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Hao GW, Wu JQ, Yu SJ, Liu K, Xue Y, Gong Q, Xie RC, Ma GG, Su Y, Hou JY, Zhang YJ, Liu WJ, Li W, Tu GW, Luo Z. Remifentanil vs. dexmedetomidine for cardiac surgery patients with noninvasive ventilation intolerance: a multicenter randomized controlled trial. J Intensive Care 2024; 12:35. [PMID: 39294818 PMCID: PMC11409483 DOI: 10.1186/s40560-024-00750-2] [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: 05/15/2024] [Accepted: 09/07/2024] [Indexed: 09/21/2024] Open
Abstract
BACKGROUND The optimal sedative regime for noninvasive ventilation (NIV) intolerance remains uncertain. The present study aimed to assess the efficacy and safety of remifentanil (REM) compared to dexmedetomidine (DEX) in cardiac surgery patients with moderate-to-severe intolerance to NIV. METHODS In this multicenter, prospective, single-blind, randomized controlled study, adult cardiac surgery patients with moderate-to-severe intolerance to NIV were enrolled and randomly assigned to be treated with either REM or DEX for sedation. The status of NIV intolerance was evaluated using a four-point NIV intolerance score at different timepoints within a 72-h period. The primary outcome was the mitigation rate of NIV intolerance following sedation. RESULTS A total of 179 patients were enrolled, with 89 assigned to the REM group and 90 to the DEX group. Baseline characteristics were comparable between the two groups, including NIV intolerance score [3, interquartile range (IQR) 3-3 vs. 3, IQR 3-4, p = 0.180]. The chi-squared test showed that mitigation rate, defined as the proportion of patients who were relieved from their initial intolerance status, was not significant at most timepoints, except for the 15-min timepoint (42% vs. 20%, p = 0.002). However, after considering the time factor, generalized estimating equations showed that the difference was statistically significant, and REM outperformed DEX (odds ratio = 3.31, 95% confidence interval: 1.35-8.12, p = 0.009). Adverse effects, which were not reported in the REM group, were encountered by nine patients in the DEX group, with three instances of bradycardia and six cases of severe hypotension. Secondary outcomes, including NIV failure (5.6% vs. 7.8%, p = 0.564), tracheostomy (1.12% vs. 0%, p = 0.313), ICU LOS (7.7 days, IQR 5.8-12 days vs. 7.0 days, IQR 5-10.6 days, p = 0.219), and in-hospital mortality (1.12% vs. 2.22%, p = 0.567), demonstrated comparability between the two groups. CONCLUSIONS In summary, our study demonstrated no significant difference between REM and DEX in the percentage of patients who achieved mitigation among cardiac surgery patients with moderate-to-severe NIV intolerance. However, after considering the time factor, REM was significantly superior to DEX. Trial registration ClinicalTrials.gov (NCT04734418), registered on January 22, 2021. URL of the trial registry record: https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AM4S&selectaction=Edit&uid=U00038YX&ts=3&cx=eqn1z0 .
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Affiliation(s)
- Guang-Wei Hao
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jia-Qing Wu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yan Xue
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Qian Gong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, Anhui, China
| | - Rong-Cheng Xie
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, 361015, Fujian, China
| | - Guo-Guang Ma
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Ying Su
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jun-Yi Hou
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yi-Jie Zhang
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Jun Liu
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wei Li
- Department of Intensive Care Unit, The People's Hospital of Fujian Traditional Medical University, Fuzhou, 350004, Fujian, China.
| | - Guo-Wei Tu
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
| | - Zhe Luo
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
- Department of Critical Care Medicine, Shanghai Xuhui Central Hospital, Zhongshan Xuhui Hospital, Fudan University, Shanghai, 200020, China.
- Shanghai Key Lab of Pulmonary Inflammation and Injury, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
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Mocellin A, Guidotti F, Rizzato S, Tacconi M, Bruzzi G, Messina J, Puggioni D, Patsoura A, Fantini R, Tabbì L, Castaniere I, Marchioni A, Clini E, Tonelli R. Monitoring and modulation of respiratory drive in patients with acute hypoxemic respiratory failure in spontaneous breathing. Intern Emerg Med 2024:10.1007/s11739-024-03715-3. [PMID: 39207721 DOI: 10.1007/s11739-024-03715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/10/2024] [Indexed: 09/04/2024]
Abstract
Non-invasive respiratory support, namely, non-invasive ventilation, continuous positive airway pressure, and high-flow nasal cannula, has been increasingly used worldwide to treat acute hypoxemic respiratory failure, giving the benefits of keeping spontaneous breathing preserved. In this scenario, monitoring and controlling respiratory drive could be helpful to avoid patient self-inflicted lung injury and promptly identify those patients that require an upgrade to invasive mechanical ventilation. In this review, we first describe the physiological components affecting respiratory drive to outline the risks associated with its hyperactivation. Further, we analyze and compare the leading strategies implemented for respiratory drive monitoring and discuss the sedative drugs and the non-pharmacological approaches used to modulate respiratory drive during non-invasive respiratory support. Refining the available techniques and rethinking our therapeutic and monitoring targets can help critical care physicians develop a personalized and minimally invasive approach.
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Affiliation(s)
- Anna Mocellin
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Federico Guidotti
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Simone Rizzato
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Matteo Tacconi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Giulia Bruzzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Jacopo Messina
- Internal Medicine Unit, University of Rome, Roma 1, Rome, Italy
| | - Daniele Puggioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Athina Patsoura
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Alessandro Marchioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy.
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
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Haak F, Nocera F, Merlo L, Dursunoglu B, Däster S, Angehrn FV, Steinemann DC. Omission of perioperative morphine reduces postoperative pain in proctological interventions: a single-center analysis. Updates Surg 2024; 76:155-161. [PMID: 37668891 PMCID: PMC10806230 DOI: 10.1007/s13304-023-01640-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023]
Abstract
There is an increase in outpatient procedures and this trend will continue in the future. For hemorrhoidectomy, it is the standard of treatment in many health care systems. Perioperative management including adequate pain control is of paramount importance to ensure successful ambulatory surgery. This study investigates the role and effect of morphine compared to short-acting opiates applied before, during, or after proctological interventions and with focus on hemorrhoidectomy. A retrospective analysis of a prospective database was conducted comparing two populations. The control cohort received morphine (Yes-Mô) intra- and postoperatively, while the intervention group did not receive morphine (No-Mô) between January 2018 and January 2020. Both cohorts were balanced by propensity score matching. The outcomes were postoperative pain measured by numeric ratings scale (NRS) one hour postoperatively, pain 24 h postoperatively, success rate of outpatient management, and complication rate including postoperative nausea and vomiting as well as urinary retention. The intervention population comprised 54 patients and the control group contained 79 patients. One hour after surgery, patients in No-Mô reported lower NRS (1.44 ± 1.41) compared to Yes-Mô (2.48 ± 2.30) (p = 0.029). However, there was no difference in NRS 24 h postoperatively (No-Mô: 1.61 ± 1.41 vs Yes-Mô: 1.63 ± 1.72; p = 0.738). 100% of No-Mô was managed as outpatients while only 50% of Yes-Mô was dismissed on the day of the operation (p = < 0.001). There was no difference in postoperative complications (including postoperative nausea and vomiting (PONV) and urinary retention) between the two groups (PONV No-Mô 7.4% vs Yes-Mô 5.6%, p = 1.0 and urinary retention No-Mô 3.7% vs Yes-Mô 7.4%, p = 0.679). No-Mô received an oral morphine equivalent of 227.25 ± 140.35 mg intraoperatively and 11.02 ± 18.02 mg postoperatively. Yes-Mô received 263.17 ± 153.60 mg intraoperatively and 15.97 ± 14.17 mg postoperatively. The difference in received morphine equivalent between the groups was not significant after matching for the intraoperative (p = 0.212) and postoperative (p = 0.119) received equivalent. Omission of perioperative morphine is a viable but yet not understood method for reducing postoperative pain. Omission of morphine leads to a lower use of total morphine equivalent to attain satisfactory analgesia. The reduction of the overall opiate load and using opiates with a very short half-life potentially leads to a reduction of side effects like sedation. This in turn promotes discharge of the patient on the day of surgery. Omission of morphine is safe and does not increase postoperative complications.
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Affiliation(s)
- Fabian Haak
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland
| | - Fabio Nocera
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland
| | - Lorena Merlo
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland
| | - Belma Dursunoglu
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland
| | - Silvio Däster
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland
| | - Fiorenzo V Angehrn
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland.
- Medical Faculty, University of Basel, Basel, Switzerland.
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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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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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Amend N, Thiermann H, Worek F, Wille T. A pharmacologically pre-contracted smooth muscle bowel model for the study of highly-potent opioid receptor agonists and antagonists. Toxicol Lett 2023:S0378-4274(23)00187-X. [PMID: 37245850 DOI: 10.1016/j.toxlet.2023.05.010] [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: 07/18/2022] [Revised: 02/24/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Abstract
Isolated organ models are a versatile tool for pharmacological and toxicological research. Small bowel has been used to assess the inhibition of smooth muscle contraction by opioids. In the present study, we set out to establish a pharmacologically stimulated rat bowel model. The effects of carfentanil, remifentanil and the new synthetic opioid U-48800 and their respective antagonists naloxone, nalmefene and naltrexone were studied in a small bowel model in rats. The IC50 values of the tested opioids were as follows: carfentanil (IC50 = 0.02 µmol/L, CI 0.02-0.03 µmol/L) ≫ remifentanil (IC50 = 0.51 µmol/L, CI 0.40-0.66 µmol/L) ≫ U-48800 (IC50 = 1.36 µmol/L, CI 1.20-1.54 µmol/L). The administration of the opioid receptor antagonists naloxone, naltrexone and nalmefene led to progressive, parallel rightward shifts of the dose-response curves. Naltrexone was most potent in antagonizing the effects of U-48800, whereas naltrexone and nalmefene were most effective in antagonizing the effects of carfentanil. In summary, the current model seems to be a robust tool to study opioid effects in a small bowel model without the necessity of using electrical stimulation.
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Affiliation(s)
- Niko Amend
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany.
| | - Horst Thiermann
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany
| | - Timo Wille
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany
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Fan X, Cai H, Pan B, Xie Y. Comparison of dexmedetomidine and remifentanil on reducing coughing during emergence from anesthesia with tracheal intubation: A meta-analysis. Front Pharmacol 2022; 13:993239. [PMID: 36249748 PMCID: PMC9561905 DOI: 10.3389/fphar.2022.993239] [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: 07/20/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Dexmedetomidine and remifentanil are well known to suppress airway reflex during emergence from anesthesia, but which one is more effective is unclear. We conducted a meta-analysis to compare the effect of dexmedetomidine and remifentanil on reducing the occurrence of coughing.Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (published between 1 January 1950, and 30 December 2021; no language restrictions) comparing dexmedetomidine infusion with remifentanil infusion. The primary endpoint was the incidence of moderate to severe coughing during the recovery period. The secondary endpoints were the time of recovery and extubation, and residual sedation. We assessed pooled data by using a random-effects model.Results: Eight studies with 502 participants were included. The meta-analysis showed no statistically difference between dexmedetomidine and remifentanil in the occurrence of moderate to severe coughing during emergence from anesthesia (OR 1.45,95%CI 0.62–3.38), the extubation time (MD 0.93 min, 95%CI -0.28–2.14), and the residual sedation (OR 2.52, 95%CI 0.92–6.91). Compared with dexmedetomidine, the average recovery time of remifentanil was shorter (MD 3.88 min, 95%CI 1.01–6.75).Conclusion: Dexmedetomidine and remifentanil infusion had no difference in the occurrence of moderate to severe coughing during emergence from anesthesia.Clinical Trial Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021239710
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Affiliation(s)
- Xing Fan
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Department of Anesthesiology, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Hai Cai
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Bingbing Pan
- Department of Anesthesiology, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Yubo Xie,
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Han Y, Dai Y, Shi Y, Zhang X, Xia B, Ji Q, Yu X, Bian J, Xu T. Ultrasound-guided paravertebral blockade reduced perioperative opioids requirement in pancreatic resection: A randomized controlled trial. Front Surg 2022; 9:903441. [PMID: 36111230 PMCID: PMC9468231 DOI: 10.3389/fsurg.2022.903441] [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: 03/24/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPerioperative opioid use for pain control has been found to be associated with side effects and adverse prognosis. In this study, we hypothesized that paravertebral block could reduce the consumption of opioids during pancreatic resection surgery.MethodsWe conducted a prospective, randomized trial. Patients with resectable pancreatic cancer were randomly assigned to one of the two groups: those who received bilateral paravertebral block combined with general anesthesia [bilateral paravertebral blockade (PTB) group] or those who received only general anesthesia (Control group). The primary endpoint was the perioperative consumption of opioids (sufentanil and remifentanil). The main secondary endpoints were pain scores, complications, and serum cytokine levels.ResultsA total of 153 patients were enrolled in the study and 119 cases were analyzed. Compared to the control group, patients in PTB patients had significantly lower perioperative (30.81 vs. 56.17 µg), and intraoperative (9.58 vs. 33.67 µg) doses of sufentanil (both p < 0.001). Numerical rating scale scores of pain were comparable between the two groups. No statistical differences in complications were detected.ConclusionBilateral paravertebral block combined with general anesthesia reduced the perioperative consumption of opioids by 45%.Registration numberChiCTR1800020291 (available on http://www.chictr.org.cn/).
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Affiliation(s)
| | | | | | | | | | | | - Xiya Yu
- Correspondence: Tao Xu Jinjun Bian Xiya Yu
| | | | - Tao Xu
- Correspondence: Tao Xu Jinjun Bian Xiya Yu
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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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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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Yu X, Zhou Y, Zheng X, Shao S, He H. Clinical efficacy of intravenous anesthesia on breast segmental surgery and its effects on oxidative stress response and hemodynamics of patients. Exp Ther Med 2021; 21:11. [PMID: 33235620 PMCID: PMC7678611 DOI: 10.3892/etm.2020.9443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 08/03/2020] [Indexed: 12/17/2022] Open
Abstract
This study was designed to investigate the clinical efficacy of intravenous anesthesia on breast segmental surgery and the effects on hemodynamics of patients. A total of 267 patients were collected as research subjects. These patients underwent breast segmental surgery in Chun'an First People's Hospital from March 2015 to September 2018. Among them, 137 patients undergoing intravenous anesthesia were the research group, and 130 patients undergoing inhalation anesthesia were the control group. The following parameters were recorded: Clinical efficacy, postoperative adverse conditions, hemodynamic indicators including systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR). Visual analogue scale (VAS) was used to observe the analgesic effect of the two groups, the mental state of patients in the two groups was observed by mini-mental state examination (MMSE) scoring method, and systemic evaluation was made by oxidative stress (OS) reaction indicators. The MMSE scores of the two groups decreased one day after surgery, but the score in the research group was higher than that in the control group (P<0.05). The levels of SBP and DBP at T1 and T2 in the control group were significantly higher than those in the research group (P<0.05). HR of research group at T1 and T2 was lower than that at T0 and that at corresponding time of control group (P<0.05). The incidence rate of postoperative adverse reactions in the research group was significantly lower than that in the control group (P<0.05). In conclusion, intravenous anesthesia for breast segmental surgery can reduce the occurrence of adverse reactions after surgery, with complete sedation and analgesia. Patients were able to wake up quickly and stably after surgery, and their cognitive function and OS recovered rapidly. However, due to the great impact on hemodynamics during surgery, attention should be paid to maintain hemodynamic stability during surgery to avoid hypotension and bradycardia.
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Affiliation(s)
- Xiaohong Yu
- Department of Nursing Care, Chun'an First People's Hospital, Hangzhou, Zhejiang 311700, P.R. China
| | - Yinchan Zhou
- Department of Nursing Care, Chun'an First People's Hospital, Hangzhou, Zhejiang 311700, P.R. China
| | - Xuezhen Zheng
- Department of Nursing Care, Chun'an First People's Hospital, Hangzhou, Zhejiang 311700, P.R. China
| | - Su Shao
- Department of Nursing Care, Chun'an First People's Hospital, Hangzhou, Zhejiang 311700, P.R. China
| | - Huihong He
- Department of Nursing Care, Chun'an Hospital of TCM, Hangzhou, Zhejiang 311700, P.R. China
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Pota V, Passavanti MB, Aurilio C, Barbarisi M, Giaccari LG, Colella U, Fiore M, Mangoni di Santostefano GSRC, Sansone P, Pace MC. Ketamine Infusion in Post-Surgical Pain Management after Head and Neck Surgery: A Retrospective Observational Study. THE OPEN ANESTHESIA JOURNAL 2019. [DOI: 10.2174/2589645801913010132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Head and neck cancer affects approximately 382,000 new patients per year worldwide with a significant portion undergoing surgical treatment. During postoperative period key elements in the Intensive Care Unit (ICU) are airway management and pain control.
Objective:
We evaluated the average change of inpatient pain control using a Numerical Rating Score (NRS). We also evaluated the time of extubation after ICU admission recording the incidence of desaturation and the necessity of re-intubation. Secondary outcomes were the incidence of postoperative complications, included those narcotics-related, and the use of rescue analgesics.
Methods:
In this retrospective observational study, we analyzed data of registry before and after we have changed our postoperative analgesic protocol from remifentanil infusion to ketamine infusion.
Results:
Medical records of 20 patients were examined. 10 patients received 0.5 mg/kg ketamine bolus at the end of surgery, followed by a continuous infusion of 0.25 mg/kg/h. All patients presented a significant decrease in pain intensity from the 4th to 48th postoperative hour (p < 0.05), but statically not a significant difference in NRS score was recorded between the two groups. Time to extubation was shorter in ketamine group compared to the remifentanil group (112.30 min ± 16.78 vs. 78 min ± 14.17; p < 0.05). Desaturation rate was 10% in the remifentanil group, while no case was recorded in the ketamine group.
Conclusion:
The level of analgesia provided by ketamine and remifentanil was comparable. Ketamine was superior in ventilatory management of the patient with more rapid extubation and with no case of desaturation.
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Talsi O, Kiiski Berggren R, Johansson G, Winsö O. A national survey on routines regarding sedation in Swedish intensive care units. Ups J Med Sci 2019; 124:199-202. [PMID: 31119971 PMCID: PMC6758647 DOI: 10.1080/03009734.2019.1616339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator from the Swedish Intensive Care Registry, we performed a national survey. Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hypnosedatives, analgosedatives, protocols, sedation scales, etc. Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents for analgosedation. Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004.
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Affiliation(s)
- Oskar Talsi
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Ritva Kiiski Berggren
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
- Swedish National Quality Registry for Intensive Care (SIR), Karlstad, Sweden
| | - Göran Johansson
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Ola Winsö
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
- CONTACT Ola Winsö Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
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14
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Karacaer F, Biricik E, Ilgınel M, Küçükbingöz Ç, Ağın M, Tümgör G, Güneş Y, Özcengiz D. Remifentanil–ketamine vs. propofol–ketamine for sedation in pediatric patients undergoing colonoscopy: A randomized clinical trial. Braz J Anesthesiol 2018. [PMID: 30205906 PMCID: PMC9391731 DOI: 10.1016/j.bjane.2018.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and objectives Pediatric patients frequently require deep sedation or general anesthesia for colonoscopy. This study was designed to compare the sedative efficacy of remifentanil–ketamine combination with propofol–ketamine combination in children undergoing colonoscopy. Methods Seventy patients, between 2 and 16 years of age, scheduled for diagnostic colonoscopy were randomly allocated into two groups. Remifentanil–ketamine group received intravenous ketamine 2 mg.kg−1 and remifentanil 0.25 μg.kg−1 combination, followed by 0.1 μg.kg−1.min−1 remifentanil infusion. Propofol–ketamine group received intravenous propofol 1 and 2 mg.kg−1 ketamine combination, followed by 1 mg.kg−1.h−1 propofol infusion. In the case of children discomfort (cry, movement, and cough), remifentanil 0.1 μg.kg−1 in the remifentanil–ketamine group or propofol 0.5 mg.kg−1 in the propofol–ketamine group were administered to improve children discomfort. Despite the therapy given above, if children still experience discomfort, 1 mg.kg−1 of ketamine was administered as a rescue drug, regardless of the group. Ramsay sedation score, hemodynamic variables, drug requirements, gastroenterologists’ satisfaction, colonoscopy duration, recovery time, and side effects were recorded throughout the procedure and the recovery period. Results The percentage of patients with a Ramsay sedation score of 4 or higher during the procedure was 73.5 and 37.1% in remifentanil–ketamine and propofol–ketamine groups, respectively (p = 0.02). Systolic and diastolic blood pressure variables were significantly higher only after induction in the remifentanil–ketamine group than in the propofol–ketamine group (p = 0.015). Conclusion Coadministration of ketamine with either remifentanil or propofol effectively and safely provides sedation and analgesia in children undergoing colonoscopy. Sedation scores were significantly better in remifentanil–ketamine group than in propofol–ketamine group.
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15
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Karacaer F, Biricik E, Ilgınel M, Küçükbingöz Ç, Ağın M, Tümgör G, Güneş Y, Özcengiz D. [Remifentanil-ketamine vs. propofol-ketamine for sedation in pediatric patients undergoing colonoscopy: A randomized clinical trial]. Rev Bras Anestesiol 2018; 68:597-604. [PMID: 30205906 DOI: 10.1016/j.bjan.2018.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 04/26/2018] [Accepted: 06/22/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric patients frequently require deep sedation or general anesthesia for colonoscopy. This study was designed to compare the sedative efficacy of remifentanil-ketamine combination with propofol-ketamine combination in children undergoing colonoscopy. METHODS Seventy patients, between 2 and 16 years of age, scheduled for diagnostic colonoscopy were randomly allocated into two groups. Remifentanil-ketamine group received intravenous ketamine 2mg.kg-1 and remifentanil 0.25μg.kg-1 combination, followed by 0.1μg.kg-1.min-1 remifentanil infusion. Propofol-ketamine group received intravenous propofol 1 and 2mg.kg-1 ketamine combination, followed by 1mg.kg-1.h-1 propofol infusion. In the case of children discomfort (cry, movement, and cough), remifentanil 0.1μg.kg-1 in the remifentanil-ketamine group or propofol 0.5mg.kg-1 in the propofol-ketamine group were administered to improve children discomfort. Despite the therapy given above, if children still experience discomfort, 1mg.kg-1 of ketamine was administered as a rescue drug, regardless of the group. Ramsay sedation score, hemodynamic variables, drug requirements, gastroenterologists' satisfaction, colonoscopy duration, recovery time, and side effects were recorded throughout the procedure and the recovery period. RESULTS The percentage of patients with a Ramsay sedation score of 4 or higher during the procedure was 73.5 and 37.1% in remifentanil-ketamine and propofol-ketamine groups, respectively (p=0.02). Systolic and diastolic blood pressure variables were significantly higher only after induction in the remifentanil-ketamine group than in the propofol-ketamine group (p=0.015). CONCLUSION Coadministration of ketamine with either remifentanil or propofol effectively and safely provides sedation and analgesia in children undergoing colonoscopy. Sedation scores were significantly better in remifentanil-ketamine group than in propofol-ketamine group.
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Affiliation(s)
- Feride Karacaer
- Çukurova University Medical Faculty, Anesthesiology and Reanimation Department, Adana, Turquia.
| | - Ebru Biricik
- Çukurova University Medical Faculty, Anesthesiology and Reanimation Department, Adana, Turquia
| | - Murat Ilgınel
- Çukurova University Medical Faculty, Anesthesiology and Reanimation Department, Adana, Turquia
| | - Çağatay Küçükbingöz
- Numune Training and Research Hospital, Anesthesiology and Reanimation Department, Adana, Turquia
| | - Mehmet Ağın
- Şanlıurfa Training and Research Hospital, Pediatric Gastroenterology Department, Şanlıurfa, Turquia
| | - Gökhan Tümgör
- Çukurova University Medical Faculty, Pediatric Gastroenterology Department, Adana, Turquia
| | - Yasemin Güneş
- Çukurova University Medical Faculty, Pediatric Gastroenterology Department, Adana, Turquia
| | - Dilek Özcengiz
- Çukurova University Medical Faculty, Pediatric Gastroenterology Department, Adana, Turquia
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16
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Seo KH, Choi JW, Jung HS, Yoo H, Joo JD. The Effects of Remifentanil on Expression of High Mobility Group Box 1 in Septic Rats. J Korean Med Sci 2017; 32:542-551. [PMID: 28145661 PMCID: PMC5290117 DOI: 10.3346/jkms.2017.32.3.542] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/11/2016] [Indexed: 02/01/2023] Open
Abstract
High mobility group box 1 (HMGB1) is a pivotal mediator of sepsis progression. Remifentanil, an opioid agonist, has demonstrated anti-inflammatory effects in septic mice. However, it is not yet known whether remifentanil affects the expression of HMGB1. We investigated the effects of remifentanil on HMGB1 expression and the underlying mechanism in septic rats. Forty-eight male Sprague-Dawley rats were randomly divided into 3 groups; a sham group, a cecal ligation and puncture (CLP) group, and a CLP with remifentanil treatment (Remi) group. The rat model of CLP was used to examine plasma concentrations of proinflammatory cytokines, tissue HMGB1 mRNA and the activity of nuclear factor (NF)-κB in the liver, lungs, kidneys, and ileum. Pathologic changes and immunohistochemical staining of NF-κB in the liver, lungs, and kidneys tissue were observed. We found that remifentanil treatment suppressed the level of serum interleukin (IL)-6 and tumor necrosis factor (TNF)-α 6 hours after CLP, and serum HMGB1 24 hours after CLP. HMGB1 mRNA levels and the activity of NF-κB in multiple organs decreased by remifentanil treatment 24 hours after CLP. Remifentanil treatment also attenuated nuclear expression of NF-κB in immunohistochemical staining and mitigated pathologic changes in multiple organs. Altogether, these results suggested that remifentanil inhibited expression of HMGB1 in vital organs and release of HMGB1 into plasma. The mechanism was related to the inhibitory effect of remifentanil on the release of proinflammatory cytokines and activation of NF-κB.
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Affiliation(s)
- Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, Saint Vincent's Hospital, The College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jin Woo Choi
- Department of Anesthesiology and Pain Medicine, Saint Vincent's Hospital, The College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hong Soo Jung
- Department of Anesthesiology and Pain Medicine, Saint Vincent's Hospital, The College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hansol Yoo
- Department of Anesthesiology and Pain Medicine, Saint Vincent's Hospital, The College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jin Deok Joo
- Department of Anesthesiology and Pain Medicine, Saint Vincent's Hospital, The College of Medicine, The Catholic University of Korea, Suwon, Korea.
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17
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A Randomized Comparison of Remifentanil Target-Controlled Infusion Versus Dexmedetomidine Single-Dose Administration. Am J Ther 2016; 23:e690-6. [DOI: 10.1097/01.mjt.0000433939.84373.2d] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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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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Seol TK, Lim JK, Yoo EK, Min SW, Kim CS, Hwang JY. Propofol-ketamine or propofol-remifentanil for deep sedation and analgesia in pediatric patients undergoing burn dressing changes: a randomized clinical trial. Paediatr Anaesth 2015; 25:560-6. [PMID: 25557125 DOI: 10.1111/pan.12592] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE In this study, we compared the propofol-ketamine and propofol-remifentanil combinations for deep sedation and analgesia during pediatric burn wound dressing changes. METHODS Fifty pediatric patients aged 12-36 months, undergoing burn wound dressing changes, were randomly assigned to receive propofol-remifentanil (group PR) or propofol-ketamine (group PK) for deep sedation and analgesia. Patients in the group PR received 2 mg·kg(-1) propofol and 0.1 μg·kg(-1) remifentanil, and 0.05 μg·kg(-1) ·min(-1) remifentanil was infused continuously until the end of the procedure. Patients in the group PK received 2 mg·kg(-1) propofol and 1 mg·kg(-1) ketamine, and the same volume of isotonic saline was infused continuously until the end of the procedure. Additional propofol with remifentanil or ketamine was administered when required. Hemodynamic variables, drug requirements, occurrence of patient movement, surgeon's satisfaction score, recovery time, and the incidence of adverse events were recorded throughout the procedure and recovery. RESULTS Recovery time was significantly shorter in the group PR compared to that in the group PK (10.3 [9.1-11.5] min vs 22.5 [20.3-25.6] min, median [interquartile range], respectively; P < 0.001). No significant hypotension or bradycardia occurred throughout the procedure. No significant differences were observed in terms of drug requirements, occurrence of patient movement, surgeon's satisfaction, incidence of respiratory depression, hypoxia, or nausea and vomiting CONCLUSIONS The combinations of propofol-ketamine and propofol-remifentanil were effective for sedation and analgesia in pediatric patients undergoing burn dressing changes, but the propofol-remifentanil combination provided faster recovery compared to the propofol-ketamine combination.
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Affiliation(s)
- Tai-Kyung Seol
- Department of Anesthesiology & Pain Medicine, Bestian Burn Care Center, Seoul, Korea
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20
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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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21
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Schaaf T, Lyutenska M, Urban BW, Wittmann M. Direct effects of morphine but not of fentanyl-type opioids on human 5-HT3A receptors in outside-out patch-clamp studies. Eur J Pain 2014; 18:1165-72. [PMID: 24590579 DOI: 10.1002/j.1532-2149.2014.00463.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND The alkaloid morphine is historically the oldest opiate, yet still today it has clinically important uses in analgesic therapies. The main analgesic effect of opioids, including synthetic opioids belonging to the family of 4-anilidopiperidines, is mediated via activation of opioid receptors spread throughout the peripheral and central nervous system. However, morphine acting as a 'dirty' drug also exhibits effects on other receptor systems, e.g., the serotonergic system and its 5-HT3 receptor. Therefore, this study focuses on the interaction of morphine and fentanyl-type opioids (alfentanil, remifentanil and sufentanil) with 5-HT3A receptors. METHODS Excised outside-out patches from human embryonic kidney-293 cells, stably transfected with the human 5-HT3A receptor cDNA, were used to determine the opioid effects using the patch-clamp technique. RESULTS Within clinical concentrations, the effects of morphine are concentration-dependent. Morphine reduced current amplitudes, as well as activation and decay time constants. These effects were not competitive. Contrary to these results, all fentanyl-type opioids only exerted effects far above their clinical concentration ranges. These effects were not homogenous but varying. CONCLUSIONS Morphine is an opioid compound exhibiting special antagonistic interaction with 5-HT3A receptors. This interaction is not shared by the newer synthetic derivatives of the fentanyl-type opioids in the clinical relevant concentration range.
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Affiliation(s)
- T Schaaf
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany
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Vardanyan RS, Hruby VJ. Fentanyl-related compounds and derivatives: current status and future prospects for pharmaceutical applications. Future Med Chem 2014; 6:385-412. [PMID: 24635521 PMCID: PMC4137794 DOI: 10.4155/fmc.13.215] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Fentanyl and its analogs have been mainstays for the treatment of severe to moderate pain for many years. In this review, we outline the structural and corresponding synthetic strategies that have been used to understand the structure-biological activity relationship in fentanyl-related compounds and derivatives and their biological activity profiles. We discuss how changes in the scaffold structure can change biological and pharmacological activities. Finally, recent efforts to design and synthesize novel multivalent ligands that act as mu and delta opioid receptors and NK-1 receptors are discussed.
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MESH Headings
- Analgesics, Opioid/chemical synthesis
- Analgesics, Opioid/chemistry
- Analgesics, Opioid/therapeutic use
- Animals
- Fentanyl/chemical synthesis
- Fentanyl/chemistry
- Fentanyl/therapeutic use
- Humans
- Neuralgia/drug therapy
- Receptors, Opioid, delta/agonists
- Receptors, Opioid, delta/metabolism
- Receptors, Opioid, mu/agonists
- Receptors, Opioid, mu/metabolism
- Structure-Activity Relationship
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Affiliation(s)
- Ruben S Vardanyan
- Department of Chemistry & Biochemistry, University of Arizona, Tucson, AZ 85721, USA
| | - Victor J Hruby
- Department of Chemistry & Biochemistry, University of Arizona, Tucson, AZ 85721, USA
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23
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Park JM, Kim JH. Assessment and Treatment of Pain in Adult Intensive Care Unit Patients. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.3.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Jun-Mo Park
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ji Hyun Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
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Quaedflieg CWEM, Münte S, Kalso E, Sambeth A. Effects of remifentanil on processing of auditory stimuli: a combined MEG/EEG study. J Psychopharmacol 2014; 28:39-48. [PMID: 24257810 DOI: 10.1177/0269881113512036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Remifentanil (Ultiva(®)) is a potent ultra-short acting mu-opioid receptor agonist used for perioperative pain treatment and anaesthesia. So far, it is not known how sensitive the cognitive processing of auditory perception elicited by the mismatch negativity (MMN) paradigm is to opioids. The present exploratory study investigated how the opioid remifentanil modulates different stages of auditory processing as reflected in the MMN(m) and P3a(m). We recorded electroencephalography (EEG) and magnetoencephalography (MEG) during auditory stimulation under remifentanil or placebo infusion in 20 healthy participants. For the MMN, a gender effect was found for tones deviating in frequency (± 10%) from the standard tone. Remifentanil increased the amplitude of the frequency MMN at F3 in females but not in males. No effect of treatment was found for the MMN(m) or the novel P3a(m). These results suggest that while the bottom-up stimulus change detection system for auditory stimuli appears to be relatively insensitive to opioids, the automatic attention switch caused by the change detection seems to be modulated by the opioid system in females. The multiple deviant paradigm including novel sounds is a promising tool for investigating pharmacological manipulation of different stages of auditory processing. Furthermore, combining the two techniques will yield more specific information about the drug effects on MMN(m).
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Chechik O, Arbel R, Salai M, Gigi R, Beilin M, Flaishon R, Sever R, Khashan M, Ben-Tov T, Gal-Levy R, Yayon A, Blumenstein S. Opiates do not violate the viability and proliferative activity of human articular chondrocytes. Cell Tissue Bank 2013; 15:391-5. [PMID: 24046083 DOI: 10.1007/s10561-013-9399-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/11/2013] [Indexed: 10/26/2022]
Abstract
Articular cartilage injuries present a challenge for the clinician. Autologous chondrocyte implantation embedded in scaffolds are used to treat cartilage defects with favorable outcomes. Autologous serum is often used as a medium for chondrocyte cell culture during the proliferation phase of the process of such products. A previous report showed that opiate analgesics (fentanyl, alfentanil and diamorphine) in the sera have a significant inhibitory effect on chondrocyte proliferation. In order to determine if opiates in serum inhibit chondrocyte proliferation, twenty two patients who underwent knee arthroscopy and were anesthetized with either fentanyl or remifentanil were studied. Blood was drawn before and during opiate administration and up to 2 h after its discontinuation. The sera were used as medium for in vitro proliferation of both cryopreserved and freshly isolated chondrocytes, and the number and viability of cells were measured. There was no difference in the yield or cell viability between the serum samples of patients anesthetized with fentanyl when either fresh or cryopreserved human articular chondrocytes (hACs) were used. Some non-significant reduction in the yield of cells was observed in the serum samples of patients anesthetized with remifentanil when fresh hAC were used. We conclude that Fentanyl in human autologous serum does not inhibit in vitro hAC proliferation. Remifentanil may show minimal inhibitory effect on in vitro fresh hAC proliferation.
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Affiliation(s)
- Ofir Chechik
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel,
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Khan ZH. Pain management in intensive care unit patients: the role of ultra-short acting opioid: remifentanil. Anesth Pain Med 2013; 3:188-90. [PMID: 24223360 PMCID: PMC3821149 DOI: 10.5812/aapm.10299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/20/2013] [Indexed: 11/30/2022] Open
Affiliation(s)
- Zahid Hussain Khan
- Department of Anesthesiology and Intensive Care, Imam Khomeini Medical Center, Tehran University of Medical Sciences (TUMS), Tehran, Iran
- Corresponding author: Zahid Hussain Khan, Department of Anesthesiology and Intensive Care, Imam Khomeini Medical Center, Keshavarz Blvd., Tehran University of Medical Sciences (TUMS), 1419733141 Tehran, Iran. Tel: +98-2161192828, Fax: +98-2166581537, E-mail:
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Muñoz L, Arévalo JJ, Reyes LE, Balaguera CE. Remifentanilo versus propofol con infusión controlada a objetivo en sitio efecto para la sedación de pacientes durante procedimientos endoscópicos gastrointestinales: ensayo clínico controlado aleatorizado. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2012.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Muñoz L, Arévalo JJ, Reyes LE, Balaguera CE. Remifentanil vs. propofol controlled infusion for sedation of patients undergoing gastrointestinal endoscopic procedures: A clinical randomized controlled clinical trial. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2012.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Paul BS, Paul G. Sedation in neurological intensive care unit. Ann Indian Acad Neurol 2013; 16:194-202. [PMID: 23956563 PMCID: PMC3724073 DOI: 10.4103/0972-2327.112465] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 11/10/2012] [Accepted: 12/04/2012] [Indexed: 11/12/2022] Open
Abstract
Analgesia and sedation has been widely used in intensive care units where iatrogenic discomfort often complicates patient management. In neurological patients maximal comfort without diminishing patient responsiveness is desirable. In these patients successful management of sedation and analgesia incorporates a patient based approach that includes detection and management of predisposing and causative factors, including delirium, monitoring using sedation scales, proper medication selection, emphasis on analgesia based drugs and incorporation of protocols or algorithms. So, to optimize care clinician should be familiar with the pharmacokinetic and pharmacodynamic variables that can affect the safety and efficacy of analgesics and sedatives.
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Affiliation(s)
- Birinder S. Paul
- Department of Neurology, Dayanand Medical College, Ludhiana, India
| | - Gunchan Paul
- Critical Care Division, Dayanand Medical College, Ludhiana, India
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Remifentanil vs. propofol controlled infusion for sedation of patients undergoing gastrointestinal endoscopic procedures: A clinical randomized controlled clinical trial☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341020-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abu-Kishk I, Hod-Feins R, Anekstein Y, Mirovsky Y, Barr J, Lahat E, Eshel G. Remifentanil use in pediatric scoliosis surgery-an effective alternative to morphine (a retrospective study). Yonsei Med J 2012; 53:1014-21. [PMID: 22869487 PMCID: PMC3423840 DOI: 10.3349/ymj.2012.53.5.1014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The unique properties of remifentanil make it ideal for pediatric use despite a lack of wide randomized clinical trials and fear of adverse events due to its high potency. We aimed to consolidate preliminary conclusions regarding the efficacy of remifentanil use in pediatric scoliosis surgery. MATERIALS AND METHODS The medical charts of children with idiopathic scoliosis who underwent primary spinal fusion between 1998 and 2007 at a large tertiary university-affiliated hospital were retrospectively reviewed and divided into two groups according to anesthetic regime (remifentanil vs. morphine). Demographic, surgery-related details and immediate postoperative course were recorded and compared. RESULTS All 36 remifentanil children were extubated shortly after termination of surgery, compared to 2 of the 84 patients in the morphine group. The remaining patients in the morphine group were extubated hours after surgery [5.4 hours; standard deviation (SD) 1.7 hours]. Six remifentanil children were spared routine intensive care hospitalization (vs. 2 morphine children-significant difference). Shorter surgeries [5.6 hours (SD 1.82 hours) vs. 7.14 hours (SD 2.15 hours); p=0.0004] were logged for the remifentanil group. To achieve controlled hypotension during surgery, vasodilator agents were used in the morphine group only. A comparison of early postoperative major or minor complication rates (including neurological and pulmonary complications) between the two groups yielded no significant differences. CONCLUSION Remifentanil use can shorten operating time and facilitate earlier spontaneous ventilation and extubation, with less of a need for intensive care hospitalization and no increase in significant complications.
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Affiliation(s)
- Ibrahim Abu-Kishk
- Pediatric Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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Quintard H, Pavlakovic I, Mantz J, Ichai C. Adjunctive remifentanil infusion in deeply sedated and paralyzed ICU patients during fiberoptic bronchoscopy procedure: a prospective, randomized, controlled study. Ann Intensive Care 2012; 2:29. [PMID: 22800647 PMCID: PMC3487977 DOI: 10.1186/2110-5820-2-29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 06/04/2012] [Indexed: 11/28/2022] Open
Abstract
Background Even with an adequate pain assessment, critically ill patients under sedation experience pain during procedures in the intensive care unit (ICU). We evaluated the effects of adjunctive administration of Remifentanil, a short-acting drug, in deeply sedated patient on variation of Bispectral Index (BIS) during a fiberoptic bronchoscopy. Methods A prospective, randomized, blinded, placebo-controlled study was conducted in 18-bed ICU. Patients needing a tracheal fibroscopy under deep sedation (midazolam (0.1 mg/kg per hour) fentanyl (4 μg/kg per hour)) and neuromuscular blocking (atracurium 0.5 mg/kg) were included in the study. A continuous monitoring of BIS, arterial pressure, and heart rate were realized before, during, and after the fiberoptic exam. An adjunctive continuous placebo or Remifentanil infusion was started just before the fiberoptic exam with a target effect-site concentration of 4 ng/ml using a Base Primea pump. Results Mean arterial pressure and heart rates were comparable between the placebo and Remifentanil groups at all times of the procedure. We did not observe differences in the variation of BIS values between the two groups during procedure. We described no change in BIS values relative to the placebo group in this population. Conclusions In deeply sedated and paralyzed patients, receiving analgesic support based on a scale score an additional administration of short-acting analgesic drug, such as Remifentanil, seems not to be necessary for acute pain control. Trial registration NCT00162591.
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Al MJ, Hakkaart L, Tan SS, Bakker J. Cost-consequence analysis of remifentanil-based analgo-sedation vs. conventional analgesia and sedation for patients on mechanical ventilation in the Netherlands. Crit Care 2010; 14:R195. [PMID: 21040558 PMCID: PMC3219979 DOI: 10.1186/cc9313] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 09/02/2010] [Accepted: 11/01/2010] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Hospitals are increasingly forced to consider the economics of technology use. We estimated the incremental cost-consequences of remifentanil-based analgo-sedation (RS) vs. conventional analgesia and sedation (CS) in patients requiring mechanical ventilation (MV) in the intensive care unit (ICU), using a modelling approach. METHODS A Markov model was developed to describe patient flow in the ICU. The hourly probabilities to move from one state to another were derived from UltiSAFE, a Dutch clinical study involving ICU patients with an expected MV-time of two to three days requiring analgesia and sedation. Study medication was either: CS (morphine or fentanyl combined with propofol, midazolam or lorazepam) or: RS (remifentanil, combined with propofol when required). Study drug costs were derived from the trial, whereas all other ICU costs were estimated separately in a Dutch micro-costing study. All costs were measured from the hospital perspective (price level of 2006). Patients were followed in the model for 28 days. We also studied the sub-population where weaning had started within 72 hours. RESULTS The average total 28-day costs were €15,626 with RS versus €17,100 with CS, meaning a difference in costs of €1474 (95% CI -2163, 5110). The average length-of-stay (LOS) in the ICU was 7.6 days in the RS group versus 8.5 days in the CS group (difference 1.0, 95% CI -0.7, 2.6), while the average MV time was 5.0 days for RS versus 6.0 days for CS. Similar differences were found in the subgroup analysis. CONCLUSIONS Compared to CS, RS significantly decreases the overall costs in the ICU. TRIAL REGISTRATION Clinicaltrials.gov NCT00158873.
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Affiliation(s)
- Maiwenn J Al
- Institute for Medical Technology Assessment, Erasmus University, Burg. Oudlaan 50, Rotterdam, 3062 PA, The Netherlands
| | - Leona Hakkaart
- Institute for Medical Technology Assessment, Erasmus University, Burg. Oudlaan 50, Rotterdam, 3062 PA, The Netherlands
| | - Siok Swan Tan
- Institute for Medical Technology Assessment, Erasmus University, Burg. Oudlaan 50, Rotterdam, 3062 PA, The Netherlands
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC University Medical Centre, Dr. Molewaterplein 50, Rotterdam, 3015 GE, The Netherlands
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Sakata RK. Analgesia and Sedation in Intensive Care Unit. Rev Bras Anestesiol 2010; 60:648-58, 360-5. [DOI: 10.1016/s0034-7094(10)70081-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 06/04/2010] [Indexed: 10/26/2022] Open
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Baron DM, Metnitz PGH, Gustorff B. [Sedation and analgesia in intensive care: physiology and application]. Wien Klin Wochenschr 2010; 122:455-64. [PMID: 20683673 DOI: 10.1007/s00508-010-1418-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Many therapeutic and diagnostic procedures in intensive care medicine are perceived as painful by most patients. As a consequence analgesia and sedation represent two of the main pillars in the treatment of the critically ill. Adaptation to the individual needs of the patients poses one of the biggest challenges that we are confronted with. Both morbidity and mortality can be positively influenced by adequate treatment. In the first part of this review we will discuss the physiology of sleep patterns and pain. Furthermore modes of action and side effects of the most common anesthetics and analgetics will be presented. Finally, the last part of the manuscript deals with the practical application of these therapeutics and their monitoring in intensive care medicine.
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Affiliation(s)
- David M Baron
- Univ.Klinik für Anästhesie, Allgemeine Intensivmedizin und Schmerztherapie, Medizinische Universität Wien, Wien, Austria
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Ypsilantis P, Politou M, Mikroulis D, Lambropoulou M, Bougioukas I, Theodoridis G, Tsigalou C, Manolas C, Papadopoulos N, Bougioukas G, Simopoulos C. Attenuation of propofol tolerance conferred by remifentanil co-administration does not reduce propofol toxicity in rabbits under prolonged mechanical ventilation. J Surg Res 2009; 168:253-61. [PMID: 20036388 DOI: 10.1016/j.jss.2009.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 08/06/2009] [Accepted: 08/12/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prolonged sedation with propofol at high doses may lead to fatal multi-organ dysfunction, know as propofol infusion syndrome. We tested the hypothesis that propofol plus remifentanil co-administration attenuates propofol tolerance to its sedative effect and assessed if such an effect has an impact on propofol toxicity in rabbits under prolonged mechanical ventilation. MATERIALS AND METHODS Eighteen healthy male rabbits were mechanically ventilated and received propofol (group P, n = 6), propofol plus remifentanil (group PR, n = 6), or remifentanil plus sevoflurane (group RS, n = 6) in order to be kept under sedation (group P) or sedation/analgesia (groups PR and RS) for up to 48 h. Initial propofol and remifentanil infusion rates (IRs) were adjusted, if needed, to maintain the desired level of sedation and analgesia, respectively (groups P and PR). In group RS, remifentanil was infused at IRs equivalent to those of group PR. Propofol IRs were recorded, propofol concentrations were measured in the arterial plasma, and blood biochemical parameters and organ histopathology were assessed. RESULTS Animals survived for 29-36 h in group P and 22-38 h in group PR (100% mortality rate). Tolerance was developed to propofol's sedative effect. The onset of tolerance was delayed and its magnitude was decreased in group PR compared with group P. Propofol was accumulated in the systemic circulation. Propofol clearance rate was gradually decreased. Arterial lactate, and serum aspartate aminotransferase (AST), lactate dehydrogenase (LDH), bilirubin, cholesterol, triglycerides, and creatine kinase (CK) levels were increased. The heart, lungs, liver, gallbladder, kidneys, urinary bladder, and skeletal muscles were seriously injured in groups P and PR. In group RS, mortality was 0%, while there was only mild injury of the lungs, liver, gallbladder, kidneys, and urinary bladder. CONCLUSIONS Although propofol tolerance is attenuated in propofol plus remifentanil receiving rabbits under prolonged mechanical ventilation, fatal multi-organ injury occurs resembling human propofol infusion syndrome.
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Affiliation(s)
- Petros Ypsilantis
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece.
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Girard F, Moumdjian R, Boudreault D, Chouinard P, Bouthilier A, Ruel M. The Effect of Sedation on Intracranial Pressure in Patients with an Intracranial Space-Occupying Lesion: Remifentanil Versus Propofol. Anesth Analg 2009; 109:194-8. [DOI: 10.1213/ane.0b013e3181a3ea3a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lee YK, Yang HS, Jeong SM, Jun GW, Um SJ. Clinical survey of sedation and analgesia procedures in intensive care units. Korean J Anesthesiol 2009; 56:295-302. [PMID: 30625739 DOI: 10.4097/kjae.2009.56.3.295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The proper use of sedation and analgesia in the intensive care unit (ICU) minimizes its physical and psychological impact. Otherwise, patients can suffer from recall, nightmares, and depression after discharge. We investigated the sedatives, analgesics, and muscle relaxants used in the ICU. METHODS We visited 79 ICUs in 52 training hospitals and noted the use of sedatives, analgesics, and muscle relaxants from July, 2007, to December, 2007, using a 5-item questionnaire with 57 sub-questions. The survey evaluated the ICU system administration of analgesics and muscle relaxants. RESULTS Most ICU management is done by the anesthesiology department (55%). Most have resident doctors (63.3%) and an ICU committee (60.8%) in charge of the ICU, as well as a special ICU chart (88.6%) and scoring system (65.8%). Most hospitals have a consulting system (94.9%). The standard ICU analgesics are fentanyl (65.8%), NSAIDs (53.2%), and morphine (48.1%). CONCLUSIONS Adequate sedation is difficult to achieve in the ICU, but is important for patient comfort and to reduce ICU stay duration. Awareness of patient status and appropriate drug/protocol use are therefore important.
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Affiliation(s)
- Yoon Kyung Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
| | - Sung Moon Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
| | - Go Woon Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
| | - Su Jeong Um
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
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Gregoretti C, Decaroli D, Piacevoli Q, Mistretta A, Barzaghi N, Luxardo N, Tosetti I, Tedeschi L, Burbi L, Navalesi P, Azzeri F. Analgo-sedation of patients with burns outside the operating room. Drugs 2009; 68:2427-43. [PMID: 19016572 DOI: 10.2165/0003495-200868170-00003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Following the initial resuscitation of burn patients, the pain experienced may be divided into a 'background' pain and a 'breakthrough' pain associated with painful procedures. While background pain may be treated with intravenous opioids via continuous infusion or patient-controlled analgesia (PCA) and/or less potent oral opioids, breakthrough pain may be treated with a variety of interventions. The aim is to reduce patient anxiety, improve analgesia and ensure immobilization when required. Untreated pain and improper sedation may result in psychological distress such as post-traumatic stress disorder, major depression or delirium. This review summarizes recent developments and current techniques in sedation and analgesia in non-intubated adult burn patients during painful procedures performed outside the operating room (e.g. staple removal, wound-dressing, bathing). Current techniques of sedation and analgesia include different approaches, from a slight increase in background pain therapy (e.g. morphine PCA) to PCA with rapid-onset opioids, to multimodal drug combinations, nitrous oxide, regional blocks, or non-pharmacological approaches such as hypnosis and virtual reality. The most reliable way to administer drugs is intravenously. Fast-acting opioids can be combined with ketamine, propofol or benzodiazepines. Adjuvant drugs such as clonidine or NSAIDs and paracetamol (acetaminophen) have also been used. Patients receiving ketamine will usually maintain spontaneous breathing. This is an important feature in patients who are continuously turned during wound dressing procedures and where analgo-sedation is often performed by practitioners who are not specialists in anaesthesiology. Drugs are given in small boluses or by patient-controlled sedation, which is titrated to effect, according to sedation and pain scales. Patient-controlled infusion with propofol has also been used. However, we must bear in mind that burn patients often show an altered pharmacokinetic and pharmacodynamic response to drugs as a result of altered haemodynamics, protein binding and/or increased extracellular fluid volume, and possible changes in glomerular filtration. Because sedation and analgesia can range from minimal sedation (anxiolysis) to general anaesthesia, sedative and analgesic agents should always be administered by designated trained practitioners and not by the person performing the procedure. At least one individual who is capable of establishing a patent airway and positive pressure ventilation, as well as someone who can call for additional assistance, should always be present whenever analgo-sedation is administered. Oxygen should be routinely delivered during sedation. Blood pressure and continuous ECG monitoring should be carried out whenever possible, even if a patient is undergoing bathing or other procedures that may limit monitoring of vital pulse-oximetry parameters.
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Affiliation(s)
- Cesare Gregoretti
- Intensive Care Unit, Azienda Ospedaliera CTO-CRF-ICORMA, Turin, Italy
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Coller JK, Christrup LL, Somogyi AA. Role of active metabolites in the use of opioids. Eur J Clin Pharmacol 2008; 65:121-39. [PMID: 18958460 DOI: 10.1007/s00228-008-0570-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 09/16/2008] [Indexed: 11/26/2022]
Abstract
The opioid class of drugs, a large group, is mainly used for the treatment of acute and chronic persistent pain. All are eliminated from the body via metabolism involving principally CYP3A4 and the highly polymorphic CYP2D6, which markedly affects the drug's function, and by conjugation reactions mainly by UGT2B7. In many cases, the resultant metabolites have the same pharmacological activity as the parent opioid; however in many cases, plasma metabolite concentrations are too low to make a meaningful contribution to the overall clinical effects of the parent drug. These metabolites are invariably more water soluble and require renal clearance as an important overall elimination pathway. Such metabolites have the potential to accumulate in the elderly and in those with declining renal function with resultant accumulation to a much greater extent than the parent opioid. The best known example is the accumulation of morphine-6-glucuronide from morphine. Some opioids have active metabolites but at different target sites. These are norpethidine, a neurotoxic agent, and nordextropropoxyphene, a cardiotoxic agent. Clinicians need to be aware that many opioids have active metabolites that will become therapeutically important, for example in cases of altered pathology, drug interactions and genetic polymorphisms of drug-metabolizing enzymes. Thus, dose individualisation and the avoidance of adverse effects of opioids due to the accumulation of active metabolites or lack of formation of active metabolites are important considerations when opioids are used.
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Affiliation(s)
- Janet K Coller
- Discipline of Pharmacology, School of Medical Sciences, University of Adelaide, Adelaide, 5005, Australia
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Remifentanil-propofol analgo-sedation shortens duration of ventilation and length of ICU stay compared to a conventional regimen: a centre randomised, cross-over, open-label study in the Netherlands. Intensive Care Med 2008; 35:291-8. [PMID: 18949456 DOI: 10.1007/s00134-008-1328-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 09/17/2008] [Indexed: 10/21/2022]
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Abstract
Sedation-analgesia occupies an essential place in the specific therapeutic arsenal of the brain-injured patients. The maintenance of the perfusion of the brain, its relaxation and its protection are the fundamental objectives whose finality is to avoid the extension of the lesions and to preserve the neuronal capital. Sedation is instituted when patients are severely agitated or present a deterioration of their state of consciousness (GCS< or =8). Under cover of mechanical ventilation, sedation is the first line treatment of intracranial hypertension, a common pathway of various acute brain diseases of traumatic, vascular or other origin. The use of the combination of hypnotic and opioids is the rule. The combined action of these two classes reinforces and improves their sedative effects. Midazolam is the 2 benzodiazepine of reference. Propofol is more and more frequently added to the combination of hypnotic and opioids. The "propofol infusion syndrome" is a severe limitation to its long term administration in particular among patients presenting a severe septic or inflammatory state. Propofol will be imperatively stopped in the event of metabolic acidosis, rhabdomyolysis, acute renal insufficiency, hyperkaliemia or increase in the blood triglyceride levels. The use of thiopental is restricted to the most severe cases. Its use as a monotherapy at high doses is abandoned to the profit of a co-administration with midazolam or even with the combination of midazolam and propofol. Thiopental overdose is very frequent in the event of associated hypothermia. Etomidate does not have its place apart from induction in fast sequence. The neuro-protective effects of ketamine require to be demonstrated in man before being recommended routinely. Withdrawal of sedation can be responsible for a state of agitation which can be controlled by neuroleptics.
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Affiliation(s)
- L Abdennour
- Unité de neuroanesthésie réanimation, département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, université Pierre-et-Marie-Curie-Paris-6, 75013 Paris, France.
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Sztark F, Lagneau F. [Agents for sedation and analgesia in the intensive care unit]. ACTA ACUST UNITED AC 2008; 27:560-6. [PMID: 18595650 DOI: 10.1016/j.annfar.2008.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sedation-analgesia for critically ill patients is usually performed with the combination of a sedative agent and an opioid. Midazolam and propofol are the agents most commonly used for sedation in ICU. The quality of the sedation is quite comparable with both agents, but pharmacokinetic properties of propofol allow a more rapid weaning process from mechanical ventilation. However, implementation of algorithms to adjust drug dosages reduces ventilator days and limits the kinetic differences between propofol and midazolam. Among the adverse events associated with propofol, propofol infusion syndrome is a rare but lethal aspect of propofol therapy. Opioids are the mainstay of analgesic therapy. They interact synergistically with hypnotics. Sufentanil, fentanyl and morphine are the most frequently used opioids. Remifentanil is an ultrashort acting opiate that does not appear to accumulate with prolonged use. The advent of remifentanil has allowed the use of analgesia-based sedation.
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Affiliation(s)
- F Sztark
- Service d'anesthésie-réanimation 1, université Victor-Segalen Bordeaux-2, groupe hospitalier Pellegrin, CHU de Bordeaux, 33076 Bordeaux cedex, France.
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Silva JA, Romera MA, Chamorro C, Martín-Vivas A, Blanco JJ. Sedo-analgesia in neurologically ill patients: guidelines revisited. Stroke 2008; 39:e67; auhtor reply e68. [PMID: 18309165 DOI: 10.1161/strokeaha.107.498410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lee HY, Son SC. Experiences of the Total Intravenous Anesthesia with Remifentanil in High-risk Preterm Infants - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.2.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ho-Young Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Soo-Chang Son
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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Kadiev E, Patel V, Rad P, Thankachan L, Tram A, Weinlein M, Woodfin K, Raffa RB, Nagar S. Role of pharmacogenetics in variable response to drugs: focus on opioids. Expert Opin Drug Metab Toxicol 2007; 4:77-91. [DOI: 10.1517/17425255.4.1.77] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Current World Literature. Curr Opin Anaesthesiol 2007; 20:388-94. [PMID: 17620851 DOI: 10.1097/aco.0b013e3282c3a878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Machata AM, Illievich UM, Gustorff B, Gonano C, Fässler K, Spiss CK. Remifentanil for tracheal tube tolerance: a case control study. Anaesthesia 2007; 62:796-801. [PMID: 17635427 DOI: 10.1111/j.1365-2044.2007.05100.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We assessed the minimal remifentanil dosage required for tracheal tube tolerance in awake and spontaneously breathing patients after major abdominal surgery. Forty postoperative patients received remifentanil 0.1 microg.kg(-1).min(-1), which was reduced in steps of 0.025 microg.kg(-1).min(-1) every 30 min. Respiratory response subscore of comfort scale (CSRR), Ramsay sedation scale (RSS), visual analogue scale (VAS), respiratory rate, and minute ventilation were recorded. Spontaneous respiration with no or little response to ventilation (CSRR 2) in co-operative, oriented and tranquil patients (RSS 2) was defined as the main outcome and study endpoint. Thirty-one patients (77.5%) reached a CSRR 2 and RSS 2 with remifentanil 0.025 microg.kg(-1).min(-1) and nine patients (22.5%) required remifentanil 0.05 microg.kg(-1).min(-1). Analgesia was sufficient in all patients (VAS = 30). Remifentanil 0.025-0.05 microg.kg(-1).min(-1) achieves satisfactory tracheal tube tolerance in awake and spontaneously breathing patients.
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Affiliation(s)
- A M Machata
- Department of Anaesthesiology and General Intensive Care, Medical University of Vienna, General Hospital, Waehringer Geurtel 18-20, 1090 Vienna, Austria.
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