sábado, 14 de agosto de 2010
Remifentanil e propofol vs Midazolan e fentanil: menor tempo de VM e mesmos custos
Sedation in the intensive care unit with remifentanil/propofol versus midazolam/fentanyl: a randomised, open-label, pharmacoeconomic trial
Introduction
Remifentanil is an opioid with a unique pharmacokinetic profile. Its organ-independent elimination and short context-sensitive half time of 3 to 4 minutes lead to a highly predictable offset of action. We tested the hypothesis that with an analgesia-based sedation regimen with remifentanil and propofol, patients after cardiac surgery reach predefined criteria for discharge from the intensive care unit (ICU) sooner, resulting in shorter duration of time spent in the ICU, compared to a conventional regimen consisting of midazolam and fentanyl. In addition, the two regimens were compared regarding their costs.
Methods
In this prospective, open-label, randomised, single centre study, a total of 80 patients (18 to 75 years old), who had undergone cardiac surgery, were postoperatively assigned to one of two treatment regimens for sedation in the ICU for 12 to 72 hours. Patients in the remifentanil/propofol group received remifentanil (6- max. 60 μg kg-1 h-1; dose exceeds recommended labelling). Propofol (0.5 to 4.0 mg kg-1 h-1) was supplemented only in the case of insufficient sedation at maximal remifentanil dose. Patients in the midazolam/fentanyl group received midazolam (0.02 to 0.2 mg kg-1 h-1) and fentanyl (1.0 to 7.0 μg kg-1 h-1). For treatment of pain after extubation, both groups received morphine and/or non-opioid analgesics.
Results
The time intervals (mean values ± standard deviation) from arrival at the ICU until extubation (20.7 ± 5.2 hours versus 24.2 h ± 7.0 hours) and from arrival until eligible discharge from the ICU (46.1 ± 22.0 hours versus 62.4 ± 27.2 hours) were significantly (p < 0.05) shorter in the remifentanil/propofol group. Overall costs of the ICU stay per patient were equal (approximately €1,700 on average).
Conclusion
Compared with midazolam/fentanyl, a remifentanil based regimen for analgesia and sedation supplemented with propofol significantly reduced the time on mechanical ventilation and allowed earlier discharge from the ICU, at equal overall costs.
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Introduction
Remifentanil is an opioid with a unique pharmacokinetic profile. Its organ-independent elimination and short context-sensitive half time of 3 to 4 minutes lead to a highly predictable offset of action. We tested the hypothesis that with an analgesia-based sedation regimen with remifentanil and propofol, patients after cardiac surgery reach predefined criteria for discharge from the intensive care unit (ICU) sooner, resulting in shorter duration of time spent in the ICU, compared to a conventional regimen consisting of midazolam and fentanyl. In addition, the two regimens were compared regarding their costs.
Methods
In this prospective, open-label, randomised, single centre study, a total of 80 patients (18 to 75 years old), who had undergone cardiac surgery, were postoperatively assigned to one of two treatment regimens for sedation in the ICU for 12 to 72 hours. Patients in the remifentanil/propofol group received remifentanil (6- max. 60 μg kg-1 h-1; dose exceeds recommended labelling). Propofol (0.5 to 4.0 mg kg-1 h-1) was supplemented only in the case of insufficient sedation at maximal remifentanil dose. Patients in the midazolam/fentanyl group received midazolam (0.02 to 0.2 mg kg-1 h-1) and fentanyl (1.0 to 7.0 μg kg-1 h-1). For treatment of pain after extubation, both groups received morphine and/or non-opioid analgesics.
Results
The time intervals (mean values ± standard deviation) from arrival at the ICU until extubation (20.7 ± 5.2 hours versus 24.2 h ± 7.0 hours) and from arrival until eligible discharge from the ICU (46.1 ± 22.0 hours versus 62.4 ± 27.2 hours) were significantly (p < 0.05) shorter in the remifentanil/propofol group. Overall costs of the ICU stay per patient were equal (approximately €1,700 on average).
Conclusion
Compared with midazolam/fentanyl, a remifentanil based regimen for analgesia and sedation supplemented with propofol significantly reduced the time on mechanical ventilation and allowed earlier discharge from the ICU, at equal overall costs.
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Remifentanil as a sedative agent
Use of remifentanil as a sedative agent in critically ill adult patients: a meta-analysis
This meta-analysis examined the benefits of using remifentanil as a sedative agent in critically ill
patients. A total of 11 randomised controlled trials, comparing remifentanil with another opioid or
hypnotic agent in 1067 critically ill adult patients, were identified from the Cochrane controlled
trials register and EMBASE and MEDLINE databases, and subjected to meta-analysis. Remifentanil
was associated with a reduction in the time to tracheal extubation after cessation of sedation
(weighted-mean-difference )2.04 h (95% CI )0.39 to )3.69 h); p = 0.02). Remifentanil was,
however, not associated with a significant reduction in mortality (relative risk 1.01 (95% CI 0.67–
1.52); p = 0.96), duration of mechanical ventilation, length of intensive care unit stay, and risk of
agitation (relative risk 1.08 (95% CI 0.64–1.82); p = 0.77) when compared to an alternative
sedative or analgesic agent. The current evidence does not support the routine use of remifentanil
as a sedative agent in critically ill adult patients.
Para download
This meta-analysis examined the benefits of using remifentanil as a sedative agent in critically ill
patients. A total of 11 randomised controlled trials, comparing remifentanil with another opioid or
hypnotic agent in 1067 critically ill adult patients, were identified from the Cochrane controlled
trials register and EMBASE and MEDLINE databases, and subjected to meta-analysis. Remifentanil
was associated with a reduction in the time to tracheal extubation after cessation of sedation
(weighted-mean-difference )2.04 h (95% CI )0.39 to )3.69 h); p = 0.02). Remifentanil was,
however, not associated with a significant reduction in mortality (relative risk 1.01 (95% CI 0.67–
1.52); p = 0.96), duration of mechanical ventilation, length of intensive care unit stay, and risk of
agitation (relative risk 1.08 (95% CI 0.64–1.82); p = 0.77) when compared to an alternative
sedative or analgesic agent. The current evidence does not support the routine use of remifentanil
as a sedative agent in critically ill adult patients.
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