Estrategias de analgesia multimodal en pacientes con alto riesgo de depresión respiratoria: una scoping review de la evidencia disponible entre 2015 y 2026
DOI:
https://doi.org/10.71112/djhp9f80Palabras clave:
Trauma, AINEs, Bloqueo, Analgesia, Dolor.Resumen
La evidencia analizada demuestra que la analgesia multimodal representa un pilar fundamental en el manejo del dolor agudo, especialmente en pacientes con alto riesgo de depresión respiratoria inducida por opioides. Este enfoque, basado en la combinación de intervenciones farmacológicas y técnicas regionales, permite reducir de forma consistente el consumo de opioides, lo cual constituye el principal mecanismo de disminución del riesgo de eventos respiratorios adversos.
Los resultados evidencian que fármacos como la ketamina/esketamina, la dexmedetomidina y la lidocaína intravenosa, junto con técnicas como los bloqueos regionales (por ejemplo, TAP y analgesia epidural), no solo mejoran el control del dolor, sino que también contribuyen a preservar la función respiratoria y reducir complicaciones postoperatorias. Asimismo, estrategias de monitorización continua y herramientas de estratificación como el puntaje PRODIGY permiten identificar tempranamente a los pacientes con mayor riesgo, facilitando intervenciones más seguras y personalizadas.
Se identificó que el riesgo de depresión respiratoria no es homogéneo, concentrándose en poblaciones vulnerables como pacientes con obesidad, síndrome de apnea obstructiva del sueño, edad avanzada, uso crónico de opioides y comorbilidades cardiovasculares o respiratorias. En estos grupos, la implementación de analgesia multimodal adquiere un rol prioritario no solo como estrategia terapéutica, sino también preventiva.
Aunque no todos los estudios evaluaron directamente la depresión respiratoria, existe una relación consistente entre la reducción del consumo de opioides y la disminución del riesgo respiratorio, lo que refuerza el concepto de estrategias “opioid-sparing” como eje central de seguridad clínica. Sin embargo, la heterogeneidad metodológica de los estudios y la variabilidad en los desenlaces limitan la capacidad de establecer conclusiones causales definitivas.
En conjunto, la analgesia multimodal se consolida como una estrategia eficaz y segura que no solo optimiza el control del dolor, sino que mejora la seguridad respiratoria y la calidad de la atención, constituyendo un enfoque clave en la medicina perioperatoria moderna.
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Al-Hassan, A., Weissman, B., Chowdhury, S., Sawires, J., & Soti, V. (2025). Comparative Efficacy of Dexmedetomidine and Remifentanil in Reducing Postoperative Pain and Opioid Use: A Systematic Review. Cureus. https://doi.org/10.7759/cureus.79759 DOI: https://doi.org/10.7759/cureus.79759
Assadi, A., Chung, F., & Yadollahi, A. (2024). Measures of overnight oxygen saturation to characterize sleep apnea severity and predict postoperative respiratory depression. BioMedical Engineering Online, 23(1). https://doi.org/10.1186/s12938-024-01254-8 DOI: https://doi.org/10.1186/s12938-024-01254-8
Baldo, B. A. (2025). Opioid-induced respiratory depression: clinical aspects and pathophysiology of the respiratory network effects. In American Journal of Physiology - Lung Cellular and Molecular Physiology (Vol. 328, Number 2, pp. L267–L289). American Physiological Society. https://doi.org/10.1152/ajplung.00314.2024 DOI: https://doi.org/10.1152/ajplung.00314.2024
Casas-Arroyave, F. D., Osorno-Upegui, S. C., & Zamudio-Burbano, M. A. (2023). Therapeutic efficacy of intravenous lidocaine infusion compared with thoracic epidural analgesia in major abdominal surgery: a noninferiority randomised clinical trial. British Journal of Anaesthesia, 131(5), 947–954. https://doi.org/10.1016/j.bja.2023.07.032 DOI: https://doi.org/10.1016/j.bja.2023.07.032
Champreeda, V., Hu, R., Chan, B., Tomasek, O., Lin, Y. H., Weinberg, L., Howard, W., & Tan, C. O. (2023). Nocturnal respiratory abnormalities among ward-level postoperative patients as detected by the Capnostream 20p monitor: A blinded observational study. PLoS ONE, 18(1 January). https://doi.org/10.1371/journal.pone.0280436 DOI: https://doi.org/10.1371/journal.pone.0280436
Chaouch, M. A. M. A., Daghmouri, M. A., Boutron, M. christine, Ferraz, J. marc, Usai, S., Soubrane, O., Beaussier, M., Pourcher, G., & Oweira, H. (2022). Ketamine as a component of multimodal analgesia for pain management in bariatric surgery: A systematic review and meta-analysis of randomized controlled trials. In Annals of Medicine and Surgery (Vol. 78). Elsevier Ltd. https://doi.org/10.1016/j.amsu.2022.103783 DOI: https://doi.org/10.1016/j.amsu.2022.103783
Chen, R., Sun, S., Li, Y., Dou, X., Dai, M., Wu, Y., & Lin, Y. (2022). Efficacy and safety evaluation of dexmedetomidine for postoperative patient controlled intravenous analgesia: A systematic review and meta-analysis. In Frontiers in Pharmacology (Vol. 13). Frontiers Media S.A. https://doi.org/10.3389/fphar.2022.1028704 DOI: https://doi.org/10.3389/fphar.2022.1028704
de Carvalho, C. C., El-Boghdadly, K., Guedes, I. H. L., Dantas, M. V. M., Tomé, D. P. B., Ramos, I. B., Gomes, C. S. H., Alves, G. K. P. A., Bezerra, A. P., Santos Neto, J. M., Pandit, J. J., & Braz, L. G. (2026). Opioid-free vs. opioid-inclusive anaesthesia with or without regional anaesthesia for postoperative pain: a systematic review with network meta-analysis of randomised controlled trials. In Anaesthesia. John Wiley and Sons Inc. https://doi.org/10.1111/anae.70121 DOI: https://doi.org/10.1111/anae.70121
Du, J., Li, C., Zhang, W., Lu, X., Xia, Y., & Qin, X. (2025). Efficacy and Safety of Adding Ketamine to Lidocaine in Intravenous Regional Anesthesia: A Meta-analysis of Randomized Controlled Trials. In Journal of Perianesthesia Nursing (Vol. 40, Number 1, pp. 195-204.e5). W.B. Saunders. https://doi.org/10.1016/j.jopan.2024.03.013 DOI: https://doi.org/10.1016/j.jopan.2024.03.013
Fan, Y. Z., Duan, Y. L., Chen, C. T., Wang, Y., & Zhu, A. P. (2024). Advances in attenuating opioid-induced respiratory depression: A narrative review. In Medicine (United States) (Vol. 103, Number 29, p. e38837). Lippincott Williams and Wilkins. https://doi.org/10.1097/MD.0000000000038837 DOI: https://doi.org/10.1097/MD.0000000000038837
Fu, M., Xu, R., Chen, G., Zheng, X., Shu, B., Huang, H., Duan, G., & Chen, Y. (2024). Postoperative esketamine improves ventilation after video-assisted thoracoscopic lung resection: A double-blinded randomized controlled trial. Heliyon, 10(3). https://doi.org/10.1016/j.heliyon.2024.e25100 DOI: https://doi.org/10.1016/j.heliyon.2024.e25100
Jansen, S. C., & Dahan, A. (2024). Opioid-induced respiratory depression. In BJA Education (Vol. 24, Number 3, pp. 100–106). Elsevier Ltd. https://doi.org/10.1016/j.bjae.2023.12.007 DOI: https://doi.org/10.1016/j.bjae.2023.12.007
Jing, Z., Han, Y., Li, Y., Zeng, R., Wu, J., Wang, Y., & Jiang, P. (2024). Effect of subanesthetic dose of esketamine on postoperative pain in elderly patients undergoing laparoscopic gastrointestinal tumor Surgery:A prospective, double-blind, randomized controlled trial. Heliyon, 10(5). https://doi.org/10.1016/j.heliyon.2024.e27593 DOI: https://doi.org/10.1016/j.heliyon.2024.e27593
Kanaparthi, A., Chung, F., Lichtenthal, P. R., Sprung, J., & Weingarten, T. N. (2024). PRODIGY score predicts respiratory depression in the post-anesthesia care unit: A post-hoc analysis. Biomolecules and Biomedicine, 24(6), 1662–1668. https://doi.org/10.17305/bb.2024.10585 DOI: https://doi.org/10.17305/bb.2024.10585
Katasani, T., Holt, G., Al-Khyatt, W., & Idris, I. (2023). Peri- and Postoperative Outcomes for Obstructive Sleep Apnoea Patients after Bariatric Surgery—a Systematic Review and Meta-analysis. Obesity Surgery, 33(7), 2016–2024. https://doi.org/10.1007/s11695-023-06557-8 DOI: https://doi.org/10.1007/s11695-023-06557-8
Komatsu, R., Nash, M. G., Wu, J., Dinges, E. M., Delgado, C. M., & Bollag, L. A. (2023). Prediction of postoperative respiratory depression and respiratory complications in patients on preoperative methadone. Journal of Anesthesia, 37(1), 79–91. https://doi.org/10.1007/s00540-022-03134-8 DOI: https://doi.org/10.1007/s00540-022-03134-8
Li, F., Guo, L., Huang, Z., Lin, F., & Pan, L. (2023). Effects of dexmedetomidine as an adjuvant to ropivacaine or ropivacaine alone on duration of postoperative analgesia: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE, 18(10 October). https://doi.org/10.1371/journal.pone.0287296 DOI: https://doi.org/10.1371/journal.pone.0287296
Li, Q., Liu, T., & Chen, X. (2025). Medical Adhesive-related Skin Injuries Caused by Eye Taping: A Case Report. Journal of Perianesthesia Nursing, 40(1), 10–12. https://doi.org/10.1016/j.jopan.2024.03.003 DOI: https://doi.org/10.1016/j.jopan.2024.03.003
Liu, J., Yin, J., Yin, J., Zhou, M., Chen, L., Dong, X., & Li, Y. (2024). Effect of esketamine-based opioid-sparing anesthesia strategy on postoperative pain and recovery quality in patients undergoing total laparoscopic hysterectomy: A randomized controlled trail. Heliyon, 10(3). https://doi.org/10.1016/j.heliyon.2024.e24941 DOI: https://doi.org/10.1016/j.heliyon.2024.e24941
Montana, M. C., McLeland, M., Fisher, M., Juriga, L., Ercole, P. M., & Kharasch, E. D. (2024). Opioid sensitivity in treated and untreated obstructive sleep apnoea: a prospective cohort study. British Journal of Anaesthesia, 132(1), 145–153. https://doi.org/10.1016/j.bja.2023.09.032 DOI: https://doi.org/10.1016/j.bja.2023.09.032
Shanthanna, H., Tian, C., Lee, Y., Oparin, Y., & Hong, D. (2021). Systematic Review Benefits of Transversus Abdominis Plane Block on Postoperative Analgesia after Bariatric Surgery: A Systematic Review and Meta-Analysis. http://clinicaltrials.gov/;
Sladkey, N., King, D. D., & Reede, L. J. (2025). Enhancing the Preanesthesia Evaluation: Consensus Development of the Cannabis Use and Behaviors Assessment Tool (CUBAT). Journal of Perianesthesia Nursing, 40(1), 83–89. https://doi.org/10.1016/j.jopan.2024.03.011 DOI: https://doi.org/10.1016/j.jopan.2024.03.011
Urman, R. D., Khanna, A. K., Bergese, S. D., Buhre, W., Wittmann, M., Le Guen, M., Overdyk, F. J., Di Piazza, F., & Saager, L. (2021). Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial. Journal of Clinical Anesthesia, 70. https://doi.org/10.1016/j.jclinane.2021.110167 DOI: https://doi.org/10.1016/j.jclinane.2021.110167
Wang, P., Song, M., Wang, X., Zhang, Y., & Wu, Y. (2023). Effect of esketamine on opioid consumption and postoperative pain in thyroidectomy: A randomized controlled trial. British Journal of Clinical Pharmacology, 89(8), 2542–2551. https://doi.org/10.1111/bcp.15726 DOI: https://doi.org/10.1111/bcp.15726
Weingarten, T. N., Deljou, A., & Sprung, J. (2025). Research and clinical implications of emerging evidence regarding patterns of postoperative opioid-induced respiratory depression. In Biomolecules and Biomedicine (Vol. 25, Number 2, pp. 327–337). Association of Basic Medical Sciences of FBIH. https://doi.org/10.17305/bb.2024.11123 DOI: https://doi.org/10.17305/bb.2024.11123
Xu, Y., Ye, M., Liu, F., Hong, Y., Kang, Y., Li, Y., Li, H., Xiao, X., Yu, F., Zhou, M., Zhou, L., & Jiang, C. (2023). Efficacy of prolonged intravenous lidocaine infusion for postoperative movement-evoked pain following hepatectomy: a double-blinded, randomised, placebo-controlled trial. British Journal of Anaesthesia, 131(1), 113–121. https://doi.org/10.1016/j.bja.2023.03.026 DOI: https://doi.org/10.1016/j.bja.2023.03.026
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Derechos de autor 2026 Carina Alexandra Trujillo Saavedra, Sonia Carolina Arias Durán, Tania Dayanara Chanaluisa Cerda, Shirley Marisol Angamarca Jara, Sandra Del Rocio Morocho Imbacuan (Autor/a)
Esta obra está bajo una licencia internacional Creative Commons Atribución 4.0.
