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Okano H, Kataoka Y, Sakuraya M, Aoki Y, Okamoto H, Imai E, Yamazaki T. Efficacy of Remifentanil in Patients Undergoing Cardiac Surgery: A Systematic Review and Network Meta-Analysis. Cureus 2023; 15:e51278. [PMID: 38161541 PMCID: PMC10756075 DOI: 10.7759/cureus.51278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/03/2024] Open
Abstract
Remifentanil, characterized by its ultra-short action duration and nonorgan-dependent metabolism, is applied in postcardiac surgery settings worldwide. While previous studies have compared its efficacy with that of other opioids, it has never been compared to a single specific opioid. Here, we evaluated whether remifentanil shortens mechanical ventilation (MV) times in patients after cardiac surgery. We identified randomized controlled trials that compared various opioids in adults (≥18 years) admitted to the intensive care unit after cardiac surgery. The primary outcome was the duration of MV, expressed as the mean difference (MD) in minutes, with a 95% confidence interval (CI). A 60-min reduction was considered significant based on prior research. Data were sourced from MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platforms Search Portal, and ClinicalTrials.gov, and a frequentist network meta-analysis was conducted. The eight identified studies indicate no differences in the duration of MV between remifentanil and fentanyl (MD 0.09 min; 95%CI -36.89-37.08), morphine (MD -19 min; 95%CI -55.86-16.21), or sufentanil (MD -2.44 min; 95%CI -67.52-62.55). Our study revealed that remifentanil did not reduce MV times in patients after cardiac surgery. The study protocol was registered with the Open Science Forum (https://osf.io/) (DOI 10.17605/OSF.IO/YAHW2).
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Affiliation(s)
- Hiromu Okano
- Department of Critical Care Medicine, St. Luke's International Hospital, Tokyo, JPN
- Department of Social Medical Sciences, Graduate School of Medicine, International University of Health and Welfare, Tokyo, JPN
| | - Yuki Kataoka
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, JPN
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, JPN
- Department of Systematic Reviewers, Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, JPN
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, JPN
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, JPN
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Hiroshi Okamoto
- Department of Critical Care Medicine, St. Luke's International Hospital, Tokyo, JPN
| | - Eriya Imai
- Division of Anesthesiology, Mitsui Memorial Hospital, Tokyo, JPN
| | - Tsutomu Yamazaki
- Department of Social Medical Sciences, Graduate School of Medicine, International University of Health and Welfare, Tokyo, JPN
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2
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Rajamani A, Subramaniam A, Lung B, Masters K, Gresham R, Whitehead C, Lowrey J, Seppelt I, Kumar H, Kumar J, Hassan A, Orde S, Bharadwaj PA, Arvind H, Huang S. Remi-fent 1-A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients. CRIT CARE RESUSC 2023; 25:216-222. [PMID: 38234321 PMCID: PMC10790007 DOI: 10.1016/j.ccrj.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
Objective To evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients. Design Single-center, open-labelled, pRCT with blinded analysis. Setting Australian tertiary intensive care unit (ICU). Participants Consecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation >12 h, or study-drug hypersensitivity. Interventions Open-label fentanyl and remifentanil infusions per existing ICU protocols. Outcomes Primary outcomes were feasibility of recruiting ≥1 patient/week and >90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group. Results 208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p < 0.001); hypotension (n = 78 versus n = 53; p < 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01). Conclusions We demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.
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Affiliation(s)
- Arvind Rajamani
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW 2747, Australia
| | | | - Brian Lung
- Department of Anaesthesia, Nepean Hospital, Kingswood, NSW 2747, Australia
| | - Kristy Masters
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Rebecca Gresham
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Christina Whitehead
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Julie Lowrey
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
- Faculty of Medicine, University of Sydney, Australia
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Hemant Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Jayashree Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Anwar Hassan
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Sam Orde
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | | | | | - Stephen Huang
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
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3
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Doi M, Takahashi N, Nojiri R, Hiraoka T, Kishimoto Y, Inoue S, Oya N. Efficacy, safety, and pharmacokinetics of MR13A11A, a generic of remifentanil, for pain management of Japanese patients in the intensive care unit: a double-blinded, fentanyl-controlled, randomized, non-inferiority phase 3 study. J Intensive Care 2023; 11:51. [PMID: 37953283 PMCID: PMC10641973 DOI: 10.1186/s40560-023-00698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND The aims of this study were to evaluate the efficacy, safety, and pharmacokinetics (PK) of continuous intravenous administration of remifentanil in mechanically ventilated patients in the intensive care unit (ICU). METHODS This was a multicenter, randomized, double-blinded, fentanyl-controlled, non-inferiority phase 3 study. Patients aged ≥ 20 years requiring 6 h to 10 days mechanical ventilation in an ICU and requiring pain relief were randomly assigned in a 1:1 ratio to receive either remifentanil (n = 98) or fentanyl (n = 98). Dose was titrated from an infusion rate of 1 mL/h (remifentanil: 0.025 µg/kg/min, fentanyl: 0.1 µg/kg/h) until the target level of analgesia (behavioral pain scale [BPS] ≤ 5 or numerical rating score [NRS] ≤ 3) was achieved by escalating the dose in 1 mL/h increasing. Administration was then adjusted to maintain the target level of analgesia until weaning from the ventilator. The primary endpoint was the proportion of patients who did not require rescue fentanyl. Safety was assessed according to standard procedures. PK of remifentanil in the arterial blood was assessed in 24 patients. RESULTS The proportion of patients achieving the primary endpoint in the remifentanil and fentanyl groups was 100% (92/92) and 97.8% (88/90), respectively. The difference between the groups was 2.2% (95% confidence interval, - 0.8-5.3) and non-inferiority of remifentanil to fentanyl was verified (p < 0.0001). The incidences of any adverse events in the remifentanil and fentanyl groups was 34 of 92 patients (37.0%) and 34 of 90 patients (37.8%), respectively. Adverse drug reactions was 12 in 92 patients (13.0%) and 15 in 90 patients (16.7%), respectively. In the PK analysis, blood remifentanil concentration decreased within 10 min to almost 50% of the end of administration, suggesting rapid offset of action following discontinuation of remifentanil. CONCLUSIONS Remifentanil can be used safely for pain management in mechanically ventilated Japanese patients in the ICU. TRIAL REGISTRATION Japan Registry of Clinical Trials, jRCT2080224954. Registered 20 November 2019, https://jrct.niph.go.jp/latest-detail/jRCT2080224954 .
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Affiliation(s)
- Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Naoki Takahashi
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Rumi Nojiri
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan.
| | - Takehiko Hiraoka
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Yusuke Kishimoto
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Shinichi Inoue
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Nobuyo Oya
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
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4
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De Bels D, Bousbiat I, Perriens E, Blackman S, Honoré PM. Sedation for adult ICU patients: A narrative review including a retrospective study of our own data. Saudi J Anaesth 2023; 17:223-235. [PMID: 37260674 PMCID: PMC10228859 DOI: 10.4103/sja.sja_905_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/06/2023] [Accepted: 01/19/2023] [Indexed: 06/02/2023] Open
Abstract
The optimization of patients' treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.
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Affiliation(s)
- David De Bels
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Ibrahim Bousbiat
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Emily Perriens
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Sydney Blackman
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Patrick M Honoré
- Department of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
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5
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Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care 2022; 50:108-126. [PMID: 35172616 DOI: 10.1177/0310057x211070008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.
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Affiliation(s)
- Benjamin L Moran
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Department of Intensive Care, 90112Gosford Hospital, Gosford Hospital, Gosford, Australia.,Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - John A Myburgh
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Faculty of Medicine, 7800University of New South Wales, University of New South Wales, Kensington, Australia.,St George Hospital, Kogarah, Australia
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Fitzroy, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
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6
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Yang S, Zhao H, Wang H, Zhang H, An Y. Comparison between remifentanil and other opioids in adult critically ill patients: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27275. [PMID: 34559131 PMCID: PMC8462581 DOI: 10.1097/md.0000000000027275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/15/2021] [Accepted: 08/31/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND AIMS To identify the efficacy and safety of remifentanil when compared with other opioids in adult critically ill patients. METHODS We searched for studies in the Cochrane Library, MEDLINE, and EMBASE that had been published up to May 31st, 2019. Randomized clinical trials using remifentanil comparing with other opioids for analgesia were included. Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. Duration of mechanical ventilation was the primary outcome, and secondary outcomes included weaning time, intensive care unit (ICU), length of stay (LOS), hospital LOS, mortality, side effects, and costs. RESULTS Fifteen studies with 1233 patients were included. Remifentanil was associated with a significant reduction in the duration of mechanical ventilation in the adult ICU patients when compared with other opioids (P = .01). Remifentanil also reduced the weaning time (P = .02) and the ICU LOS when compared with other opioids (P = .01). There was no difference in the hospital LOS (P = .15), side effects (P = .39), and mortality (P = .79) between remifentanil and other opioids, what's more, remifentanil increased the costs of anesthesia (P < .001) but did not increase cost of hospitalization (P = .30) when comparing with other opioids. CONCLUSIONS Remifentanil reduced the duration of mechanical ventilation, weaning time, and ICU LOS when compared with other opioids in adult critically ill patients. Higher quality RCTs are necessary to prove our findings. PROSPERO REGISTRATION NUMBER CRD42016041438.
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Affiliation(s)
- Shuguang Yang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Huixia Wang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Hua Zhang
- Epidemiology Center, Peking University Third Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
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Ammar MA, Tran LJ, McGill B, Ammar AA, Huynh P, Amin N, Guerra M, Rouse GE, Lemieux D, McManus D, Topal JE, Davis MW, Miller L, Yazdi M, Leber MB, Pulk RA. Pharmacists leadership in a medication shortage response: Illustrative examples from a health system response to the COVID-19 crisis. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021; 4:1134-1143. [PMID: 34230910 PMCID: PMC8250559 DOI: 10.1002/jac5.1443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 12/17/2022]
Abstract
As medication experts, clinical pharmacists play an active and dynamic role in a medication shortage response. Supplementing existing guidelines with an actionable framework of discrete activities to support effective medication shortage responses can expand the scope of pharmacy practice and improve patient care. Dissemination of best practices and illustrative, networked examples from health systems can support the adoption of innovative solutions. In this descriptive report, we document the translation of published shortage mitigation guidelines into system success through broad pharmacist engagement and the adaption and implementation of targeted strategies. The profound, wide‐reaching medication shortages that accompanied the coronavirus disease 2019 (COVID‐19) pandemic are used to highlight coordinated but distinct practices and how they have been combined to expand the influence of the pharmacy enterprise.
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Affiliation(s)
- Mahmoud A Ammar
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Lydia J Tran
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Bryan McGill
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Abdalla A Ammar
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Phu Huynh
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
| | - Nilesh Amin
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Michael Guerra
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Ginger E Rouse
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Diana Lemieux
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Dayna McManus
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Jeffrey E Topal
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Matthew W Davis
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - LeeAnn Miller
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
| | - Marina Yazdi
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
| | | | - Rebecca A Pulk
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
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8
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Donato M, Carini FC, Meschini MJ, Saubidet IL, Goldberg A, Sarubio MG, Olmos D, Reina R. Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome. Rev Bras Ter Intensiva 2021; 33:48-67. [PMID: 33886853 PMCID: PMC8075332 DOI: 10.5935/0103-507x.20210005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources. METHODS A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva. RESULTS Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19. DISCUSSION Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.
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Affiliation(s)
- Manuel Donato
- Hospital General de Agudos José María Penna - Buenos Aires, Argentina
- Ministerio de Salud de la Nación Argentina - Buenos Aires, Argentina
- Instituto de Efectividad Clínica y Sanitaria - Buenos Aires, Argentina
| | | | | | - Ignacio López Saubidet
- Centro de Educación Médica e Investigaciones Clínicas “Norberto Quirno” - Buenos Aires, Argentina
| | - Adela Goldberg
- Sanatorio de La Trinidad Mitre - Buenos Aires, Argentina
| | | | - Daniela Olmos
- Hospital Municipal Príncipe de Asturias - Córdoba, Argentina
| | - Rosa Reina
- Hospital Interzonal General de Agudos General San Martín - La Plata, Argentina
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9
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Shehabi Y, Al-Bassam W, Pakavakis A, Murfin B, Howe B. Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm. Semin Respir Crit Care Med 2020; 42:98-111. [PMID: 32957139 DOI: 10.1055/s-0040-1716736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents-that are easily titratable-reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.
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Affiliation(s)
- Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia.,Prince of Wales Clinical School of Medicine, University of New South Wales, Randwick, New South Wales, Sydney, Australia
| | - Wisam Al-Bassam
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Adrian Pakavakis
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Brendan Murfin
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Belinda Howe
- The Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
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10
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Ammar MA, Sacha GL, Welch SC, Bass SN, Kane-Gill SL, Duggal A, Ammar AA. Sedation, Analgesia, and Paralysis in COVID-19 Patients in the Setting of Drug Shortages. J Intensive Care Med 2020; 36:157-174. [PMID: 32844730 DOI: 10.1177/0885066620951426] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The rapid spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to a global pandemic. The 2019 coronavirus disease (COVID-19) presents with a spectrum of symptoms ranging from mild to critical illness requiring intensive care unit (ICU) admission. Acute respiratory distress syndrome is a major complication in patients with severe COVID-19 disease. Currently, there are no recognized pharmacological therapies for COVID-19. However, a large number of COVID-19 patients require respiratory support, with a high percentage requiring invasive ventilation. The rapid spread of the infection has led to a surge in the rate of hospitalizations and ICU admissions, which created a challenge to public health, research, and medical communities. The high demand for several therapies, including sedatives, analgesics, and paralytics, that are often utilized in the care of COVID-19 patients requiring mechanical ventilation, has created pressure on the supply chain resulting in shortages in these critical medications. This has led clinicians to develop conservation strategies and explore alternative therapies for sedation, analgesia, and paralysis in COVID-19 patients. Several of these alternative approaches have demonstrated acceptable levels of sedation, analgesia, and paralysis in different settings but they are not commonly used in the ICU. Additionally, they have unique pharmaceutical properties, limitations, and adverse effects. This narrative review summarizes the literature on alternative drug therapies for the management of sedation, analgesia, and paralysis in COVID-19 patients. Also, this document serves as a resource for clinicians in current and future respiratory illness pandemics in the setting of drug shortages.
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Affiliation(s)
- Mahmoud A Ammar
- Department of Pharmacy, 25047Yale-New Haven Health System, New Haven, CT, USA
| | - Gretchen L Sacha
- Department of Pharmacy, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Sarah C Welch
- Department of Pharmacy, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Stephanie N Bass
- Department of Pharmacy, 2569Cleveland Clinic, Cleveland, OH, USA
| | | | - Abhijit Duggal
- Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Abdalla A Ammar
- Department of Pharmacy, 25047Yale-New Haven Health System, New Haven, CT, USA
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11
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Rodriguez PO, Tiribelli N, Fredes S, Gogniat E, Plotnikow G, Fernandez Ceballos I, Pratto R, Raimondi A, Guaymas M, Ilutovich S, San Román E, Madorno M, Maskin P, Brochard L, Setten M. Prevalence of Reverse Triggering in Early ARDS: Results From a Multicenter Observational Study. Chest 2020; 159:186-195. [PMID: 32805238 DOI: 10.1016/j.chest.2020.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The prevalence of reverse triggering (RT) in the early phase of ARDS is unknown. RESEARCH QUESTION During early ARDS, what is the proportion of patients affected by RT, what are its potential predictors, and what is its association with clinical outcomes? STUDY DESIGN AND METHODS This was prospective, multicenter, and observational study. Patients who met the Berlin definition of ARDS with less than 72 h of mechanical ventilation and had not been paralyzed with neuromuscular blockers were screened. A 30-min recording of respiratory signals was obtained from the patients as soon as they were enrolled, and the number of breaths with RT were counted. RESULTS One hundred patients were included. ARDS was mild to moderate in 92% of them. The recordings were obtained after a median of 1 day (interquartile range, 1-2 days) of ventilation. Fifty patients had RT, and most of these events (97%) were not associated with breath stacking. Detecting RT was associated with lower tidal volume (Vt) and less opiate infusion. The presence of RT was not associated with time to discontinuation of mechanical ventilation (subdistribution hazard ratio, 1.03; 95% CI, 0.6-1.77), but it possibly was associated with a reduced hospital mortality (hazard ratio, 0.65; 95% CI, 0.57-0.73). INTERPRETATION Fifty percent of patients receiving assist-control ventilation for mild or moderate ARDS, sedated and nonparalyzed, demonstrate RT without breath stacking on the first day of mechanical ventilation. RT may be associated with low VTS and opiate doses. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02732041; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Pablo O Rodriguez
- Intensive Care Unit, Centro de Educación Médica e Investigaciones Clínicas, Ciudad Autónoma de Buenos Aires, Argentina; Pulmonary Medicine School of Medicine, Centro de Educación Médica e Investigaciones Clínicas, Ciudad Autónoma de Buenos Aires, Argentina; Instituto Universitario, Centro de Educación Médica e Investigaciones Clínicas, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Norberto Tiribelli
- Intensive Care Unit, Complejo Médico Churruca Visca, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sebastián Fredes
- Intensive Care Unit, Complejo Médico Churruca Visca, Ciudad Autónoma de Buenos Aires, Argentina; Intensive Care Unit, Sanatorio de la Trinidad Mitre, Ciudad Autónoma de Buenos Aires, Argentina
| | - Emiliano Gogniat
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gustavo Plotnikow
- Intensive Care Unit, Sanatorio Anchorena, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Romina Pratto
- Intensive Care Unit, Sanatorio Anchorena, Ciudad Autónoma de Buenos Aires, Argentina
| | - Alejandro Raimondi
- School of Medicine, University of Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - María Guaymas
- Intensive Care Unit, Complejo Médico Churruca Visca, Ciudad Autónoma de Buenos Aires, Argentina
| | - Santiago Ilutovich
- Intensive Care Unit, Sanatorio de la Trinidad Mitre, Ciudad Autónoma de Buenos Aires, Argentina
| | - Eduardo San Román
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Matías Madorno
- MBMed SA, Ciudad Autónoma de Buenos Aires, Argentina; Instituto Tecnológico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Patricio Maskin
- Intensive Care Unit, Centro de Educación Médica e Investigaciones Clínicas, Ciudad Autónoma de Buenos Aires, Argentina; Pulmonary Medicine School of Medicine, Centro de Educación Médica e Investigaciones Clínicas, Ciudad Autónoma de Buenos Aires, Argentina; Instituto Universitario, Centro de Educación Médica e Investigaciones Clínicas, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laurent Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Mariano Setten
- Intensive Care Unit, Centro de Educación Médica e Investigaciones Clínicas, Ciudad Autónoma de Buenos Aires, Argentina; Universidad del Salvador Medical School, Ciudad Autónoma de Buenos Aires, Argentina
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12
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Donato J, Rao K, Lewis T. Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit. Clin Perinatol 2019; 46:673-692. [PMID: 31653302 DOI: 10.1016/j.clp.2019.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.
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Affiliation(s)
- Jamesia Donato
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Karishma Rao
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Tamorah Lewis
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Division of Pediatric Clinical Pharmacology, UMKC School of Medicine, Children's Mercy Hospital, Kansas City, MO, USA.
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13
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Patel M, Altshuler D, Lewis TC, Merchan C, Smith DE, Toy B, Zakhary B, Papadopoulos J. Sedation Requirements in Patients on Venovenous or Venoarterial Extracorporeal Membrane Oxygenation. Ann Pharmacother 2019; 54:122-130. [PMID: 31544474 DOI: 10.1177/1060028019877806] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background:There is a paucity of data evaluating optimal dosing strategies of commonly utilized opioids and sedatives for patients on extracorporeal membrane oxygenation (ECMO) support where pharmacokinetic and pharmacodynamic variables of these administered agents are altered. Objective: To assess the daily dosing requirement of sedatives and analgesics for patients on venovenous (VV) and venoarterial (VA) ECMO after the initial ECMO cannulation period. Methods: We performed a retrospective, observational study of adult patients receiving sedation and analgesia while receiving ECMO support for at least 24 hours. Patients cannulated at an outside hospital more than 24 hours before transfer, those with a history of intravenous drug use or acute alcohol withdrawal, or those who died within 48 hours of ECMO initiation were excluded. Results: We evaluated 26 patients on ECMO, including 13 on VV and 13 on VA ECMO. The median dose of fentanyl was 140 µg/h, with the VV group requiring a higher dose compared with the VA group (167 vs 106 µg/h, P < 0.001). The median doses of dexmedetomidine and propofol were 0.7 µg/kg/h and 26 µg/kg/min, respectively, with no significant differences between groups (P = 0.38 and P = 0.24, respectively). The median daily doses of fentanyl, dexmedetomidine, and propofol did not significantly increase throughout the time on ECMO support. Conclusions and Relevance: We found that the overall opioid daily dosing requirements were lower than previously reported in the literature. Additionally, light sedation strategies with a target RASS of -1 to 0 are feasible in this patient population.
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14
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Yeary J, Greco A, McKnight R, Petros K, Schaefer G, Garavaglia J. Adjusted vs Total Body Weight-Based Dosing of Sedation and Analgesia Used in the Intensive Care Unit. Hosp Pharm 2019; 55:400-404. [PMID: 33245723 DOI: 10.1177/0018578719851452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The purpose of this study was to evaluate if dosing fentanyl, dexmedetomidine, and propofol based on ideal or adjusted vs actual weight in patients would decrease overall opioid and sedative use. Methods: This was a retrospective chart review comparing adjusted vs actual weight-based dosing protocol of mechanically ventilated (MV) intensive care unit (ICU) adult patients who required fentanyl and either propofol or dexmedetomidine. Results: A total of 261 patients were included in which 101 patients were in the actual weight group and 160 patients were in the adjusted weight group. Total doses per MV day of fentanyl was 1042 ± 1060 µg in the actual weight group vs 901 ± 1025 µg in the adjusted weight group (P = .13). Total doses per MV day of midazolam was 20 ± 19 mg in the actual group vs 15 ± 19 mg adjusted group (P = .02). Average MV days was 8.2 vs 7.1 days, ICU length of stay was 10.6 vs 9.4 days, and self-extubation rates were 17.8% vs 4.4% in the actual group and adjusted group, respectively. Conclusion: Total midazolam doses per MV day were lower in the adjusted group. No significant change was seen in MV days, ICU length of stay, or self-extubation rates.
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15
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Pharmacology in Critical Care. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Bodnar J. Terminal Withdrawal of Mechanical Ventilation: A Hospice Perspective for the Intensivist. J Intensive Care Med 2018; 34:156-164. [PMID: 30189788 DOI: 10.1177/0885066618797918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The intensive care unit (ICU) and hospice inpatient unit (IPU) environments differ in many ways. Although both endeavor to provide the best care possible for their patients, the day-to-day goals of these environments are almost antithetical. Similarly, the experiences and expertise of the staff differ. When performing a similar clinical task, it may be addressed in different ways because each group is engrained in their primary day-to-day focus. Terminal withdrawal of mechanical ventilation is a procedure that is performed in both ICUs and some hospice IPUs. Previous examinations of this subject have been based largely upon the correlative background, practices, and perceptions of the ICU prescriber. The purpose of this review is to examine how the manner in which this procedure is performed in the hospice environment may differ in ways that the intensivist can incorporate into their own plan of care, or better appreciate when making the decision to remove mechanical ventilation in the critical care unit or transfer the patient to a hospice environment for the procedure to be completed.
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Affiliation(s)
- John Bodnar
- 1 Neighborhood Hospice, Penn Medicine Chester County Hospital, West Chester, PA, USA
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17
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Panahi Y, Dehcheshmeh HS, Mojtahedzadeh M, Joneidi-Jafari N, Johnston TP, Sahebkar A. Analgesic and sedative agents used in the intensive care unit: A review. J Cell Biochem 2018; 119:8684-8693. [PMID: 30076655 DOI: 10.1002/jcb.27141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/18/2018] [Indexed: 11/10/2022]
Abstract
Pain is a common experience for most patients in the intensive care unit (ICU). In the current study, the advantages and disadvantages of analgesic and sedative drugs used in the ICU are reviewed. An ideal sedative and analgesic agent should have features such as rapid onset of action, rapid recovery after discontinuation, predictability, minimal accumulation of the agent and metabolites in the body, and lack of toxicity. None of the sedative and analgesic agents have all of these desired characteristics; nevertheless, clinicians must be familiar with these classes of drugs to optimize pharmacotherapy and ensure as few side-effects as possible for ICU patients.
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Affiliation(s)
- Yunes Panahi
- Pharmacotherapy Department, School of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Mojtaba Mojtahedzadeh
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Thomas P Johnston
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri
| | - Amirhossein Sahebkar
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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18
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Schenone AL, Chen K, Andress K, Militello M, Cho L. Editor’s Choice- Sedation in the coronary intensive care unit: An adapted algorithm for critically ill cardiovascular patient. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:167-175. [DOI: 10.1177/2048872617753797] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the current era, cardiovascular intensive care units care for more complex patients who are far sicker than historical post-myocardial infarction patients, and sedation has become a common intervention in these units. Current sedation best practices derive mainly from non-cardiac units which limits their generalization to the critically ill cardiac patient. Thus, a great variability in sedation protocols, especially the selection of sedative agents, is commonly seen in daily practice across cardiac units. We present an updated review on sedation in cardiovascular critical care medicine with emphasis on the hemodynamic impact. The goal of this review is to generate a general sedation algorithm specific for the cardiac patient.
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Affiliation(s)
- AL Schenone
- Department of Cardiovascular Medicine, Cleveland Clinic, USA
| | - K Chen
- Internal Medicine Department, Cleveland Clinic, USA
| | - K Andress
- Internal Medicine Department, Cleveland Clinic, USA
| | | | - L Cho
- Department of Cardiovascular Medicine, Cleveland Clinic, USA
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19
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Zham P, Kumar DK, Dabnichki P, Poosapadi Arjunan S, Raghav S. Distinguishing Different Stages of Parkinson's Disease Using Composite Index of Speed and Pen-Pressure of Sketching a Spiral. Front Neurol 2017; 8:435. [PMID: 28932206 PMCID: PMC5592741 DOI: 10.3389/fneur.2017.00435] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/08/2017] [Indexed: 11/20/2022] Open
Abstract
The speed and pen-pressure while sketching a spiral are lower among Parkinson’s disease (PD) patients with higher severity of the disease. However, the correlation between these features and the severity level (SL) of PD has been reported to be 0.4. There is a need for identifying parameters with a stronger correlation for considering this for accurate diagnosis of the disease. This study has proposed the use of the Composite Index of Speed and Pen-pressure (CISP) of sketching as a feature for analyzing the severity of PD. A total of 28 control group (CG) and 27 PD patients (total 55 participants) were recruited and assessed for Unified Parkinson’s Disease Rating Scale (UPDRS). They drew guided Archimedean spiral on an A3 sheet. Speed, pen-pressure, and CISP were computed and analyzed to obtain their correlation with severity of the disease. The correlation of speed, pen-pressure, and CISP with the severity of PD was −0.415, −0.584, and −0.641, respectively. Mann–Whitney U test confirmed that CISP was suitable to distinguish between PD and CG, while non-parametric k-sample Kruskal–Wallis test confirmed that it was significantly different for PD SL-1 and PD SL-3. This shows that CISP during spiral sketching may be used to differentiate between CG and PD and between PD SL-1 and PD SL-3 but not SL-2.
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Affiliation(s)
- Poonam Zham
- School of Engineering, RMIT University, Melbourne, VIC, Australia
| | - Dinesh K Kumar
- School of Engineering, RMIT University, Melbourne, VIC, Australia
| | - Peter Dabnichki
- School of Engineering, RMIT University, Melbourne, VIC, Australia
| | | | - Sanjay Raghav
- School of Engineering, RMIT University, Melbourne, VIC, Australia.,Dandenong Neurology, Melbourne, VIC, Australia
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20
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Zhu Y, Wang Y, Du B, Xi X. Could remifentanil reduce duration of mechanical ventilation in comparison with other opioids for mechanically ventilated patients? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:206. [PMID: 28774327 PMCID: PMC5543734 DOI: 10.1186/s13054-017-1789-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/05/2017] [Indexed: 02/02/2023]
Abstract
Background Sedation and analgesia are commonly required to relieve anxiety and pain in mechanically ventilated patients. Fentanyl and morphine are the most frequently used opioids. Remifentanil is a selective μ-opioid receptor that is metabolized by unspecific esterases and eliminated independently of liver or renal function. Remifentanil has a rapid onset and offset and a short context-sensitive half-life regardless of the duration of infusion, which may lead to reductions in weaning and extubation. We aimed to compare the efficacy and safety of remifentanil to that of other opioids in mechanically ventilated patients. Methods We conducted a search to identify relevant randomized controlled studies (RCTs) in the PubMed, Embase, Cochrane Library and SinoMed databases that had been published up to 31 December 2016. The results were analysed using weighted mean differences (WMDs) and 95% confidence intervals (CIs). Results Twenty-three RCTs with 1905 patients were included. Remifentanil was associated with reductions in the duration of mechanical ventilation (mean difference -1.46; 95% CI -2.44 to -0.49), time to extubation after sedation cessation (mean difference -1.02; 95% CI -1.59 to -0.46), and ICU-LOS (mean difference -0.10; 95% CI -0.16 to -0.03). No significant differences were identified in hospital-LOS (mean difference -0.05; 95% CI -0.25 to 0.15), costs (mean difference -709.71; 95% CI -1590.98 to 171.55; I2 88%), mortality (mean difference -0.64; 95% CI -1.33 to 0.06; I2 87%) or agitation (mean difference -0.71; 95% CI -1.80 to 0.37; I2 93%). Conclusions Remifentanil seems to be associated with reductions in the duration of mechanical ventilation, time to extubation after cessation of sedation, and ICU-LOS. No significant differences were identified between remifentanil and other opioids in terms of hospital-LOS, costs, mortality or agitation. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1789-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yibing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A FuXing Men Wai Da Jie, Xicheng District, Beijing, 100038, China
| | - Yinhua Wang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A FuXing Men Wai Da Jie, Xicheng District, Beijing, 100038, China.,Department of Critical Care Medicine, North China University of Science and Technology Affiliated Hospital, 73 Jianshe Road, Tangshan, 063000, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, China.
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A FuXing Men Wai Da Jie, Xicheng District, Beijing, 100038, China.
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21
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Faust AC, Rajan P, Sheperd LA, Alvarez CA, McCorstin P, Doebele RL. Impact of an Analgesia-Based Sedation Protocol on Mechanically Ventilated Patients in a Medical Intensive Care Unit. Anesth Analg 2017; 123:903-9. [PMID: 27644010 DOI: 10.1213/ane.0000000000001393] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent attention to adverse effects of intensive care unit (ICU) sedation has led to the use of strategies that target a "lighter" depth of sedation. Among these strategies are "analgosedation" protocols, which prioritize pain management and preferentially use IV opioids before administration of continuously infused sedatives such as propofol or midazolam. We hypothesized that using an analgosedation protocol would result in a shorter duration of mechanical ventilation than a protocol with greater emphasis on IV sedatives METHODS : We conducted a retrospective study comparing the duration of mechanical ventilation before and after implementation of an analgosedation protocol in a 24-bed medical ICU. Patients were aged 18 years or older and required mechanical ventilation where a light level of sedation was clinically appropriate. Exclusion criteria included a clinical need for deeper levels of sedation or tracheal intubation confined to the perioperative period. RESULTS Seventy-nine patients were included in the postimplementation group and 65 in the preimplementation group. After adjustment for baseline covariates, introduction of the 2013 analgosedation protocol was associated with a decreased duration of mechanical ventilation (-26.62 hours; 95% confidence interval, - 44.98 to -8.26, P = 0.005). Patients managed with the analgosedation protocol experienced a lighter level of sedation (median Richmond Agitation-Sedation Scale, -2.57 vs -1.25, P = 0.001) and improved pain management (median Critical-Care Pain Observation Tool score, 2.0 vs 1.5, P = 0.03). The use of continuously infused sedatives was reduced by 54.3% (92.3% vs 38.0%, P < 0.001). CONCLUSIONS Our findings suggest that implementation of an analgosedation protocol was associated with an overall lighter level of sedation, shorter mean ventilator duration, and a reduced use of continuous infusion sedatives. Further studies are needed to assess the impact of such protocols on ICU delirium.
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Affiliation(s)
- Andrew C Faust
- From the *Department of Pharmacy, Texas Health Resources Presbyterian Hospital of Dallas, Dallas, Texas; †Texas Tech University Health Sciences Center, College of Pharmacy, Dallas, Texas; ‡Department of Pulmonary and Critical Care Medicine, Texas Health Resources Presbyterian Hospital of Dallas, Dallas, Texas; and §Southwest Pulmonary Associates, Dallas, Texas
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22
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Yamashita A, Yamasaki M, Matsuyama H, Amaya F. Risk factors and prognosis of pain events during mechanical ventilation: a retrospective study. J Intensive Care 2017; 5:17. [PMID: 28194277 PMCID: PMC5299760 DOI: 10.1186/s40560-017-0212-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 02/02/2017] [Indexed: 02/06/2023] Open
Abstract
Background Pain assessment is highly recommended in patients receiving mechanical ventilation. However, pain intensity and its impact on outcomes in these patients remain obscure. We collected the results of routine pain assessments, utilizing the behavioral pain scale (BPS), from 151 patients receiving mechanical ventilation. Risk factors associated with a pain event, defined as BPS of >5, and its impact on patient outcomes were investigated. Methods A total of 151 consecutive adult patients receiving mechanical ventilation for more than 24 h in a single 10-bed ICU were enrolled in this study. The highest BPS within 48 h after the initiation of mechanical ventilation was collected, as well as information about the patients’ characteristics and medication received. We also recorded patient outcomes, including time to successful weaning from mechanical ventilation, time to successful ICU discharge, and 30-day in-hospital mortality. Multivariate logistic regression analysis was used to determine factors independently associated with patients with a BPS of >5. Clinical outcomes were also assessed using multivariate logistic regression analysis, correcting for risk factors. Results We analyzed 151 patients. The median highest BPS was 4. The percentage of patients who recorded a BPS of >5 was 19.9% (n = 30). Multivariate logistic regression analysis revealed that the disuse of fentanyl and inotropic support was an independent predictor of pain event. Multivariable Cox regression analysis suggested that the development of a BPS of >5 was associated with increased mortality and a not statistically significant trend towards prolonged mechanical ventilation. Conclusions A significant proportion of ventilated patients experienced a BPS of >5 soon after the initiation of mechanical ventilation. Disuse of fentanyl and use of inotropic agents increased the risk of developing a BPS of >5 during mechanical ventilation. An association between adequate analgesia and improved patient outcomes provides a rationale for the assessment of pain during mechanical ventilation, with subsequent intervention if necessary. Pain events were common among ventilated patients. In critical care settings, appropriate and adequate pain management is warranted, given the association with improved patient outcomes.
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Affiliation(s)
- Ayahiro Yamashita
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-Ku, Kyoto 602-8566 Japan
| | - Masaki Yamasaki
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-Ku, Kyoto 602-8566 Japan
| | - Hiroki Matsuyama
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-Ku, Kyoto 602-8566 Japan.,Department of Anesthesia, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Fumimasa Amaya
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-Ku, Kyoto 602-8566 Japan
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23
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Stephens J, Wright M. Pain and Agitation Management in Critically Ill Patients. Nurs Clin North Am 2016; 51:95-106. [PMID: 26897427 DOI: 10.1016/j.cnur.2015.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pain and agitation may be difficult to assess in a critically ill patient. Pain is best assessed by self-reporting pain scales; but in patients who are unable to communicate, behavioral pain scales seem to have benefit. Patients' sedation level should be assessed each shift and preferably by a validated ICU tool, such as the RASS or SAS scale. Pain is most appropriately treated with the use of opiates, and careful consideration should be given to the pharmacokinetic and pharmacodynamic properties of various analgesics to determine the optimal agent for each individual patient. Sedation levels should preferably remain light or with the use of a daily awakening trial. Preferred treatment of agitation is analgosedation with the addition of nonbenzodiazepine sedatives if necessary. There are risks associated with each agent used in the treatment of pain and agitation, and it is important to monitor patients for effectiveness, signs of toxicity, and adverse drug reactions.
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Affiliation(s)
- Julie Stephens
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, One University Park Drive, Nashville, TN 37204, USA.
| | - Michael Wright
- Department of Pharmacy, Williamson Medical Center, 4321 Carothers Parkway, Franklin, TN 37067, USA
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24
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Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health Syst Pharm 2016; 72:1531-43. [PMID: 26346209 DOI: 10.2146/ajhp140541] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The pathophysiology of pain in critically ill patients, the role of pain assessment in optimal pain management, and pharmacologic and nonpharmacologic strategies for pain prevention and treatment are reviewed. SUMMARY There are many short- and long-term consequences of inadequately treated pain, including hyperglycemia, insulin resistance, an increased risk of infection, decreased patient comfort and satisfaction, and the development of chronic pain. Clinicians should have an understanding of the basic physiology of pain and the patient populations that are affected. Pain should be assessed using validated pain scales that are appropriate for the patient's communication status. Opioids are the cornerstone of pain treatment. The use of opioids, administered via bolus dosing or continuous infusion, should be guided by patient-specific goals of care in order to avoid adverse events. A multimodal approach to pain management, including the use of regional analgesia, may improve patient outcomes and decrease opioid-related adverse events, though there are limited relevant data in adult critically ill patient populations. Nonpharmacologic strategies have been shown to be effective adjuncts to pharmacologic regimens that can improve patient-reported pain intensity and reduce analgesic requirements. Analgesic regimens need to take into account patient-specific factors and be closely monitored for safety and efficacy. CONCLUSION Acute pain management in the critically ill is a largely underassessed and undertreated area of critical care. Opioids are the cornerstone of treatment, though a multimodal approach may improve patient outcomes and decrease opioid-related adverse events.
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Affiliation(s)
- David P Reardon
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA.
| | - Kevin E Anger
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Paul M Szumita
- David P. Reardon, Pharm.D., BCPS, is Multispecialty Care Clinical Pharmacist, Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT. Kevin E. Anger, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care; and Paul M. Szumita, Pharm.D., BCPS, is Clinical Pharmacy Practice Manager, Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
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Analgosedation: Improving Patient Outcomes in ICU Sedation and Pain Management. Pain Manag Nurs 2016; 17:204-17. [DOI: 10.1016/j.pmn.2016.02.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 11/21/2022]
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Kohler M, Chiu F, Gelber KM, Webb CA, Weyker PD. Pain management in critically ill patients: a review of multimodal treatment options. Pain Manag 2016; 6:591-602. [PMID: 27188977 DOI: 10.2217/pmt-2016-0002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pain management for critically ill patients provides physicians with the challenge of maximizing patient comfort while avoiding the risks that arise with oversedation. Preventing oversedation has become increasingly important as we better understand the negative impact it has on patients' experiences and outcomes. Current research suggests that oversedation can result in complications such as thromboembolism, pulmonary compromise, immunosuppression and delirium. Fortunately, the analgesic options available for physicians to limit these complications are growing as more treatment modalities are being researched and implemented in the intensive care unit. Our goal is to outline some of the effective and widely utilized tools available to physicians to appropriately and safely manage pain while avoiding oversedation in the critically ill population.
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Affiliation(s)
- Matthew Kohler
- Department of Anesthesiology Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Felicia Chiu
- Department of Anesthesiology Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Katherine M Gelber
- Department of Anesthesiology Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Christopher Aj Webb
- Department of Anesthesiology Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Paul D Weyker
- Department of Anesthesiology Columbia University College of Physicians & Surgeons, New York, NY, USA
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Patanwala AE, Martin JR, Erstad BL. Ketamine for Analgosedation in the Intensive Care Unit: A Systematic Review. J Intensive Care Med 2015; 32:387-395. [PMID: 26647407 DOI: 10.1177/0885066615620592] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the evidence for the use of intravenous ketamine for analgosedation in the intensive care unit. METHODS MEDLINE and EMBASE were queried from inception until July 2015. Search terms used included ketamine, intensive care, and critical care. The search retrieved 584 articles to be screened for inclusion. The intent was to include randomized controlled studies using sustained intravenous infusions (>24 hours) of ketamine in the critically ill patients. RESULTS One trial evaluated opioid consumption as an outcome in postoperative critically ill patients who were randomized to ketamine or saline infusions. The mean cumulative morphine consumption at 48 hours was significantly lower in the ketamine group (58 ± 35 mg) compared to the morphine-only group (80 ± 37 mg; P < .05). Other trials showed the potential safety of ketamine in terms of cerebral hemodynamics in patients with traumatic brain injury, improved gastrointestinal motility, and decreased vasopressor requirements. The observational study and case reports suggest that ketamine is safe and effective and may have a role in patients who are refractory to other therapies. CONCLUSION Ketamine use may decrease analgesic consumption in the intensive care unit. Additional trials are needed to further delineate the role of ketamine for analgosedation.
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Affiliation(s)
- Asad E Patanwala
- 1 Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Jennifer R Martin
- 1 Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona, USA.,2 Arizona Health Sciences Library, University of Arizona, Tucson, Arizona, USA
| | - Brian L Erstad
- 1 Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona, USA
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Remifentanil, ketamine, and fospropofol: a review of alterative continuous infusion agents for sedation in the critically ill. Crit Care Nurs Q 2015; 37:137-51. [PMID: 24595251 DOI: 10.1097/cnq.0000000000000012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sedation and analgesia are integral aspects in the care of critically ill patients admitted to the intensive care unit. In recent years, many of the commonly used sedative agents in the United States have experienced manufacturing and sterility issues leading to decreased availability. In addition, current practice has shifted to providing lighter levels of sedation as clinicians have gained a better understanding of the consequences of prolonged deep sedation. Benzodiazepines have fallen out of favor due to findings including increased delirium and duration of mechanical ventilation. Alterations in end-organ function in critically ill patients may also lead to varied responses to commonly used sedatives. With numerous factors impacting choice of sedation in the intensive care unit, fospropofol, ketamine, and remifentanil have been considered potential alternatives to standard therapy. The purpose of this review was to discuss strategies for the safe and effective use of fospropofol, ketamine, and remifentanil for continuous intravenous sedation in critically ill patients.
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Tedders KM, McNorton KN, Edwin SB. Efficacy and safety of analgosedation with fentanyl compared with traditional sedation with propofol. Pharmacotherapy 2014; 34:643-7. [PMID: 24753262 DOI: 10.1002/phar.1429] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To compare the efficacy and safety of analgosedation with fentanyl versus traditional sedation with propofol in critically ill patients receiving mechanical ventilation. METHODS Retrospective, observational study evaluating adult critically ill patients on mechanical ventilation at a community teaching hospital who received continuous infusion fentanyl (n=50) or propofol (n=50) from September 2011-March 2013. RESULTS Median duration of mechanical ventilation was similar between patients receiving propofol and fentanyl infusions (46.7 hr vs 46.0 hr, p=0.19). No difference was noted in median intensive care unit length of stay between groups (p=0.42). A larger percentage of patients receiving propofol required rescue opioids compared with patients receiving fentanyl (56% vs 34%, p=0.04). Furthermore, patients receiving propofol required significantly more rescue opioid therapy during the course of mechanical ventilation as calculated by fentanyl equivalents (150 μg vs 100 μg, p=0.03). No difference in the rate of intensive care unit delirium was noted between groups (fentanyl 23% vs propofol 27%, p=0.80). CONCLUSION Analgosedation with fentanyl appears to be a safe and effective strategy to facilitate mechanical ventilation. This regimen does not appear to affect duration of mechanical ventilation when compared with propofol, but may allow for more optimal pain management in critically ill patients.
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Affiliation(s)
- Kristen M Tedders
- Department of Pharmacy, St. John Macomb-Oakland Hospital, Warren, Michigan
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Lee JM, Lee SH, Kwak SH, Kang HH, Lee SH, Lim JM, Jeong MA, Lee YJ, Lim CM. Comparison of Morphine and Remifentanil on the Duration of Weaning from Mechanical Ventilation. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.4.281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jae Myeong Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Seong Heon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University, Medical School, Gwangju, Korea
| | - Sang Hyun Kwak
- Department of Anesthesiology and Pain Medicine, Chonnam National University, Medical School, Gwangju, Korea
| | - Hyeon Hui Kang
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sang Haak Lee
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jae Min Lim
- Department of Pulmonology, Kangreung Asan Medical Center, Kangreung, Korea
| | - Mi Ae Jeong
- Department of Anesthesiology and Pain Medicine, Hanyang University school of Medicine, Seoul, Korea
| | - Young Joo Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Chae Man Lim
- University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Prasad SR, Simha PP, Jagadeesh AM. Comparative study between dexmedetomidine and fentanyl for sedation during mechanical ventilation in post-operative paediatric cardiac surgical patients. Indian J Anaesth 2013; 56:547-52. [PMID: 23325939 PMCID: PMC3546241 DOI: 10.4103/0019-5049.104572] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIMS AND OBJECTIVES To compare the efficacy of sedation and time taken for extubation using dexmedetomidine and fentanyl sedation in post-operative paediatric cardiac surgical patients. METHODS A prospective randomized double-blind study involving 60 children undergoing open heart surgery was conducted. The patients were divided into two groups, each involving 30 patients. One group received fentanyl at 1 μg/kg/h (Group A) and the other received dexmedetomidine at 0.5 μg/kg/h (Group B) for post-operative sedation with intermittent rescue fentanyl 0.5 μg/kg bolus in either group as per requirement during suctioning. The efficacy of sedation was assessed using the Ramsay sedation score, paediatric intensive care unit sedation score and the tracheal suction score. The time taken for extubation from the stoppage of infusion was noted. RESULTS Haemodynamic parameters between the two groups were comparable. All sedation scores were comparable in the fentanyl and dexmedetomidine groups. Average time (in minutes) required for extubation was 131.0 (±51.06 SD) in the dexmedetomidine group compared with 373.0 (±121.4 SD) in the fentanyl group. The difference in mean time for extubation was statistically significant. CONCLUSIONS Dexmedetomidine facilitates adequate sedation for mechanical ventilation and also early extubation as compared with fentanyl.
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Affiliation(s)
- S R Prasad
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bannerghatta Road, Bangalore, Karnataka, India
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Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263-306. [PMID: 23269131 DOI: 10.1097/ccm.0b013e3182783b72] [Citation(s) in RCA: 2284] [Impact Index Per Article: 207.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
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Abstract
Pain management in the intensive care unit (ICU) is a complex process. Both the experience of pain as well as its treatment can have consequences relating to the overall outcome of the patient. Further, lack of the ability of many patients in the ICU to communicate their distress makes it even more critical for the ICU practitioner to understand the typical causes of pain in this setting and the applicability of many pain management regimens.
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Affiliation(s)
- Larry Lindenbaum
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
Critically ill patients are routinely provided analgesia and sedation to prevent pain and anxiety, permit invasive procedures, reduce stress and oxygen consumption, and improve synchrony with mechanical ventilation. Regional preferences, patient history, institutional bias, and individual patient and practitioner variability, however, create a wide discrepancy in the approach to sedation of critically ill patients. Untreated pain and agitation increase the sympathetic stress response, potentially leading to negative acute and long-term consequences. Oversedation, however, occurs commonly and is associated with worse clinical outcomes, including longer time on mechanical ventilation, prolonged stay in the intensive care unit, and increased brain dysfunction (delirium and coma). Modifying sedation delivery by incorporating analgesia and sedation protocols, targeted arousal goals, daily interruption of sedation, linked spontaneous awakening and breathing trials, and early mobilization of patients have all been associated with improvements in patient outcomes and should be incorporated into the clinical management of critically ill patients. To improve outcomes, including time on mechanical ventilation and development of acute brain dysfunction, conventional sedation paradigms should be altered by providing necessary analgesia, incorporating propofol or dexmedetomidine to reach arousal targets, and reducing benzodiazepine exposure.
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Chanques G, Conseil M, Coisel Y, Carr J, Jung B, Jaber S. Sédation-analgésie en réanimation : arrêt quotidien par les médecins ou gestion continue par les infirmières. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0511-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kim SY, Yang SY, Na SW, Jo YY, Koh SO. Low-Dose Remifentanil Infusion during Ventilator Weaning and Tracheal Extubation in Postoperative Intensive Care Unit Patients Sedated with Propofol-Remifentanil: A Randomised Clinical Trial. Anaesth Intensive Care 2012; 40:656-62. [DOI: 10.1177/0310057x1204000412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Discontinuation of sedatives for ventilator weaning and extubation can be associated with hyperdynamic responses, including hypertension and tachycardia. We examined the effects of a maintained low dose of remifentanil infusion on cardiovascular responses and coughing during extubation in postoperative intensive care unit patients sedated with propofol-remifentanil. Fifty patients who required mechanical ventilation after major abdominal surgery were randomised into remifentanil group (n=25) or control group (n=25). Sedation during mechanical ventilation was maintained with remifentanil and propofol via a target-controlled infusion system. These drugs were titrated to the target sedation range, bispectral index values of 60 to 75 and Richmond Agitation Sedation Scale values of −3 to −2. When weaning was initiated, propofol was stopped in both groups. In the control group, remifentanil infusion was also stopped; in the remifentanil group, remifentanil infusion was maintained until extubation at a target effect site concentration of 1.0 ng/ml. Extubation was performed if the patient's respiratory, haemodynamic states were stable and if the patient was able to follow commands. Heart rate, mean arterial pressure and cough severity were evaluated. The mean arterial pressure, heart rate and cough severity did not differ between the two groups during extubation. The time from stopping of propofol infusion to extubation was significantly longer in the remifentanil group compared to that in the control group (P=0.020). Maintaining a low-dose remifentanil infusion during ventilator weaning delayed tracheal extubation without any differences in haemodynamic changes or coughing in postoperative intensive care unit patients.
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Affiliation(s)
- S. Y. Kim
- Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - S. Y. Yang
- Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Department of Anaesthesiology and Pain Medicine, Chung-Ang University College of Medicine
| | - S. W. Na
- Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Y. Y. Jo
- Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Department of Anaesthesiology and Pain Medicine, Gachon University of Medicine and Science, Gil Medical Centre, Incheon
| | - S. O. Koh
- Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
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Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: A Paradigm Shift in Intensive Care Unit Sedation Practice. Ann Pharmacother 2012; 46:530-40. [DOI: 10.1345/aph.1q525] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To critically evaluate the use of analgosedation in the management of agitation in critically ill mechanically ventilated patients. Data Sources: Literature was accessed through MEDLINE (1948-November 2011) and Cochrane Library (2011, issue 1) using the terms analgosedation, analgosedation, or analgesia-based sedation alone or in combination with intensive care unit or critically ill. Reference lists of related publications were also reviewed. Study Selection and Data Extraction: All articles published in English were evaluated. Randomized controlled trials examining critically ill mechanically ventilated patients older than 18 years were included. Data Synthesis: Limitations of current sedation practices include serious adverse drug events, prolonged mechanical ventilation time, and intensive care unit (ICU) length of stay. Studies have demonstrated that analgosedation, a strategy that manages patient pain and discomfort first, before providing sedative therapy, results in improved patient outcomes compared to standard sedative-hypnotic regimens. Nine randomized controlled trials comparing remifentanil-based analgosedation to other commonly used agents (fentanyl, midazolam, morphine, and propofol) for ICU sedation and 1 trial comparing morphine to daily sedation interruption with propofol or midazolam were reviewed. Remifentanil is an ideal agent for analgosedation due to its easy titratability and organ-in dependent metabolism. When compared to sedative-hypnotic regimens, remifentanil-based regimens were associated with shorter duration of mechanical ventilation, more rapid weaning from the ventilator, and shorter ICU length of stay. Compared to fentanyl-based regimens, remifentanil had similar efficacy with the exception of increased pain requirements upon remifentanil discontinuation. Analgosedation was well tolerated, with no significant differences in hemodynamic stability compared to sedative-hypnotic regimens. Conclusions: Analgosedation is an efficacious and well-tolerated approach to management of ICU sedation with improved patient outcomes compared to sedative-hypnotic approaches. Additional well-designed trials are warranted to clarify the role of analgosedation in the management of ICU sedation, including trials with nonopioid analgesics.
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Affiliation(s)
- Sandeep Devabhakthuni
- University of Pittsburgh Medical Center, Pittsburgh, PA; now, Assistant Professor of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore
| | - Michael J Armahizer
- University of Pittsburgh Medical Center; how, Critical Care Pharmacy Specialist, Cardiothoracic Intensive Care Unit, University of Pittsburgh Medical Center
| | - Joseph F Dasta
- The Ohio State University, Columbus; Adjunct Professor, The University of Texas, Austin
| | - Sandra L Kane-Gill
- Center for Pharmacoinformatics and Outcomes Research, University of Pittsburgh
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Combes X, Michelet P. [Sedation and analgesia in emergency structure. Which sedation and analgesia for the intubated patient under mechanical ventilation?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:322-326. [PMID: 22440815 DOI: 10.1016/j.annfar.2012.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- X Combes
- Samu de Paris, département d'anesthésie-réanimation, université Paris-Descartes Paris 5, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75730 Paris cedex 15, France.
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Welzing L, Oberthuer A, Junghaenel S, Harnischmacher U, Stützer H, Roth B. Remifentanil/midazolam versus fentanyl/midazolam for analgesia and sedation of mechanically ventilated neonates and young infants: a randomized controlled trial. Intensive Care Med 2012; 38:1017-24. [PMID: 22456770 DOI: 10.1007/s00134-012-2532-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 03/05/2012] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Lars Welzing
- Department of Neonatology and Paediatric Intensive Care, Childrens Hospital, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
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Riker RR, Fraser GL. Altering intensive care sedation paradigms to improve patient outcomes. Anesthesiol Clin 2011; 29:663-74. [PMID: 22078915 DOI: 10.1016/j.anclin.2011.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Providing sedation and comfort for intensive care patients has evolved in the last 30 years but remains difficult for clinicians. As research has focused on this challenging area, the authors have identified ways to improve practice, including providing analgesia before sedation, strategies to help recognize dangerous adverse effects associated with the medications that are used, and better ways to monitor pain and delirium in patients. Dexmedetomidine and propofol have become the preferred sedatives for many ICU situations, and creative ways to administer them, such as linking awakening and breathing trials, are emerging. Finally, screening survivors for cognitive impairments may allow clinicians to refer them for the focused rehabilitation they require.
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Abstract
Protocolized target-based sedation and analgesia is central to effective management of sedation. Important components include identifying goals and specific targets,using valid and reliable tools to measure pain, agitation, and sedation, and titrating a logically selected combination of sedatives and analgesics to defined end-points.A variety of approaches to structured management have been tested in controlled trials with major categories of (1) sedation algorithms and protocols and (2) daily interruption of sedation. Although not all studies that compare new interventions to “usual care” document dramatic improvements, many studies show that by reducing oversedation, using a structured approach, faster recovery from respiratory failure may ensue. The somewhat discrepant results illustrate, however, that various approaches,such as DIS, may not be optimal for all patients. Further research will be necessary to define these patients and examine alternative strategies. Finally, implementation of structured approaches to sedation management is a challenging, time-consuming process for clinicians that must be supported with sufficient resources to be successful.
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Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Box 980050, Richmond, VA 23298-0050, USA.
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Devlin JW, Roberts RJ. Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids. Anesthesiol Clin 2011; 29:567-585. [PMID: 22078910 DOI: 10.1016/j.anclin.2011.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The ideal sedative or analgesic agent should have a rapid onset of activity, a rapid recovery after drug discontinuation, a predictable dose response, a lack of drug accumulation,and no toxicity. Unfortunately, none of the earlier analgesics, the benzodiazepines,or propofol share all of these characteristics. Patients who are critically ill experience numerous physiologic derangements and commonly require high doses and long durations of analgesic and sedative therapy. There is a paucity of well designed clinical trials evaluating the safety and efficacy of earlier sedative and analgesic agents in the ICU. In addition, the ever-changing dynamics of patients who are critically ill makes the use of sedation a continual challenge during the course of each patient’s admission. To optimize care, clinicians should be familiar with the many pharmacokinetic, pharmacodynamic, and pharmacogenetic variables that can affect the safety and efficacy of sedatives and analgesics.
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Affiliation(s)
- John W Devlin
- Northeastern University School of Pharmacy, MU206, 360 Huntington Avenue, Boston, MA 02115, USA.
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Panzer O, Moitra V, Sladen RN. Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral Mu antagonists. Anesthesiol Clin 2011; 29:587-vii. [PMID: 22078911 DOI: 10.1016/j.anclin.2011.09.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In this article, the authors discuss the pharmacology of sedative-analgesic agents like dexmedetomidine, remifentanil, ketamine, and volatile anesthetics. Dexmedetomidine is a highly selective alpha-2 agonist that provides anxiolysis and cooperative sedation without respiratory depression. It has organ protective effects against ischemic and hypoxic injury, including cardioprotection, neuroprotection, and renoprotection. Remifentanil is an ultra-short-acting opioid that acts as a mu-receptor agonist. Ketamine is a nonbarbiturate phencyclidine derivative and provides analgesia and apparent anesthesia with relative hemodynamic stability. Volatile anesthetics such as isoflurane, sevoflurane, and desflurane are in daily use in the operating room in the delivery of general anesthesia. A major advantage of these halogenated ethers is their quick onset, quick offset, and ease of titration in rendering the patient unconscious, immobile, and amnestic.
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Affiliation(s)
- Oliver Panzer
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA
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Patel SB, Kress JP. Sedation and analgesia in the mechanically ventilated patient. Am J Respir Crit Care Med 2011; 185:486-97. [PMID: 22016443 DOI: 10.1164/rccm.201102-0273ci] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Sedation and analgesia are important components of care for the mechanically ventilated patient in the intensive care unit (ICU). An understanding of commonly used medications is essential to formulate a sedation plan for individual patients. The specific physiological changes that a critically ill patient undergoes can have direct effects on the pharmacology of drugs, potentially leading to interpatient differences in response. Objective assessments of pain, sedation, and agitation have been validated for use in the ICU for assessment and titration of medications. An evidence-based strategy for administering these drugs can lead to improvements in short- and long-term outcomes for patients. In this article, we review advances in the field of ICU sedation to provide an up-to-date perspective on management of the mechanically ventilated ICU patient.
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Affiliation(s)
- Shruti B Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Illinois, USA
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Byun SH, Hwang DY, Hong SW, Kim SO. Target-controlled infusion of remifentanil for conscious sedation during spinal anesthesia. Korean J Anesthesiol 2011; 61:195-200. [PMID: 22025939 PMCID: PMC3198178 DOI: 10.4097/kjae.2011.61.3.195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 02/21/2011] [Accepted: 02/25/2011] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to define the optimal target concentration of remifentanil which effectively achieves conscious sedation without significant vital sign changes and side effects during spinal anesthesia. Methods Sixty patients underwent spinal anesthesia with 0.5% hyperbaric bupivacaine (8-16 mg), and were infused with a target controlled infusion (TCI) of remifentanil at 1.0 ng/ml (group R10, n = 15), 2.0 ng/ml (group R20, n = 15), 3.0 ng/ml (group R30, n = 15), and 3.5 ng/ml (group R35, n = 15). Observer's assessment of alertness/sedation (OAA/S) scale, the bispectral index (BIS), anxiety levels and infusion rate of remifentanil were monitored during the operation. Results OAA/S scale was significantly lower in groups R30 (3.96) and R35 (3.34) than groups R10 (4.31) and R20 (4.26). Incidence of intraoperative respiratory depression events, post operative nausea and vomiting were significantly higher in group R35 than the other groups. There were no significant differences in BIS, anxiety level and incidences of recall of the operative procedure among the groups. Conclusions We conclude that the TCI of remifentanil at 3.0 ng/ml produces an effective sedation and anti-anxiety effects without significant side effects during spinal anesthesia.
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Affiliation(s)
- Sung Hye Byun
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Sedation and analgesia in intensive care: a comparison of fentanyl and remifentanil. PAIN RESEARCH AND TREATMENT 2011; 2011:650320. [PMID: 22110929 PMCID: PMC3197257 DOI: 10.1155/2011/650320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 04/18/2011] [Accepted: 05/01/2011] [Indexed: 12/19/2022]
Abstract
Optimal sedation and analgesia are of key importance in intensive care. The aim of this study was to assess the quality of sedoanalgesia and outcome parameters in regimens containing midazolam and either fentanyl or remifentanil. A prospective, randomized, open-label, controlled trial was carried out in the ICU unit of a large teaching hospital in Istanbul over a 9-month period. Thirty-four patients were randomly allocated to receive either a remifentanil-midazolam regimen (R group, n = 17) or a fentanyl-midazolam regimen (F group, n = 17). A strong correlation between Riker Sedation-Agitation Scale (SAS) and Ramsey Scale (RS) measurements was observed. Comparatively, remifentanil provided significantly more potent and rapid analgesia based on Behavioral-Physiological Scale (BPS) measurements and a statistically nonsignificantly shorter time to discharge. On the other hand, remifentanil also caused a significantly sharper fall in heart rate within the first six hours of treatment.
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Sahin SH, Cinar SO, Paksoy I, Sut N, Oba S. Comparison between low flow sevoflurane anesthesia and total intravenous anesthesia during intermediate-duration surgery: effects on renal and hepatic toxicity. Hippokratia 2011; 15:69-74. [PMID: 21607040 PMCID: PMC3093149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Renal and hepatic dysfunction or injury might be involved by ether based anesthetic and intravenous anesthetic drug or surgical stress. The purpose of this study is to compare the effect of moderate duration low-flow sevoflurane versus total intravenous anesthesia on renal and hepatic functions. PATIENTS AND METHODS Eighty (80) patients between the ages of 25-70 scheduled for elective lumbar disc herniotomy, with an expected operation time of 120-240 min, were enrolled in the study. Anesthesia was induced using remifentanil, propofol and atracurium. Patients were randomly divided into two groups. After intubation, Group S (n=40) received sevoflurane and Group T (n=40) received total intravenous anesthesia with propofol in oxygen and air with a fresh gas flow of 5 L min(?1). Ten minutes after induction the fresh gas flow was decreased to 1L min(?1) in both groups. Serum BUN, creatinine, ALT, AST, LDH and 24 hours excretion of glucose, protein, and creatinine in urine were measured preoperatively and the first three postoperative days. RESULTS Serum BUN at 48 hours, creatinine at 24, 48. hours, and urine glucose at 24, and 48 hours were significantly higher from the preoperative values in Group S (p<0.05). However, serum BUN and creatinin, urine glucose were within the normal range. There were no significant differences in the renal and hepatic function tests between the groups. CONCLUSIONS These results show that the renal and hepatic effect of moderate duration low-flow sevoflurane and total intravenous anesthesia is similar.
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A prospective, randomized, double-blind, multicenter study comparing remifentanil with fentanyl in mechanically ventilated patients. Intensive Care Med 2010; 37:469-76. [PMID: 21165734 DOI: 10.1007/s00134-010-2100-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 08/25/2010] [Indexed: 12/11/2022]
Abstract
PURPOSE To compare the quality of analgesia provided by a remifentanil-based analgesia regime with that provided by a fentanyl-based regime in critically ill patients. METHODS This was a registered, prospective, two-center, randomized, triple-blind study involving adult medical and surgical patients requiring mechanical ventilation (MV) for more than 24 h. Patients were randomized to either remifentanil infusion or a fentanyl infusion for a maximum of 30 days. Sedation was provided using propofol (and/or midazolam if required). RESULTS Primary outcome was the proportion of patients in each group maintaining a target analgesia score at all time points. Secondary outcomes included duration of MV, discharge times, and morbidity. At planned interim analysis (n = 60), 50% of remifentanil patients (n = 28) and 63% of fentanyl patients (n = 32) had maintained target analgesia scores at all time points (p = 0.44). There were no significant differences between the groups with respect to mean duration of ventilation (135 vs. 165 h, p = 0.80), duration of hospital stay, morbidity, or weaning. Interim analysis strongly suggested futility and the trial was stopped. CONCLUSIONS The use of remifentanil-based analgesia in critically ill patients was not superior regarding the achievement and maintenance of sufficient analgesia compared with fentanyl-based analgesia.
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