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Lu F, Qin S, Liu C, Chen X, Dai Z, Li C. ICU patients receiving remifentanil do not experience reduced duration of mechanical ventilation: a systematic review of randomized controlled trials and network meta-analyses based on Bayesian theories. Front Med (Lausanne) 2024; 11:1370481. [PMID: 39185471 PMCID: PMC11342801 DOI: 10.3389/fmed.2024.1370481] [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] [Received: 01/28/2024] [Accepted: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
Background The purpose of this network meta-analysis (NMA) was to evaluate the efficacy of intravenous opioid μ-receptor analgesics in shortening the duration of mechanical ventilation (MV) in ICU patients. Methods Randomized controlled trials comparing the efficacy of remifentanil, sufentanil, morphine, and fentanyl on the duration of MV in ICU patients were searched in Embase, Cochrane, Pubmed, and Web of Science electronic databases. The primary outcome was MV duration. The Bayesian random-effects framework was used to evaluate relative efficacy. Results In total 20 studies were included in this NMA involving 3,442 patients. Remifentanil was not associated with a reduction in the duration of MV compared with fentanyl (mean difference (MD) -0.16; 95% credible interval (CrI): -4.75 ~ 5.63) and morphine (MD 3.84; 95% CrI: -0.29 ~ 10.68). The secondary outcomes showed that, compared with remifentanil, sufentanil can prolong the duration of extubation. No regimen significantly shortened the ICU length of stay and improved the ICU mortality, efficacy, safety, and drug-related adverse events. Conclusion Among these analgesics, remifentanil did not appear to be associated with a reduction in MV duration. Clinicians should carefully titrate the analgesia of MV patients to prevent a potentially prolonged duration of MV due to excessive or inadequate analgesic therapy. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, CRD42021232604.
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Affiliation(s)
- Fangjie Lu
- Department of Critical Care Medicine, Changshu Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Changshu, Jiangsu, China
| | - Sirun Qin
- Department of Cardiovascular Medicine, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Chang Liu
- Department of Emergency Center, Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Xunxun Chen
- Center for Tuberculosis Control of Guangdong Province, Guangzhou, China
| | - Zhaoqiu Dai
- Department of Traditional Chinese Medicine, Changshu Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Changshu, Jiangsu, China
| | - Cong Li
- Department of Critical Care Medicine, Southern University of Science and Technology Yantian Hospital, Shenzhen, Guangzhou Province, China
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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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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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Pérez Lucendo A, Piñeiro Otero P, Matía Almudévar P, Alcántara Carmona S, López López E, Ramasco Rueda F. Individualised analgesia, sedation, delirium and comfort management strategies in the ICU: a narrative review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:509-535. [PMID: 37742996 DOI: 10.1016/j.redare.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/20/2023] [Indexed: 09/26/2023]
Abstract
This group is a product of the collaboration agreement signed by SOMIAMA (Sociedad de Medicina Intensiva de Madrid) and SAR MADRID (Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid) under which the organisations agreed to create joint working groups to improve critical patient care. Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness.Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.
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Affiliation(s)
- A Pérez Lucendo
- Servicio de Medicina Intensiva, Hospital Universitario de La Princesa, Madrid, Spain.
| | - P Piñeiro Otero
- Servicio de Anestesiología y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - P Matía Almudévar
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - S Alcántara Carmona
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - E López López
- Servicio de Anestesiología y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - F Ramasco Rueda
- Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
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Ji N, Zhang Y, Li L, Du J, Tan S, Liu F. Comparison of Recovery Effect for Sufentanil vs. Remifentanil Anesthesia in Elderly Patients Undergoing Curative Resection for Hepatocellular Carcinoma. Pain Ther 2023; 12:1017-1025. [PMID: 37243868 PMCID: PMC10289946 DOI: 10.1007/s40122-023-00522-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/02/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION The aim of this work is to evaluate the clinical efficacy and safety of sufentanil vs. remifentanil anesthesia in elderly patients undergoing curative resection for hepatocellular carcinoma (HCC). METHODS Medical records of elderly patients aged ≥ 65 years who received curative resection for HCC between January 2017 and December 2020 were retrospectively reviewed. The patients were divided into either the sufentanil group or the remifentanil group according to the method of analgesia used. Vital signs including mean arterial pressure (MAP), heart rate (HR), and arterial oxygen saturation (SpO2), distribution of T-cell subsets (CD3, CD4, and CD8 lymphocytes), distribution of the stress response index [cortisol (COR), interleukin (IL)-6, C-reactive protein (CRP), and glucose (GLU)] were recorded prior to anesthesia (T0), after induction of anesthesia (T1), at the end of surgery (T2), 24 h after surgery (T3), and 72 h after surgery (T4). Postoperative adverse events were collected. RESULTS Repeated measure analysis of variance (ANOVA) showed that after controlling for baseline patient demographic and treatment characteristics as covariates, both between- and within-group effects were significant (all P < 0.01), and the interaction between time and treatments was also significant (all P < 0.01) in the vital signs (MAP, HR, and SpO2), distribution of T-cell subsets (CD3, CD4, and CD8 lymphocytes), and distribution of the stress response index (COR, IL-6, CRP, and GLU), indicating that sufentanil led to stable hemodynamic and respiratory functions, lower reduction of T-lymphocyte subsets, and stable stress response indices compared to remifentanil. There is no significant difference in adverse reactions between the two groups (P = 0.72). CONCLUSIONS Sufentanil was associated with improved hemodynamic and respiratory function, less stress response, less inhibition of cellular immunity, and similar adverse reactions compared with remifentanil.
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Affiliation(s)
- Nan Ji
- Department of Anesthesiology, General Hospital of Central Theater Command of Chinese People's Liberation Army, 627 Wuluo Road, Wuhan, 430070, Hubei, China
| | - Yan Zhang
- Department of Anesthesiology, General Hospital of Central Theater Command of Chinese People's Liberation Army, 627 Wuluo Road, Wuhan, 430070, Hubei, China
| | - Lin Li
- Department of Anesthesiology, General Hospital of Central Theater Command of Chinese People's Liberation Army, 627 Wuluo Road, Wuhan, 430070, Hubei, China
| | - Jinju Du
- Department of Anesthesiology, General Hospital of Central Theater Command of Chinese People's Liberation Army, 627 Wuluo Road, Wuhan, 430070, Hubei, China
| | - Shigang Tan
- Department of Anesthesiology, General Hospital of Central Theater Command of Chinese People's Liberation Army, 627 Wuluo Road, Wuhan, 430070, Hubei, China
| | - Fang Liu
- Department of Anesthesiology, General Hospital of Central Theater Command of Chinese People's Liberation Army, 627 Wuluo Road, Wuhan, 430070, Hubei, China.
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Wang W, He Q, Wang M, Kang Y, Ji P, Zhu S, Zhang R, Zou K, Sun X. Associations of Fentanyl, Sufentanil, and Remifentanil With Length of Stay and Mortality Among Mechanically Ventilated Patients: A Registry-Based Cohort Study. Front Pharmacol 2022; 13:858531. [PMID: 35308226 PMCID: PMC8931505 DOI: 10.3389/fphar.2022.858531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background: As the first-line treatment for mechanically ventilated patients with critical illness, fentanyl and its analogs (e.g., sufentanil and remifentanil) are commonly used in the intensive care unit (ICU). However, the pharmacokinetics, metabolism, and potency of these agents differed. Their effects on clinical outcomes have not been well-understood.Materials and Methods: Using a well-established registry, we conducted a cohort study. Patients who consistently underwent mechanical ventilation (MV) for more than 24 h were identified. We used a time-varying exposure definition, in which we coded each type of opioids as prescribed or not prescribed on each day from initiation of MV to extubation and ICU discharge. We used Fine-Gray competing risk models to compare the effects of fentanyl, sufentanil, and remifentanil on hazards for extubation, ventilator mortality, ICU discharge, and ICU mortality. All models were adjusted using a combination of fixed-time and time-varying covariates. Missing data were imputed using multiple imputation by chained equations.Results: A total of 8,165 patients were included. There were, respectively, 4,778, 4,008, and 2,233 patients receiving at least 1 day of fentanyl, sufentanil, and remifentanil dose. Compared to fentanyl, sufentanil was associated with shorter duration to extubation (hazard ratio 1.31, 95% CI, 1.20–1.41) and ICU discharge (hazard ratio 1.63, 95% CI, 1.38–1.92), and remifentanil was associated with shorter duration to extubation (hazard ratio 1.60, 95% CI, 1.40–1.84) and ICU discharge (hazard ratio 2.02, 95% CI, 1.43–2.84). No significant differences in time to extubation (Hazard ratio 1.14, 95% CI, 0.92–1.41) and ICU discharge (Hazard ratio 1.31, 95% CI, 0.81–2.14) were found between sufentanil and remifentanil. No differences were observed between any two of the agents regarding ventilator mortality or ICU mortality. The effects were similar in patients with versus without surgery.Conclusion: Sufentanil and remifentanil may be superior to fentanyl in shortening the time to extubation and ICU discharge. The effects on ventilator mortality and ICU mortality appeared similar across these agents, while further research is warranted.
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Affiliation(s)
- Wen Wang
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, China
| | - Qiao He
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, China
| | - Mingqi Wang
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, China
| | - Yan Kang
- Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, China
| | - Peng Ji
- Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, China
| | - Shichao Zhu
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Zhang
- Information Center, West China Hospital, Sichuan University, Chengdu, China
| | - Kang Zou
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, China
| | - Xin Sun
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, China
- *Correspondence: Xin Sun,
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Guo NN, Wang HL, Zhao MY, Li JG, Liu HT, Zhang TX, Zhang XY, Chu YJ, Yu KJ, Wang CS. Management of procedural pain in the intensive care unit. World J Clin Cases 2022; 10:1473-1484. [PMID: 35211585 PMCID: PMC8855268 DOI: 10.12998/wjcc.v10.i5.1473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/22/2021] [Accepted: 01/19/2022] [Indexed: 02/06/2023] Open
Abstract
Pain is a common experience for inpatients, and intensive care unit (ICU) patients undergo more pain than other departmental patients, with an incidence of 50% at rest and up to 80% during common care procedures. At present, the management of persistent pain in ICU patients has attracted considerable attention, and there are many related clinical studies and guidelines. However, the management of transient pain caused by certain ICU procedures has not received sufficient attention. We reviewed the different management strategies for procedural pain in the ICU and reached a conclusion. Pain management is a process of continuous quality improvement that requires multidisciplinary team cooperation, pain-related training of all relevant personnel, effective relief of all kinds of pain, and improvement of patients' quality of life. In clinical work, which involves complex and diverse patients, we should pay attention to the following points for procedural pain: (1) Consider not only the patient's persistent pain but also his or her procedural pain; (2) Conduct multimodal pain management; (3) Provide combined sedation on the basis of pain management; and (4) Perform individualized pain management. Until now, the pain management of procedural pain in the ICU has not attracted extensive attention. Therefore, we expect additional studies to solve the existing problems of procedural pain management in the ICU.
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Affiliation(s)
- Na-Na Guo
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Hong-Liang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Ming-Yan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Jian-Guo Li
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Hai-Tao Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Ting-Xin Zhang
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Xin-Yu Zhang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Yi-Jun Chu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Kai-Jiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Chang-Song Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
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Park YJ, Yo CH, Hsu WT, Tsou EPY, Wang YC, Ling DA, Lee AF, Liu MA, Lee CC. Use of Opioids and Outcomes of Pneumonia: Results From the US Nationwide Inpatient Sample. J Acute Med 2021; 11:113-128. [PMID: 35106277 PMCID: PMC8748203 DOI: 10.6705/j.jacme.202112_11(4).0001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/25/2020] [Accepted: 12/23/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Opioids have been shown to increase risk of pneumonia among susceptible population. However, the effect of opioid abuse on the outcome of pneumonia has not been evaluated at the population level. We aimed to compare the outcomes of pneumonia among patients with opioid use disorder and patients without substance use disorder using a large population database. METHODS We assembled a pneumonia cohort composed of 11,186,564 adult patients from the National Inpatient Sample (NIS; 2005-2014). Patients with opioid disorder were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. We compared health-related and economic outcomes between patients with and without opioid disorders using propensity score matching (PSM) analysis to balance baseline differences. The survival differences between two groups of patients were assessed using a Cox proportional hazard model. We further explored the possibility of effect modification by interaction analyses in different populations. RESULTS After PSM, patients with opioid use disorder were at increased risk of ventilator use (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.08 to 1.38, p = 0.0014) and associated with increased length of hospital stay by 0.59 days (95% CI: 0.35 to 0.83, p < 0.001), compared with those without substance use disorder. Patients with opioid use also had higher daily (228.00 USD, 95% CI: 180.51 to 275.49, p < 0.001) and total (1,875.72 USD, 95% CI: 1,259.63 to 2,491.80, p < 0.001) medical costs. Subgroup analyses showed similar results. CONCLUSIONS Compared with patients without any drug dependence, patients with opioid use disorders had increased risk of complications and resource utilization. This study adds evidence for increased risk for pneumonia complications in the growing patients with opioid use disorders.
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Affiliation(s)
- Yeongjun James Park
- Harvard TH Chan School of Public Health Department of Biostatistics Boston, MA USA
- Far Eastern Memorial Hospital Department of Emergency Medicine New Taipei City Taiwan
- Harvard TH Chan School of Public Health Department of Epidemiology Boston, MA USA
- Johns Hopkins Bloomberg School of Public Health Department of Epidemiology Baltimore USA
- Driscoll Children's Hospital Department of Pediatrics Corpus Christi, TX USA
- Albert Einstein College of Medicine/Jacobi Medical Center Department of Medicine NY USA
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
- Warren Alpert Medical School of Brown University Department of Medicine Providence, RI USA
| | - Chia-Hung Yo
- Far Eastern Memorial Hospital Department of Emergency Medicine New Taipei City Taiwan
| | - Wan-Ting Hsu
- Harvard TH Chan School of Public Health Department of Epidemiology Boston, MA USA
| | - Eric Po-Yang Tsou
- Johns Hopkins Bloomberg School of Public Health Department of Epidemiology Baltimore USA
- Driscoll Children's Hospital Department of Pediatrics Corpus Christi, TX USA
| | - Yu-Chiang Wang
- Albert Einstein College of Medicine/Jacobi Medical Center Department of Medicine NY USA
| | - Dean-An Ling
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - An-Fu Lee
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - Michael A Liu
- Warren Alpert Medical School of Brown University Department of Medicine Providence, RI USA
| | - Chien-Chang Lee
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
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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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Xu Y, Wu J, Zhao J, Zhang H. Hemodynamics and anesthetic effect of propofol combined with remifentanil in patients undergoing laparoscopic ovarian cystectomy under laryngeal mask airway anesthesia. Am J Transl Res 2021; 13:5404-5411. [PMID: 34150137 PMCID: PMC8205666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/10/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To study the effect of propofol combined with remifentanil on hemodynamics and anesthetic effect in patients undergoing laparoscopic ovarian cystectomy under laryngeal mask airway (LMA) anesthesia. METHODS From December 2018 to December 2019, gynecological patients who underwent laparoscopic ovarian cystectomy in our hospital were chosen and randomly separated into control group (group A) and combination group (group B). In the group B, patients were anesthetized with remifentanil combined with propofol. In the group A, patients were anesthetized with fentanyl combined with propofol. The anesthetic effect, hemodynamic changes, alertness-sedation score (OAAS), verbal depiction score (VRA), postoperative VAS score and adverse reactions were observed and compared in both groups. RESULTS The anesthesia induction time, recovery time of postoperative spontaneous respiration, time of opening eyes and time of removing laryngeal mask in the group B were shorter than those in the group A, and the difference was statistically significant (P<0.05). The OAAS scores at the time of recovery and 5 min after laryngeal mask removal in the group B were obviously lower than those in the group A. The mean arterial pressure and heart rate before and after 40 min pneumoperitoneum were more stable than those in the group A. The degree of postoperative pain in the group B was also significantly weaker than that in the group A. The incidence of postoperative adverse reactions was also lower than that of the group A, and the difference was statistically significant (P<0.05). CONCLUSION Propofol combined with remifentanil and LMA anesthesia has better anesthetic effect, more stable condition and higher safety for patients undergoing laparoscopic ovarian cystectomy.
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Affiliation(s)
- Yanshu Xu
- Department of Anesthesiology, Fengcheng HospitalFengxian District, Shanghai 201411, China
| | - Jiang Wu
- Department of Anesthesiology, Ninety-ninth Hospital of The Joint Support UnitZhangzhou 363000, Fujian Province, China
| | - Jili Zhao
- Department of Anesthesiology, Zhangqiu District Maternal and Child Health HospitalJinan 250200, Shandong Province, China
| | - Haiping Zhang
- Department of Anesthesiology, Sichuan Provincial Maternity and Child Health Care Health HospitalChengdu 610045, Sichuan Province, China
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11
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Aoki Y, Niwa T, Shiko Y, Kawasaki Y, Mimuro S, Doi M, Nakajima Y. Remifentanil provides an increased proportion of time under light sedation than fentanyl when combined with dexmedetomidine for mechanical ventilation. J Int Med Res 2021; 49:3000605211002683. [PMID: 33745360 PMCID: PMC7989131 DOI: 10.1177/03000605211002683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the effects of remifentanil versus fentanyl during light sedation with dexmedetomidine in adults receiving mechanical ventilation (MV) in the intensive care unit. Methods In this retrospective cohort study, we compared the use of remifentanil versus fentanyl in adults receiving MV with dexmedetomidine sedation. The primary outcome was the proportion of time under light sedation (Richmond Agitation–Sedation Scale score between −1 and 0) during MV. Results We included 94 patients and classified 58 into the remifentanil group and 36 into the fentanyl group. The mean proportion of time under light sedation during MV was 66.6% ± 18.5% in the remifentanil group and 39.9% ± 27.3% in the fentanyl group. In the multivariate analysis with control for confounding factors, patients in the remifentanil group showed a significantly higher proportion of time under light sedation than patients in the fentanyl group (mean difference: 24.3 percentage points; 95% confidence interval: 12.9–35.8). Conclusions Remifentanil use might increase the proportion of time under light sedation in patients receiving MV compared with fentanyl administration.
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Affiliation(s)
- Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Takuya Niwa
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Centre, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Soichiro Mimuro
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
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12
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Early prediction of extubation failure in patients with severe pneumonia: a retrospective cohort study. Biosci Rep 2021; 40:221958. [PMID: 31990295 PMCID: PMC7007404 DOI: 10.1042/bsr20192435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/03/2020] [Accepted: 01/28/2020] [Indexed: 02/05/2023] Open
Abstract
Backgroud: Severe pneumonia is one of the most common causes for mechanical ventilation. We aimed to early identify severe pneumonia patients with high risk of extubation failure in order to improve prognosis. Methods: From April 2014 to December 2015, medical records of intubated patients with severe pneumonia in intensive care unit were retrieved from database. Patients were divided into extubation success and failure groups, and multivariate logistic regressions were performed to identify independent predictors for extubation failure. Results: A total of 125 eligible patients were included, of which 82 and 43 patients had extubation success and failure, respectively. APACHE II score (odds ratio (OR) 1.141, 95% confident interval (CI) 1.022–1.273, P = 0.019, cutoff at 17.5), blood glucose (OR 1.122, 95%CI 1.008–1.249, P = 0.035, cutoff at 9.87 mmol/l), dose of fentanyl (OR 3.010, 95%CI 1.100–8.237, P = 0.032, cutoff at 1.135 mg/d), and the need for red blood cell (RBC) transfusion (OR 2.774, 95%CI 1.062–7.252, P = 0.037) were independent risk factors for extubation failure. Conclusion: In patients with severe pneumonia, APACHE II score > 17.5, blood glucose > 9.87 mmol/l, fentanyl usage > 1.135 mg/d, and the need for RBC transfusion might be associated with higher risk of extubation failure.
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Abstract
PURPOSES OF REVIEW Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS). RECENT FINDINGS The Society of Critical Care Medicine recently published their updated clinical practice guidelines for analgesia, agitation, sedation, delirium, immobility, and sleep in adult patients in the ICU. Deep sedation, especially early in the course of mechanical ventilation, is associated with prolonged time to liberation from mechanical ventilation, longer ICU stays, longer hospital stays, and increased mortality. Dexmedetomidine may prevent ICU delirium when administered nocturnally at low doses; however, it was not shown to improve mortality when used as the primary sedative early in the course of mechanical ventilation, though the majority of patients in the informing study failed to achieve the prescribed light level of sedation. In a follow up to the ACURASYS trial, deep sedation with neuromuscular blockade did not result in improved mortality compared to light sedation in patients with severe ARDS. SUMMARY Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS.
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Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, Yu Z, Zhang W, Zhong Q, Zheng X, Sang L, Jiang L, Zhang J, Xiong W, Liu J, Chen D. Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China. Ann Intensive Care 2020; 10:73. [PMID: 32506258 PMCID: PMC7275657 DOI: 10.1186/s13613-020-00689-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The ongoing coronavirus disease 2019 (COVID-2019) pandemic has swept all over the world, posing a great pressure on critical care resources due to large number of patients needing critical care. Statements from front-line experts in the field of intensive care are urgently needed. METHODS Sixteen front-line experts in China fighting against the COVID-19 epidemic in Wuhan were organized to develop an expert statement after 5 rounds of expert seminars and discussions to provide trustworthy recommendation on the management of critically ill COVID-19 patients. Each expert was assigned tasks within their field of expertise to provide draft statements and rationale. Parts of the expert statement are based on epidemiological and clinical evidence, without available scientific evidences. RESULTS A comprehensive document with 46 statements are presented, including protection of medical personnel, etiological treatment, diagnosis and treatment of tissue and organ functional impairment, psychological interventions, immunity therapy, nutritional support, and transportation of critically ill COVID-19 patients. Among them, 5 recommendations were strong (Grade 1), 21 were weak (Grade 2), and 20 were experts' opinions. A strong agreement from voting participants was obtained for all recommendations. CONCLUSION There are still no targeted therapies for COVID-19 patients. Dynamic monitoring and supportive treatment for the restoration of tissue vascularization and organ function are particularly important.
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Affiliation(s)
- You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Pan
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xianghong Yang
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China
| | - Xiuling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fuzhou, China
| | - Zhixiong Wu
- Department of Critical Care Medicine, Huadong Hospital, Shanghai, China
| | - Zhui Yu
- Department of Critical Care Medicine, Renmin Hospital, Wuhan University, Wuhan, China
| | - Wei Zhang
- Emergency Department, the 900th Hospital of Joint Service Corps of Chinese PLA, Fuzhou, China
| | - Qiang Zhong
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Zheng
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Ling Sang
- Department of Critical Care Medicine, The 1st Affiliated Hospital of GuangZhou Medical University, GuangZhou Institute of Respiratory Health, Guangzhou, China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiancheng Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Xiong
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiao Liu
- Department of Critical Care Medicine, Shanghai Jiaotong University, School of Medicine, Ruijin Hospital North, No. 197 Ruijin 2nd Road, Huangpu District, Shanghai, 201801, China
| | - Dechang Chen
- Department of Critical Care Medicine, Shanghai Jiaotong University, School of Medicine, Ruijin Hospital North, No. 197 Ruijin 2nd Road, Huangpu District, Shanghai, 201801, China.
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Wong IMJ, Thangavelautham S, Loh SCH, Ng SY, Murfin B, Shehabi Y. Sedation and Delirium in the Intensive Care Unit—A Practice-Based Approach. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020. [DOI: 10.47102/annals-acadmed.sg.202013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: Critically ill patients often require sedation for comfort and to
facilitate therapeutic interventions. Sedation practice guidelines provide an evidencebased framework with recommendations that can help improve key sedation-related
outcomes. Materials and Methods: We conducted a narrative review of current
guidelines and recent trials on sedation. Results: From a practice perspective, current
guidelines share many limitations including lack of consensus on the definition
of light sedation, optimal frequency of sedation assessment, optimal timing for
light sedation and consideration of combinations of sedatives. We proposed several
strategies to address these limitations and improve outcomes: 1) early light sedation
within the first 48 hours with time-weighted monitoring (overall time spent in
light sedation in the first 48 hours—sedation intensity—has a dose-dependent
relationship with mortality risk, delirium and time to extubation); 2) provision of
analgesia with minimal or no sedation where possible; 3) a goal-directed and balanced
multimodal approach that combines the benefits of different agents and minimise
their side effects; 4) use of dexmedetomidine and atypical antipsychotics as a
sedative-sparing strategy to reduce weaning-related agitation, shorten ventilation
time and accelerate physical and cognitive rehabilitation; and 5) a bundled approach
to sedation that provides a framework to improve relevant clinical outcomes.
Conclusion: More effort is required to develop a practical, time-weighted sedation
scoring system. Emphasis on a balanced, multimodal appraoch that targets light
sedation from the early phase of acute critical illness is important to achieve optimal
sedation, lower mortality, shorten time on ventilator and reduce delirium.
Ann Acad Med Singapore;49:215–25
Key words: Analgesia, Benzodiazepine, Critical Care, Dexmedetomidine, Propofol
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Affiliation(s)
- Irene MJ Wong
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | | | | | - Shin Yi Ng
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Brendan Murfin
- Faculty of Medicine Nursing and Health Sciences, Monash University, Australia
| | - Yahya Shehabi
- Faculty of Medicine Nursing and Health Sciences, Monash University, Australia
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Sedatives in neurocritical care: an update on pharmacological agents and modes of sedation. Curr Opin Crit Care 2020; 25:97-104. [PMID: 30672819 DOI: 10.1097/mcc.0000000000000592] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW In this article, the specific and general indications for sedatives in the neurocritical care unit are discussed, together with an overview on current insights in sedative protocols for these patients. In addition, physiological effects of sedative agents on the central nervous system are reviewed. RECENT FINDINGS In the general ICU population, a large body of evidence supports light protocolized sedation over indiscriminate deep sedation. Unfortunately, in patients with severe acute brain injury, the evidence from randomized controlled trials is scarce to nonexistent, and practice is supported by expert opinion, physiological studies and observational or small interventional trials. The different sedatives each have different beneficial effects and side-effects. SUMMARY Extrapolating the findings from studies in the general ICU population suggests to reserve deep continuous sedation in the neuro-ICU for specific indications. Although an improved understanding of cerebral physiological changes in patients with brain injury may be helpful to guide individualized sedation, we still lack the evidence base to make broad recommendations for specific patient groups.
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Risk factors of frailty and death or only frailty after intensive care in non-frail elderly patients: a prospective non-interventional study. J Intensive Care 2019; 7:48. [PMID: 31687161 PMCID: PMC6820956 DOI: 10.1186/s40560-019-0403-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 09/13/2019] [Indexed: 01/12/2023] Open
Abstract
Background Frailty status is recognized as an important parameter in critically ill elderly patients, but nothing is known about outcomes in non-frail patients regarding the development of frailty or frailty and death after intensive care. The aim of this study was to determine risk factors for frailty and death or only frailty 6 months after intensive care unit (ICU) admission in non-frail patients ≥ 65 years. Methods A prospective non-interventional study performed in an academic ICU from February 2015 to February 2016 included non-frail ≥ 65-year-old patients hospitalized for > 24 h in the ICU. Frailty was assessed by calculating the frailty index (FI) at admission and 6 months later. Patients who remained non-frail (FI < 0.2) were compared to patients who presented frailty (FI ≥ 0.2) and those who presented frailty and death at 6 months. Results Among 974 admissions, 136 patients were eligible for the study and 88 patients were analysed at 6 months (non-frail n = 34, frail n = 29, death n = 25). Multivariable analysis showed that mechanical ventilation duration was an independent risk factor for frailty/death at 6 months (per day of mechanical ventilation, odds ratio [OR] = 1.11; 95% confidence interval [CI] 1.04–1.19, p = 0.002). When excluding patients who died, mechanical ventilation duration remained the sole risk factor for frailty at 6 months (OR = 1.19; 95% CI 1.07–1.33, p = 0.001). Conclusion Mechanical ventilation duration was the sole predictive factor of frailty and death or only frailty 6 months after ICU hospitalization in initially non-frail patients.
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19
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de Haro C, Magrans R, López-Aguilar J, Montanyà J, Lena E, Subirà C, Fernandez-Gonzalo S, Gomà G, Fernández R, Albaiceta GM, Skrobik Y, Lucangelo U, Murias G, Ochagavia A, Kacmarek RM, Rue M, Blanch L. Effects of sedatives and opioids on trigger and cycling asynchronies throughout mechanical ventilation: an observational study in a large dataset from critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:245. [PMID: 31277722 PMCID: PMC6612107 DOI: 10.1186/s13054-019-2531-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/26/2019] [Indexed: 12/23/2022]
Abstract
Background In critically ill patients, poor patient-ventilator interaction may worsen outcomes. Although sedatives are often administered to improve comfort and facilitate ventilation, they can be deleterious. Whether opioids improve asynchronies with fewer negative effects is unknown. We hypothesized that opioids alone would improve asynchronies and result in more wakeful patients than sedatives alone or sedatives-plus-opioids. Methods This prospective multicenter observational trial enrolled critically ill adults mechanically ventilated (MV) > 24 h. We compared asynchronies and sedation depth in patients receiving sedatives, opioids, or both. We recorded sedation level and doses of sedatives and opioids. BetterCare™ software continuously registered ineffective inspiratory efforts during expiration (IEE), double cycling (DC), and asynchrony index (AI) as well as MV modes. All variables were averaged per day. We used linear mixed-effects models to analyze the relationships between asynchronies, sedation level, and sedative and opioid doses. Results In 79 patients, 14,166,469 breaths were recorded during 579 days of MV. Overall asynchronies were not significantly different in days classified as sedatives-only, opioids-only, and sedatives-plus-opioids and were more prevalent in days classified as no-drugs than in those classified as sedatives-plus-opioids, irrespective of the ventilatory mode. Sedative doses were associated with sedation level and with reduced DC (p < 0.0001) in sedatives-only days. However, on days classified as sedatives-plus-opioids, higher sedative doses and deeper sedation had more IEE (p < 0.0001) and higher AI (p = 0.0004). Opioid dosing was inversely associated with overall asynchronies (p < 0.001) without worsening sedation levels into morbid ranges. Conclusions Sedatives, whether alone or combined with opioids, do not result in better patient-ventilator interaction than opioids alone, in any ventilatory mode. Higher opioid dose (alone or with sedatives) was associated with lower AI without depressing consciousness. Higher sedative doses administered alone were associated only with less DC. Trial registration ClinicalTrial.gov, NCT03451461 Electronic supplementary material The online version of this article (10.1186/s13054-019-2531-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain. .,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. .,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
| | - Rudys Magrans
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Enrico Lena
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Carles Subirà
- ICU, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Sol Fernandez-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Gomà
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Rafael Fernández
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,ICU, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Guillermo M Albaiceta
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain.,Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montréal, Québec, Canada.,Regroupement des Soins Critiques Respiratoires, Réseau de Santé Respiratoire, Fonds de Recherche du Québec en Santé, Montréal, Québec, Canada
| | - Umberto Lucangelo
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Gastón Murias
- Critical Care Department, Hospital Británico, Buenos Aires, Argentina
| | - Ana Ochagavia
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Department of Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Montserrat Rue
- Department of Basic Medical Sciences, Universitat de Lleida-IRB Lleida, Lleida, Spain.,Health Services Research Network in Chronic Diseases (REDISSEC), Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Santonocito C, Noto A, Crimi C, Sanfilippo F. Remifentanil-induced postoperative hyperalgesia: current perspectives on mechanisms and therapeutic strategies. Local Reg Anesth 2018; 11:15-23. [PMID: 29670398 PMCID: PMC5898588 DOI: 10.2147/lra.s143618] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The use of remifentanil in clinical practice offers several advantages and it is used for a wide range of procedures, ranging from day-surgery anesthesia to more complex procedures. Nonetheless, remifentanil has been consistently linked with development of opioid-induced hyperalgesia (OIH), which is described as a paradoxical increase in sensitivity to painful stimuli that develops after exposure to opioid treatment. The development of OIH may cause several issues, delaying recovery after surgery and preventing timely patient's discharge. Moreover, it causes patient's discomfort with higher pain scores, greater use of analgesics, and associated side effects. Remifentanil is the opioid most convincingly associated with OIH, and hereby we provide a review of remifentanil-induced hyperalgesia, describing both the underlying mechanisms involved and the available studies investigating experimental and clinical pharmacologic approaches aiming at reducing its incidence and degree.
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Affiliation(s)
- Cristina Santonocito
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Alberto Noto
- Department of Anesthesia and Intensive Care, Messina University, Messina, Italy
| | - Claudia Crimi
- Department of Respiratory Medicine, AOU "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
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Najafian B, Esmaeili B, Khosravi MH. Comparison of Fentanyl and Midazolam for the Sedation of Infants Under Mechanical Ventilation; A Randomized Clinical Trial. HOSPITAL PRACTICES AND RESEARCH 2017. [DOI: 10.15171/hpr.2017.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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