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Tramadol
Tramadol
O uso dos analgsicos opiides nos perodos pr e intra-operatrios tem mostrado resultados
satisfatrios, tanto no que se refere a beneficiar o procedimento anestsico, possibilitando a
reduo dos agentes anestsicos intravenosos e inalatrios, como tambm a proporcionar
analgesia ps-operatria, melhorando a qualidade da recuperao do paciente. O tramadol
um analgsico opiide, estruturalmente semelhante codena, com menores efeitos colaterais
em relao a outros analgsicos agonistas puros, capaz de promover analgesia satisfatria, com
eficincia similar obtida com a morfina, alm de permitir a reduo da concentrao alveolar
mnima (CAM) dos anestsicos inalatrios. Este trabalho tem por objetivo fazer uma reviso do
analgsico tramadol, abordando as caractersticas e indicaes de uso clnico desse frmaco.
PALAVRAS-CHAVE: Tramadol; Analgesia veterinria; Entorpecentes/uso teraputico.
1
Tramadol
INTRODUO
Os analgsicos opiides so rotineiramente
utilizados na prtica anestsica, com a finalidade
de reduzir a dose dos agentes anestsicos
intravenosos e inalatrios, alm de proporcionar
analgesia ps-operatria1. A administrao de
opiides nos perodos pr e trans-operatrio
possibilita a reduo da concentrao alveolar
mnima (CAM) dos agentes anestsicos
inalatrios, os quais produzem depresso
progressiva do sistema nervoso central,
induzindo depresso dose-dependente do
sistema cardiovascular e respiratrio 2,3,4 . A
reduo da CAM dos anestsicos volteis varia
entre 20 e 60%, no homem e nos animais, em
dependncia da dose utilizada e via de
administrao do analgsico opiide 5,6 ,
permitindo menor depresso cardiovascular e
alterando as respostas metablicas e endcrinas
desencadeadas pelo estmulo nociceptivo7,8. A
importncia das respostas metablicas e
endcrinas conseqentes de um procedimento
cirrgico e anestsico est sendo amplamente
questionada na prtica anestsica moderna,
sendo proposta a necessidade de preveno ou
inibio dessas respostas, a fim de reduzir a
morbidade e a mortalidade ps-operatria9.
O efeito analgsico dos opiides mediado
parcialmente pela via descendente inibitria
noradrenrgica e serotoninrgica da medula
espinhal 10 . Acredita-se que a ativao dos
receptores espinhais alfa-2-adrenrgicos pelos
neurotransmissores liberados por meio dos
neurnios noradrenrgicos seja responsvel pela
modulao da transmisso nociceptiva aferente,
resultando nas propriedades antinociceptivas
dos opiides11,12.
Muitos estudos tm demonstrado resultados
satisfatrios com o uso de opiides durante os
perodos pr e trans-operatrios, tanto no homem
como em animais, podendo-se destacar o uso da
morfina1,13, buprenorfina14, butorfanol10, entre
outros, e, mais recentemente, o tramadol13.
O tramadol (4, fenilpiperidina) um
analgsico de ao central, estruturalmente
relacionado morfina e codena15. Trata-se
de um agente opiide agonista puro, com
seletividade para o receptor mu (), ligando-se
fracamente aos receptores kappa () e delta ().
A afinidade do tramadol para o receptor
aproximadamente 6000 vezes inferior da
morfina e 10 vezes inferior da codena16.
A composio desse analgsico feita de uma
mistura racmica de dois estereoismeros. O
296
PRINCIPAIS EFEITOS
FARMACOLGICOS
Efeitos Sobre
o Sistema Cardiorrespiratrio
No foram demonstradas alteraes
importantes sobre a freqncia cardaca e a
presso arterial em crianas ou adultos aps o
uso intravenoso do tramadol28,29. No entanto, no
Tramadol
co, o uso de 5mg/kg pela via intravenosa provocou reduo na contratilidade cardaca, indicando leve efeito depressor desse frmaco sobre o
miocrdio na dose e via utilizadas neste estudo30.
O tramadol praticamente desprovido de
efeito depressor respiratrio; no entanto, tal efeito
pode ser observado com o emprego de doses
elevadas31. Teppema et al.32 (2003) demonstraram depresso respiratria acentuada aps
administrao de 4mg/kg de tramadol em gatos,
a qual foi revertida com sucesso pela administrao
de naloxone. Alguns estudos tm demonstrado
que, em doses equipotentes, o tramadol produz
menor depresso respiratria quando comparado
morfina, provavelmente devido a apenas um tero
da ao analgsica do tramadol ser proveniente
da interao desse frmaco com o receptor opiide
mu () 33,34. No homem, alguns estudos tm
demonstrado menor efeito depressor do tramadol
em relao a outros analgsicos opiides, como a
nalbufina 29 e a meperidina 28, com mnimas
alteraes sobre a freqncia respiratria,
saturao de pulso de oxignio, volume corrente e
volume minuto. Paralelamente, o tramadol no
provoca alteraes importantes nas variveis
hemogasomtricas, com mnimas alteraes nas
presses arteriais de dixido de carbono (PaCO2)
e oxignio (PaO2)33. Em cadelas portadoras de
piometra, encaminhadas para procedimento
cirrgico, o tratamento analgsico profiltico com
tramadol (2mg/kg, iv) induziu menor depresso
respiratria em relao morfina (0,2mg/kg, iv),
corroborando resultados observados no homem35.
Efeitos Sobre o Sistema Digestrio
Apresenta mnimos efeitos sobre o sistema
gastrointestinal 36,37, com baixa incidncia de
nusea e vmito (30 35%)38. No entanto, a
administrao oral do tramadol no perodo properatrio provocou maior incidncia de nusea
e vmito em relao ao grupo placebo, em pacientes adultos submetidos a procedimentos cirrgicos articulares39.
Em pacientes saudveis, o tramadol no
altera o tempo de esvaziamento gstrico,
enquanto a morfina provoca reduo importante
sobre esta varivel40. Paralelamente, em pacientes submetidos a cirurgias abdominais, possveis
alteraes gastrointestinais foram avaliadas, com
o uso da infuso contnua na dose de 0,5mg/kg/
h de tramadol e 0,05 mg/kg/h de morfina durante
24 horas, com reduo de 50% em ambas as
doses nas 24 horas posteriores, no sendo
observadas alteraes no trnsito intestinal,
porm o tempo de esvaziamento gstrico foi
297
Tramadol
Tramadol
299
Tramadol
CONSIDERAES FINAIS
Na Medicina Veterinria, o analgsico
Cassu RN, Luna SPL. Tramadol. MEDVEP Rev Cientif Med Vet Pequenos Anim Anim Estim 2003, Curitiba, Oct/Dec; 1(4):295-301.
Opioids are routine perioperative analgesics used to reduce the dose of intravenous or inhalation anesthetic
agents and to improve the postoperative analgesia . Tramadol is an opioid analgesic agent structurally
related to codeine, and presenting minimal adverse effects when compared with other pure agonists.
Tramadol provides effective analgesia like morphine and can reduce the MAC of anesthetics. This
review describes the characteristics and clinical use of tramadol.
KEYWORDS: Tramadol; Analgesia,veterinary; Narcotics,therapeutic use.
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