero de 1997, de
79 farmacias de hospital en los EE. UU., Encontramos que los dos analgésicos intravenosos más comúnmente prescritos para pacientes de
hemodiálisis, mor na y meperidina, fueron los más notables por problemas graves ( Figura 1 ) .

Figura 1.

Ver la gran diapositiva de descarga

Analgésicos intravenosos para hemodiálisis en hospitales de EE. UU.

La mor na es principalmente un agonista en los receptores μ con alivio del dolor en μ y depresión respiratoria y estreñimiento resultante del
1
comportamiento agonista en los receptores μ [ 4 ]. Estudios previos de cinética de la mor na en la insu ciencia renal han demostrado la
2
acumulación de mor na 6-glucurónido, que tiene potentes propiedades analgésicas [ 5 , 6 ] y depresión respiratoria grave y prolongada [ 7 ]
que ha dado lugar al diagnóstico erróneo de daño cerebral en pacientes con insu ciencia renal. Cuidados intensivos [ 8 ] y niveles impredecibles
de sedación [ 9].]. Un grupo encontró que tan solo 10 mg de mor na administrada por vía intravenosa produjeron sedación durante 24 h,
pupilas constrictas durante 3 días y evidencia de metabolitos de mor na 19 días después de una dosis única a pesar de haber sido sometidas a
diálisis peritoneal dentro de las 36 h de la dosis. Se concluye que cualquier uso adicional de mor na ya no fue aceptable en pacientes con ESRD [
10 ]. El Dr. Pauli-Magnus y sus colegas han agregado mayor preocupación por su trabajo que documenta la acumulación de metabolito de la
mor na-3-glucuraónida también [ 1 ].

Saltar al contenido
Meperidine is a principal
μ agonist similar to morphine. Dialysis patients demonstrate an accumulation of an active metabolite normeperidine [11], with
a markedly prolonged half-life of 34.4 h that results in seizures and myoclonus [11,12] despite haemodialysis [11].

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If morphine and meperidine are to be avoided, it appears that ketoralac was the most commonly cited drug in our national survey. Ketoralac, an
intravenous NSAID, has the advantages of being a non-opiate analgesic. However, we found it to be the most common of the study drugs
associated with complications. A low frequency of use undoubtedly contributed to such a high percentage of complications, yet the dialysis
population has an inherent risk of gastrointestinal bleeding [13–15], and that appears to make ketoralac an unsuitable drug for this population
since it has already been proven to be associated with increased incidence of gastrointestinal bleeding.

In contrast, in a retrospective chart review of 753 patients with ESRD who were followed at the Hypertension, Nephrology, Dialysis and
Transplantation (HNDT) Clinic in Opelika, Alabama requiring hospitalization between January 1 1989 and March 1 1996, we found butorphanol
to be the most frequently prescribed intravenous analgesic. Furthermore, we found no signi cant complications with butorphanol. Ketoralac
was associated with 22% incidence of gastrointestinal bleeding and meperidine was associated with a 17% incidence of respiratory depression
requiring a μ antagonist.

Butorphanol has previously been reported to be used with safety in children [16,17], with fewer complications than morphine [18], outpatient
esophagogastroduodenscopy, and was found to be the drug of choice in labour because of a lack of respiratory depression in the fetus [19]. Also,
since it is a κ agonist with the advantage of having less respiratory depression and less hypotension than morphine in dogs and normal subjects
[20–24] with a ceiling e ect of no further respiratory depression at high doses than at low doses [25]. Even deliberate attempts to produce
respiratory failure have been unsuccessful. There is even one report of a 36-year-old man who injected himself with 100 mg of butorphanol
along with 50 mg of detomidine, a central α agonist designed to prolong the e ect of butorphanol, in a suicide attempt [24]. Despite the
massive doses, his respiratory rate never fell below 20 breaths/min and he never required mechanical ventilation. Likewise, in a more
controlled study in dogs, even large (0.4 mg/kg) intravenous doses produced no changes in PCO2 [26]. As a result, butorphanol has found to be
safely given traumatic shock [27] and septic shock [28].

Furthermore, because it is a partial antagonist at the μ receptor, butorphanol has been used to reverse the respiratory depression of morphine
and oxymorphone [29–31], and since it has no agonist properties at the μ receptor, unlike buprenorphine, 4 mg of butorphanol is easily revered
by 0.3 mg of naloxone [20]. Additionally its major metabolite, hydroxybutorphanol, is thought to be clinically inactive [32–34], providing
further safety in dialysis patients. Finally, the fact that butorphanol (but not morphine) has been found to actually improve nutrition in
uraemic subjects [35] would seem to make it an ideal choice for intravenous analgesia in ESRD where poor nutrition is a marker of high
mortality. We found it to be used with great safety and therefore butorphanol pharmacokinetics should be further evaluated in ESRD since it
may become the intravenous analgesic of choice.

References

1 Pauli-Magnus C, Hofmann U, Mikus G, Kuhlmann U, Mettang T. Pharmacokinetics of morphine and its glucuronides following intravenous
administration of morphine in patients undergoing continuous ambulatory peritoneal dialysis. Nephrol Dialysis Transplant 1999; 14: 903–909
Google Scholar

2 Heberden W. `Dolor'. In: T. Payne (ed), Commentaries on the History and Cure of Diseases. Mews–Gate, London: 1802; 149–152
Google Scholar

3 Snow J. On Chloroform and Other Anaesthetics: Their Action and Administration. John Churchill, New Burlington Street, London: 1858: 1–24
Google Scholar

4 Reisine T, Pasternak G. `Opiod analgesics and antagonists'. In: Goodman LS, Gilman A (eds) The Pharmacologic Basis of Therapeutics MacMillan,
London: 1996: 521–554
Google Scholar

5 Milne RW, Somogyi AA, Bochner F, Griggs WM. The influence of renal function on the renal clearance of morphine and its glucuronide metabolites in
intensive care patients. Br J Clin Pharmacol 1992; 34: 53–59
Google Scholar

6 Sear JW, Hand CW, Moore RA, Mc Quay HJ. Studies on morphine disposition: influence of renal failure on the kinetics of morphine and its
metabolites. Br J Anaesthesia 1989; 62: 28–32
Google Scholar

7 Osborne
Saltar RJ, Joel
al contenido SP, Slevin ML. Morphine intoxication in renal failure: role of morphine 6 glucuronide. Br Med J 1986; 292: 1548–1549
principal
Google Scholar

https://bibliotecavirtual.unisinu.edu.co:2320/ndt/article/14/10/2530/1806066?searchresult=1 2/6
18/2/2019 Uso de analgésicos intravenosos en pacientes en diálisis | Nefrología Diálisis Trasplante | Oxford Academic

8 Ball M, McQuay HJ, Moore RA, Allen MC, Fisher A, Sear J. Renal failure and the use of morphine in intensive care. Lancet 1985; 1: 784–786
Google Scholar

9 Bion JF, Logan BK, Newman PM, Brodie MJ. Sedation in intensive care: morphine and renal function. Intens Care Med 1986; 12: 359–365
Google Scholar

10 Michie C, Sear JU, Chapman JW, Moore RA. Opiod metabolism and the kidney. Lancet 1985; 1: 586
Google Scholar

11 Szeto HH, Inturrisi CE, Houde R, Saal S, Cheigh J, Reidenberg MM. Accumulation of normeperidine, an active metabolite of meperidine in patients
with renal failure or cancer. Ann Int Med 1977; 86: 783–741
Google Scholar

12 Hochman MS. Meperidine associated myoclonus and seizures in long term hemodialysis patients. Ann Neurology 1983; 14: 593
Google Scholar

13 Shepard AM, Stewart WK, Thjodleifsson B, Wormsley KJ. Further studies of gastric secretion in chronic renal failure. Br Med J 1974; 1: 96–98
Google Scholar

14 Zukerman GR, Cornette GL, Clouse RE, Harter HR. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985; 102:
583–592
Google Scholar

15 Muto S, Asano Y, Hosada S. Hypochlorhydria and hypergastrinemia and their mutual association with gastrointestinal bleeding in undialyzed and
hemodialyzed patients. Nephron 1988; 50: 10–13
Google Scholar

16 Splinter WM, O'Brien HV, Komocar L. Butorphanol: an opiod for day care pediatric surgery. Can J Anaesth 1995; 42: 483–486
Google Scholar

17 Lawthorn CD, Brown RE. Epidural morphine with butorphanol in pediatric patients. J Clin Anaeth 1994; 6: 91–94
Google Scholar

18 Zuber TJ. A pilot project in o ice based diagnostic esophogogastroduodenscopy comparing two nonintravenous methods of sedation and
anaesthesia. Arch Fam Med 1995; 4: 601–607
Google Scholar

19 Atkinson BD, Truitt LJ, Rayburn WF, Turnbull GL. Double blind comparison of intravenous butorphanol and fentanyl for analgesia for labor. Am J
Obstet Gynecol 1994; 171: 993–998
Google Scholar

20 Popio KA, Jackson DH, Ross AM, Schreiner BF, Yu PN. Hemodynamic and respiratory e ects of morphine and butorphanol. Clin Pharmacol
Ther 1978; 23: 281–286
Google Scholar

21 Nagashima H, Karamanian A, Malovany R, Radnay P, Ang M, Koerner S, Foldes FF. Respiratory and circulatory e ects of intravenous butorphanol
and morphine. Clin Pharmacol Ther 1976; 19: 738–745
Google Scholar

22 Lippmann M, Mok MS, Steen SS. Butorphanol analgesia. Anesth Analg 1982; 61: 624–625
Google Scholar

23 Kallos T, Caruso FS. Respiratory e ects of butorphanol and pethidine. Anaesthesia 1979; 34: 633–637
Google
Saltar al Scholar
contenido principal

24 Reid FM, Tracey JA. Parenteral exposure to detomidine and butorphanol. Clin Toxicity 1994; 32: 465–469

https://bibliotecavirtual.unisinu.edu.co:2320/ndt/article/14/10/2530/1806066?searchresult=1 3/6
18/2/2019 Uso de analgésicos intravenosos en pacientes en diálisis | Nefrología Diálisis Trasplante | Oxford Academic
Google Scholar

25 Talbert RL, Peters JI, Srrels SC, Simmons RS. Respiratory e ects of high doses butorphanol. Acute Care 1988; 12 [Suppl 1]: 47–56
Google Scholar

26 Trim CM. Cardiopulmonary e ects of butorphanol tartrate in dogs. Am J Vet Res 1983; 44: 329–331
Google Scholar

27 Jovanovic B. E ects of analgesic doses of butorphanol in circulatory and respiratory systems in surgical patients with shock. Gogisnjak
Vojnomedicinske Akademije 1986; 28: 19–22
Google Scholar

28 Tang G, Lin Y, Tsai S, Liu P, Lee T. Hemodynamic e ects of butorphanol analgesia in septic shock patient. Aneth Sinica 1988; 26: 1–8
Google Scholar

29 Mc Crackin MA, Harvey RC, Sackman JE, Paddleford RR. Butorphanol tartrate for partial reversal of oxymorphone-induced post operative
respiratory depression. Vet Anesth 1994; 23: 67–74
Google Scholar

30 Lemke KA, Tranquilli WJ, Thurmon JC, Benson GJ, Olson WA. Ability of flumazenil, butorphanol and naloxone to reverse anesthetic e ects of
oxymorphone and diazepam in dogs. JAVMA 1996; 209: 776–779
Google Scholar

31 Dyson DH, Doherty T, Anderson GI, McDonell WN. Reversal of oxymorphone sedation by naloxone, nalmefene, and butorphanol. Vet Surg 1990; 19:
398–403
Google Scholar

32 Gaver RC, Vasilev M, Wong H. Disposition of parenteral butorphanol in man. Drug Met Disp 1980; 8: 230–235
Google Scholar

33 Pfe er M, Smythe KA, Nardella PA. Pharmacokinetics of subcutaneous and intramuscular butorphanol in dogs. J Pharm Sci 1980; 69: 801–803
Google Scholar

34 Pittman KA, Smythe RD, Mayol RF. Serum levels of butorphanol by radioimmunoassay. J Pharm Sci 1980; 69: 160–163
Google Scholar

35 Levine AS, Morley JE, Raij L. Opiates and anorexia of uremia. Physiol Behavior 1986; 37: 835–838
Google Scholar

Issue Section: Letters

© 1999 European Renal Association-European Dialysis and Transplant Association

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