Abstract
Purpose
To study the analgesic and sedative effects of remifentanil in critically-ill patients.
Methods
Remifentanil infusion was started at 0.02 μg·kg−1·min−1 in ten mechanically ventilated critically-ill patients, and the infusion rate was increased to 0.05, 0.10, 0.15, 0.20, and 0.25 μg·kg−1·min−1 every 30 min. Basally and 25 min after each increase we measured: the Ramsey sedation score (RSS) and the respiratory response subscore of comfort scale (CSRR); the bispectral index (BIS) before and after lightly touching tracheal mucosa; heart rate and systemic arterial pressure; respiratory variables; plasma epinephrine and norepinephrine levels.
Results
Infusion rates up to 0.05 μg·kg−1·min−1 were effective against agitation and achieved a good degree of adaption to the respirator in all patients (RSS 2 or more and CSRR 3 or less); BIS decreased significantly; respiratory and circulatory variables were unaffected; mean plasma epinephrine levels decreased. At infusion rates higher than 0.05 μg·kg−1·min−1 RSS but not BIS decreased further and patient arousability caused by noxious stimuli was not prevented; respiratory drive suppression occurred at the infusion rates higher than 0.05 μg·kg−1·min−1 in four patients; bradycardia and arterial hypotension was observed in three patients; plasma epinephrine levels decreased significantly, while norepinephrine was unaffected; severe itching was experienced by one patient.
Conclusions
Low doses of remifentanil (upto 0.05 μg·kg−1·min−1) can be useful in critically-ill patients in order to achieve calm and sedation. Higher doses can inhibit respiratory drive and require controlled mechanical ventilation.
Zusammenfassung
Objectif
Étudier les effets analgésiques et sédatifs du rémifentanil chez de grands malades.
Méthode
Une perfusion de rémifentanil a été amorcée à 0,02 μg·kg−1·min−1 chez dix grands malades ventilés mécaniquement. La vitesse de perfusion a été augmentée à 0,05, 0,10, 0,15, 0,20 et 0,25 μg·kg−1·min−1 toutes les 30 min. Au début, et 25 min après chaque augmentation, nous avons mesuré : les scores de sédation de Ramsey (SSR) et le score auxiliaire de réponse respiratoire de l’échelle de confort (RREC); l’index bispectral (BIS) avant et après avoir légèrement stimulé la muqueuse trachéale; la fréquence cardiaque et la tension artérielle générale; les variables respiratoires; les niveaux plasmatiques d’adrénaline et de noradrénaline.
Résultats
Les vitesses de perfusion allant jusqu’à 0,05 μg·kg−1·min−1 ont été efficaces contre l’agitation et ont permis une bonne adaptation au respirateur chez tous les patients (2 ou moins à SSR et 3 ou moins à RREC); le BIS a diminué de manière significative; les variables respiratoires et circulatoires n’ont pas été affectées; il y a eu une baisse des niveaux plasmatiques d’adrénaline et de noradrénaline. Sous des vitesses de perfusion plus élevées que 0,05 μg·kg−1·min−1, le SSR, mais non le BIS, a baissé davantage et la réaction des patients aux stimuli nuisibles n’a pu être empêchée; la suppression de la commande respiratoire s’est produite avec des perfusion audessus de 0,05 μg·kg−1·min−1 chez quatre patients; on a observé de la bradycardie et de l’hypotension chez trois patients; les niveaux plasmatiques d’adrénaline ont baissé significativement, mais ceux de la noradrénaline n’ont pas changé; un prurit sévère a été noté chez un patient.
Conclusion
Des doses faibles de rémifentanil (jusqu’à 0,05 μg·kg−1·min−1) peuvent apporter calme et sédation chez de grands malades. Des doses plus élevées peuvent inhiber la commande respiratoire et exiger une ventilation mécanique contrôlée.
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Cavaliere, F., Antonelli, M., Arcangeli, A. et al. A low-dose remifentanil infusion is well tolerated for sedation in mechanically ventilated, critically-ill patients. Can J Anesth 49, 1088–1094 (2002). https://doi.org/10.1007/BF03017909
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DOI: https://doi.org/10.1007/BF03017909