Critically ill patients in intensive care unit (ICU) regularly experience nervousness and agitation and are at risk of reacting to numerous stressful and pain stimuli. Consequently, ICU patients normally require a combination of analgesia and sedation to alleviate their state of nervousness, enhance safety of the endotracheal tube, and facilitate mechanical ventilation (MV). Studies have proposed that analgesia-based sedation using remifentanil reduces the duration of MV and period of stay in the ICU compared to a conventional regimen.
Purpose and introduction
The aim of this study is to compare an analgesic sedation regimen with remifentanil against a conventional regimen using midazolam or morphine in patients requiring postoperative mechanical ventilation in the ICU.
A literature research was conducted in EBSCOhost (all databases), OvidSP and Science Direct. Keywords were Analgesia, Mechanical, ventilation, Remifentanil Sedation, Weaning and ICU.
Use of evidence
- Results showed three randomized studies had been conducted in the ICU setting.
- A summary of studies compared the safety and efficacy of the two procedures under study.
- These randomized studies focused on patients between 19-75 years.
- Each patient received either of the two treatments according to their individual body weights.
- The randomization procedure was based on a computer generated list.
- Patients were not informed of the sedation option used.
- Median duration of MV was 5.1 days with conventional treatment versus 3.9 days with remifentanil.
- The remifentanil-based regimen reduced median weaning time by 18.9 h.
- Remifentanil also improved sedation-agitation scores.
Interpretation of evidence
In patients with an expected short-term duration of MV, remifentanil significantly improves sedation and agitation levels and reduces weaning time.
Counter Arguments
- A conventional regimen using midazolam or morphine is important when a long ICU stay is anticipated
- Analgesic drugs such as Remifentanil are relatively expensive
- Evidence shows that Remifentanil can cause hypotension
Conclusion
- Remifentanil significantly improves sedation and agitation levels
- Remifentanil also reduces weaning time
- Consequently, analgesic sedation using remifentanil reduces the duration of MV and ICU stay as compared to conventional regimen using midazolam with morphine
- However, ICU costs per patient for the two sedation options is similar
Implications for practice
- Clinicians should start patients on a remifentanil-based regimen whenever short-term MV is anticipated
- Treatment should be assessed after 2–3 days
References
Battershill, A. J. and Keating G. M. (2006). Remifentanil: A Review of its Analgesic and Sedative Use in the Intensive Care Unit. Drugs 2006; 66 (3): 365-385.
Breen, D. et al. (2005). Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005, 9:R200-R210.
Dahaba,A. A. et al. (2004). Remifentanil versus Morphine Analgesia and Sedation for Mechanically Ventilated Critically Ill Patients. Anesthesiology, V 101, No 3, 640-6.
Muellejans, B. et al. (2006). Sedation in the intensive care unit with remifentanil/propofol versus midazolam/fentanyl: a randomised, open- label, pharmacoeconomic trial. Critical Care 2006, 10:R91.
Rozendaal, F.W. et al. (2009). 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 Medicine, volume 35, issue 2 pp 291-298.