Comparative Efficacy of Fentanyl and Morphine in Patients with or At Risk for Acute Respiratory Distress Syndrome: A Propensity Score-Matched Cohort Study

Endogenous opiates and behavior: 2021

This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Early Sedation Depth and Clinical Outcomes in Mechanically Ventilated Patients in a Hospital: Retrospective Cohort Study

PURPOSE

This study aimed to identify the early sedation depth in the first 48 hours of mechanical ventilation and its relationship to clinical outcomes to promote the transition to light sedation.

METHODS

This retrospective single-center cohort study was conducted in two medical intensive care units (MICUs) at a general tertiary hospital, using a standardized sedation protocol. To investigate the early sedation depth, the Sedation Index was used, which can indicate changes over the first 48 hours. Patients were divided into three groups based on tertiles of Sedation Index. The primary outcome was mortality at 30, 90, and 180 days. The secondary outcomes included length of stay in the ICU and ventilator-free days. Kaplan-Meier analysis and multivariable Cox regression were conducted to compare factors influencing mortality.

RESULTS

This study included 394 patients. The deepest sedation group showed more severe illness, delirium, and deeper sedation at admission (p < .001). The survival curve decreased as sedation increased, even within the light sedation levels. In the deepest sedation group, 30-day mortality (hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.33-3.34), 90-day mortality (HR 2.00, 95% CI 1.31-3.06), and 180-day mortality (HR 1.77, 95% CI 1.17-2.67) increased. The length of stay in the ICU and ventilator-free days did not show statistical differences.

CONCLUSIONS

These results indicate that early deep sedation is a modifiable factor that can potentially affect mortality. The protocol for inducing the transition into light sedation must comply with recommendations to improve clinical outcomes.

Effects of fentanyl administration in mechanically ventilated patients in the intensive care unit: a systematic review and meta-analysis

BACKGROUND

Fentanyl is selected to manage pain in critical care patients on mechanical ventilation in the intensive care unit (ICU). However, the usefulness of fentanyl compared with other opioids is unknown. This study examined the evidence for using fentanyl to improve the clinical outcomes of ICU patients, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

METHODS

We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases in June 2021. Two independent assessors reviewed studies to identify randomized, controlled trials (RCTs) that compared the intravenous administration of fentanyl and other opioids in mechanically ventilated patients in the ICU. The study quality was assessed using the GRADE system and Cochrane methodology. The primary outcome was mortality. The secondary outcomes were the duration of mechanical ventilation, duration of the ICU stay, incidence of severe adverse events, and incidence of delirium. We integrated outcome data using a random-effects model and showed absolute values and certainty of evidence in the GRADE evidence profile.

RESULTS

Seven RCTs met the study inclusion criteria with 534 patients (251 were treated with fentanyl and 283 with other opioids, including 242 with remifentanil and 41 with morphine). Among 191 participants from 2 RCTs, fentanyl was not associated with mortality (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.24 to 2.60; low-quality evidence). Regarding the secondary outcomes, fentanyl did not shorten the duration of mechanical ventilation (mean difference, 0.49 h; 95% CI, - 0.90 to 1.88; moderate-quality evidence) or the duration of the ICU stay (mean difference, 7.04 h; 95% CI, - 3.27 to 17.35; moderate-quality evidence) compared with other opioids. Fentanyl did not increase the incidence of severe adverse events (RR, 0.98; 95% CI, 0.50 to 1.90; low-quality evidence) or delirium (RR, 1.27; 95% CI, 0.79 to 2.04; low-quality evidence).

CONCLUSIONS

Although fentanyl is a frequently administered opioid in the ICU, patients' outcomes are not different between fentanyl use and use of other opioids. However, the GRADE evaluation provides little certainty to support the results of this systematic review. Therefore, further large RCTs are required to confirm our conclusions.

TRIAL REGISTRATION

PROSPERO, CRD42019130648 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130648 ).