Sedation and analgesia in intensive care: a comparison of fentanyl and remifentanil

Effects of fentanyl administration in mechanically ventilated patients in the intensive care unit: a systematic review and meta-analysis

BACKGROUND

Fentanyl is selected to manage pain in critical care patients on mechanical ventilation in the intensive care unit (ICU). However, the usefulness of fentanyl compared with other opioids is unknown. This study examined the evidence for using fentanyl to improve the clinical outcomes of ICU patients, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

METHODS

We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases in June 2021. Two independent assessors reviewed studies to identify randomized, controlled trials (RCTs) that compared the intravenous administration of fentanyl and other opioids in mechanically ventilated patients in the ICU. The study quality was assessed using the GRADE system and Cochrane methodology. The primary outcome was mortality. The secondary outcomes were the duration of mechanical ventilation, duration of the ICU stay, incidence of severe adverse events, and incidence of delirium. We integrated outcome data using a random-effects model and showed absolute values and certainty of evidence in the GRADE evidence profile.

RESULTS

Seven RCTs met the study inclusion criteria with 534 patients (251 were treated with fentanyl and 283 with other opioids, including 242 with remifentanil and 41 with morphine). Among 191 participants from 2 RCTs, fentanyl was not associated with mortality (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.24 to 2.60; low-quality evidence). Regarding the secondary outcomes, fentanyl did not shorten the duration of mechanical ventilation (mean difference, 0.49 h; 95% CI, - 0.90 to 1.88; moderate-quality evidence) or the duration of the ICU stay (mean difference, 7.04 h; 95% CI, - 3.27 to 17.35; moderate-quality evidence) compared with other opioids. Fentanyl did not increase the incidence of severe adverse events (RR, 0.98; 95% CI, 0.50 to 1.90; low-quality evidence) or delirium (RR, 1.27; 95% CI, 0.79 to 2.04; low-quality evidence).

CONCLUSIONS

Although fentanyl is a frequently administered opioid in the ICU, patients' outcomes are not different between fentanyl use and use of other opioids. However, the GRADE evaluation provides little certainty to support the results of this systematic review. Therefore, further large RCTs are required to confirm our conclusions.

TRIAL REGISTRATION

PROSPERO, CRD42019130648 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130648 ).

Application of remifentanil for conscious sedation and analgesia in short-term ERCP and EST surgery

This study aims to observe and evaluate the use of remifentanil in conscious sedation and analgesia for the safety and comfort of patients undergoing short-term endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST).Sixty-eight patients who underwent ERCP and EST were randomly divided into two groups: research group and control group. Patients in the research group were intravenously injected with remifentanil (80-2/3* age) for 1 to 2 minutes, combined with the intravenous injection of propofol (20-30 mg) during the course of treatment. ERCP surgery was performed when Ramsay sedation scale (RSS) score reached 2-3. During the surgery, patients were closely monitored for cough symptoms, aspiration, and respiratory and circulatory system performance, and timely treatment was performed. Sedative drugs were not given in patients in the control group.In research group, the circulatory and respiratory depression of patients was mild, only one patient needed to be treated, and there was no arrhythmia requiring treatment. Five patients had respiratory depression (blood oxygen saturation decreased to <90%), which was immediately corrected. There were no interruptions during surgery due to body movement, cough, or aspiration.The use of remifentanil for conscious sedation and analgesia can be broadly applied in short-term ERCP, which greatly improves patient comfort during the surgery. This approach may bear promise for a widespread use in future clinical practice.

Effects of nurses' practice of a sedation protocol on sedation and consciousness levels of patients on mechanical ventilation

BACKGROUND

Providing high-quality care in the intensive care units (ICUs) is a major goal of every medical system. Nurses play a crucial role in achieving this goal. One of the most important responsibilities of nurses is sedation and pain control of patients. The present study tried to assess the effect of nurses' practice of a sedation protocol on sedation and consciousness levels and the doses of sedatives and analgesics in the ICU patients.

MATERIALS AND METHODS

This clinical trial was conducted on 132 ICU patients on mechanical ventilation. The patients were randomly allocated to two groups. While the control group received the ICU's routine care, the intervention group was sedated by ICU nurses based on Jacob's modified sedation protocol. The subjects' sedation and consciousness levels were evaluated by the Richmond Agitation Sedation Scale (RASS) and the Glasgow Coma Scale (GCS), respectively. Doses of administered midazolam and morphine were also recorded.

RESULTS

The mean RASS score of the intervention group was closer to the ideal range (-1 to +1), compared to the control group (-0.95 ± 0.3 vs. -1.88 ± 0.4). Consciousness level of the control group was lower than that of the intervention group (8.4 ± 0.4 vs. 8.8 ± 0.4). Finally, higher doses of midazolam and morphine were administered in the control group than in the intervention group.

CONCLUSION

As nurses are in constant contact with the ICU patients, their practice of a sedation protocol can result in better sedation and pain control in the patients and reduce the administered doses of sedatives and analgesics.