Remifentanil and propofol for weaning of mechanically ventilated pediatric intensive care patients

Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view

In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field.    Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.

Operational Definitions Related to Pediatric Ventilator Liberation

BACKGROUND

Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices.

RESEARCH QUESTION

Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches?

STUDY DESIGN AND METHODS

A panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions.

RESULTS

In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support.

INTERPRETATION

We propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

[Midazolam/fentanyl vs propofol/remifentanil in immediate postoperative with short-term mechanical ventilation]

OBJECTIVES

Compare between 2sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation.

METHODOLOGY

Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72hours. We compared 2independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects.

RESULTS

We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean±standard deviation of patients were 49±65 months, weight 17±16kg. Mechanical ventilation time medium was 22hours (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8±10,6minutes group A and 137,3±45minutes group B (P<.001), extubation time after removing sedoanalgesia was of 24±21minutes group A and 230±102minutes group B (P<.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation), P=.572.

CONCLUSIONS

Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.

Dexmedetomidine facilitates extubation in children who require intubation and respiratory support after airway foreign body retrieval: a case-cohort analysis of 57 cases

PURPOSE

This study aimed to investigate whether dexmedetomidine had sedative weaning advantage for extubation after airway foreign body (FB) removal in children.

METHODS

A retrospective case-cohort comparison study with total of 57 critical children who required mechanical ventilation after rigid bronchoscopy was performed. After tracheal intubation, group D (received dexmedetomidine 1 µg/kg over 10 min, followed by an infusion of 0.8 µg/kg/h), and group RP (received remifentanil-propofol 6-10 µg/kg/h and 1-3 mg/kg/h, respectively). The primary outcome was successful extubation rate on first weaning trial. The minor outcomes included weaning time, emergency agitation, coughing score and the incidence of respiratory adverse complications on emergency.

MAIN RESULTS

All 57 patients were included in the analysis, with 30 patients in group D and 27 controlled cases in group RP. The success rate of first weaning trial in the D group was 96.7 vs 77.8% in the RP group, risk ratio (RR) 1.56, 95% CI [0.78-1.98]. Time for resuming spontaneous breathing after termination infusion was shorter in the D group (median 8 min, IQR 15 min) vs RP group (median 12 min, IQR 19 min, P = 0.02, RR 0.56, 95% CI 0.14-6.57).

CONCLUSIONS

In mechanical ventilation of pediatric patients following rigid bronchoscopy, in comparison to remifentanil-propofol, dexmedetomidine is proved to have high success rate for weaning strategy. WHAT IS ALREADY KNOWN?: Remifentanil is proved to be effective for weaning in ICU patients. Dexmedetomedine can provide similar rates of smooth extubation for pediatric patients who underwent airway surgery. WHAT THIS ARTICLE ADDS?: Invasive ventilation is used for patients with severe comorbidity after airway surgery, but the correct strategy for pediatric extubation after removal of airway foreign body remains unclear. For these patients with short-term mechanical ventilation, dexmedetomedine may improve the extubation rate, when compared with remifentanil-propofol.

Remifentanil/midazolam versus fentanyl/midazolam for analgesia and sedation of mechanically ventilated neonates and young infants: a randomized controlled trial

PURPOSE

Common opioids for analgesia and sedation of mechanically ventilated infants may tend to accumulate and cause prolonged sedation with an unpredictable extubation time. Remifentanil is a promising option due to its unique pharmacokinetic properties, which seem to be valid in adults as well as in infants.

METHODS

In this double-blind, randomized, controlled trial mechanically ventilated neonates and young infants (<60 days) received either a remifentanil or fentanyl-based analgesia and sedation regimen with low dose midazolam. The primary endpoint of the trial was the extubation time following discontinuation of the opioid infusion. Secondary endpoints included efficacy and safety aspects.

RESULTS

Between November 2006 and March 2010, we screened 431 mechanically ventilated infants for eligibility. The intention to treat group included 23 infants who were assigned to receive either remifentanil (n = 11) or fentanyl (n = 12). Although this was designed as a pilot study, median extubation time was significantly shorter in the remifentanil group (80.0 min, IQR = 15.0-165.0) compared to the fentanyl group (782.5 min, IQR = 250.8-1,875.0) (p = 0.005). Remifentanil and fentanyl provided comparable efficacy with more than two-thirds of the measurements indicating optimal analgesia and sedation (66.4 and 70.2 %, respectively; p = 0.743). Overall, both groups had good hemodynamic stability and a comparably low incidence of adverse events.

CONCLUSIONS

As neonates and young infants have a decreased metabolism of common opioids like fentanyl and are more prone to respiratory depression, remifentanil could be the ideal opioid for analgesia and sedation of mechanically ventilated infants.