Remifentanil patient-controlled analgesia following cardiac surgery

Neonatal Outcomes in Labor After Intravenous Remifentanil Analgesia vs. Epidural Analgesia: A Retrospective Observational Study

Background Some evidence indicates that maternal analgesia during labor may have adverse effects on neonates due to exposure to specific drugs or the potential effects of analgesia on the course of labor. We assessed the clinical outcome of term neonates born to mothers who received epidural analgesia (E) or systemic analgesia with remifentanil (R) during labor. Methods Data was collected retrospectively over one year. We have evaluated the medical records of 247 full-term neonates; 208 were born to mothers who received E and 39 to mothers who received R. Data on Apgar scores and neonatal complications (perinatal asphyxia, respiratory distress, infection, hyperbilirubinemia, and birth injuries), and average hospital stay were collected. Mann-Whitney U test, chi-square test, and logistic regression analysis were used where appropriate. Results The values of the mean Apgar scores between E and R at 1 and 5 minutes were similar (8.83 vs. 8.97, p = 0.252; 9.81 vs. 9.87, p = 0.762, respectively). The average length of neonatal hospitalization did not differ between groups (4.19 vs. 4; p = 0.557). The percentages of neonates with any complication were similar between groups (28.3% vs. 32.5%, p = 0.598). Neonates born by cesarean delivery (CD) had significantly worse outcomes than those born vaginally (p = 0.008, OR 2.8, 95% CI [1.30, 6.17]). Conclusion We did not find a statistically significant difference in mean Apgar scores and neonatal complications between neonates who received epidural vs. remifentanil analgesia. An increased rate of complications in neonates born via CD was found. Future studies should have a larger sample size and be powered to detect associations in these findings.

The efficacy and safety of remifentanil patient-controlled versus epidural analgesia in labor: A meta-analysis and systematic review

BACKGROUND

Remifentanil patient-controlled analgesia (rPCA) and epidural analgesia (EA) has been used for pain relief in labor. We aimed to evaluate the efficacy and safety of rPCA versus EA in labor, to provide evidence support for clinical analgesia and pain care.

METHODS

We searched PubMed, EMBASE, ScienceDirect, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang and Weipu databases for RCTs comparing rPCA and EA in labor until February 15, 2022. Two researchers independently screened literature and extracted data. RevMan 5.3 software was used for data analysis.

RESULTS

A total of 10 RCTs involving 3086 parturients were enrolled, 1549 parturients received rPCA and 1537 received EA. Meta-analysis indicated that the incidence of intrapartum maternal fever within 1 hour of labor analgesia (OR = 0.43, 95%CI: 0.30~0.62), after 1 hour of labor analgesia (OR = 0.42, 95%CI: 0.20~0.90) in the rPCA was significantly less than that of EA (all P<0.05). The incidence of respiratory depression (OR = 3.56, 95%CI: 2.45~5.16, P<0.001) in the rPCA was significantly higher than that of EA. There were no significant differences in the incidence of Apgar scores<7 at 5 minutes (OR = 1.18, 95%CI: 0.71~1.96, P = 0.53), the patients' satisfaction of pain relief during labor analgesia (SMD = 0.03, 95%CI: -0.40~0.46, P = 0.90) between rPCA and EA (all P>0.05).

CONCLUSION

rPCA can be an optional alternative to EA with similar pain relief and less risk of intrapartum maternal fever. However, rPCA was associated with increased risk of respiratory depression. Future studies with rigorous design and larger sample size are needed to provide more reliable evidences for clinical rPCA and EA use.

Comparison between remifentanil and other opioids in adult critically ill patients: A systematic review and meta-analysis

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.

Curative effect of remifentanil on labor analgesia in newborns

Objective: To investigate the curative effect of remifentanil on analgesia in newborns.Patients and methods: One hundred and twenty full-term puerperae from January 2013 to December 2013 were selected and randomly divided into three groups: remifentanil patient-controlled intravenous labor analgesia group (Group A, n = 40), patient-controlled epidural analgesia (PCEA) group (Group B, n = 40), and spontaneous labor group (Group C, n = 40). General conditions, visual analogue scale (VAS) score, labor stage, bleeding, delivery mode, neonatal asphyxia rate, oxyhemoglobin saturation in puerpera, and umbilical arterial blood gas analysis indexes of the fetus were measured. In addition, complications and adverse reactions were recorded.Results: VAS scores in Group A and B were significantly lower than that in Group C at each time point after analgesic intervention (p < .05), without differences at 30 min and 1 h after analgesia between Group A and B (p > .05). However, VAS scores in Group A were significantly higher than those in Group B at the full opening of the uterine orifice and fetal delivery (p < .05). The active phases in the first stage of labor in Group A and B were significantly shorter than that in Group C (p <.05). There were no significant differences in general conditions, VAS score before analgesia, the second and third stages of labor, delivery mode, bleeding, neonatal asphyxia rate, oxyhemoglobin saturation, pH value, partial pressure of oxygen (PO₂), and partial pressure of carbon dioxide (PCO₂) among three groups (p > .05).Conclusions: Remifentanil intravenous labor analgesia is not superior to PCEA, but does not increase adverse effects, suggesting it might be a supplementary method of PCEA.

Coadministration of intravenous remifentanil and morphine for post-thoracotomy pain: comparison with intravenous morphine alone

OBJECTIVES

In this double-blind, randomized study, the authors compared the effects of a patient-controlled remifentanil and morphine combination with morphine alone on post-thoracotomy pain, analgesic consumption, and side effects.

DESIGN

A prospective, randomized, double-blind clinical study.

SETTING

University hospital.

PARTICIPANTS

Volunteer patients at a university hospital undergoing elective thoracotomy surgery.

INTERVENTIONS

Patients were allocated randomly into 2 groups to receive patient-controlled analgesia: the morphine (M) group or the morphine plus remifentanil (MR) group. Pain, discomfort, sedation scores, cumulative patient-controlled morphine consumption, rescue analgesic (meperidine) requirement and side effects were recorded for 24 hours.

MEASUREMENTS AND MAIN RESULTS

Sixty patients were allocated randomly to receive intravenous patient-controlled analgesia with morphine alone (M) or morphine plus remifentanil (MR) in a double-blind manner. Patients were allowed to use bolus doses of morphine (0.02 mg/kg) or the same dose of a morphine plus remifentanil (0.2 µg/kg) mixture every 10 minutes without a background infusion. VAS scores were lower in the MR group than in the M group at 30 minutes (p = 0.04), 1 hour (p = 0.03), and 2 hours (p = 0.04). Mean cumulative doses of morphine were not significantly different at 27.8±15 mg for the M group and 21.9±10.5 mg for the MR group. Significantly more patients needed meperidine in the M group (p = 0.039); these also experienced more nausea (p = 0.01).

CONCLUSIONS

Coadministration of PCA remifentanil with morphine for the treatment of post-thoracotomy pain did not reduce morphine consumption but provided superior analgesia, less use of rescue analgesics, and fewer side effects compared to morphine alone.

Intravenous patient-controlled remifentanil versus paracetamol in post-operative pain management in patients undergoing coronary artery bypass graft surgery

Background:

Pain management after cardiac surgery has been based on parenteral long-acting opioids such as morphine. The other alternatives are paracetamol and remifentanil.

Objectives:

In this prospective, double-blind, randomized study, we compared the efficacy of intravenous patient-controlled analgesia (IV-PCA) paracetamol and remifentanil for post cardiac surgery pain relief.

Materials and Methods:

One-hundred patients scheduled for elective coronary artery bypass grafting from May to October 2011, were randomized into two groups after the surgery. For the first group (group R, n = 50, with mean age of 58.16 ± 11.80), the IV-PCA protocol was remifentanil infusion 100 μg/h; bolus of 25 μg and lockout time of 15 minutes. In the second group (group P, n = 50, with mean age of 53.8 ± 15.08), patients received paracetamol 15 mg/kg as a bolus at the end of surgery and then IV-PCA protocol was 100 μg/h, bolus of 25 μg; and lockout time of 15 minutes. Pain was assessed with visual analog scale score (VAS) in the first 24 hours after surgery for seven times.

Results:

The trend of pain scores did not have any significantly difference between group R and group P except for hour 8 and hour 18 after surgery that VAS was significantly lower in group P than group R (P = 0.031, P = 0.023, respectively). Respiratory rate (RR) was also statistically lower in group R comparing to group P in all seven evaluating times. The groups were similar in terms of hemodynamic, ABG results (except for PaO₂, which was significantly lower in group R than group P at 6 evaluating times), intubation time, renal function tests, and incidences of atelectasis, myocardial infarction or adverse effects.

Conclusions:

Both PCA techniques provided effective pain scores (< 3) after cardiac surgery; but generally, PCA-paracetamol infusion has a better analgesic effect.

Patient-controlled analgesia after coronary bypass: Remifentanil or sufentanil?

Background

adequate pain control after cardiac surgery is mandatory to reduce its remarkable morbidity. In this study, we aimed to compare the efficacy of patient-controlled analgesia with remifentanil or sufentanil for pain management after coronary artery bypass grafting.

Methods

249 patients who underwent coronary artery bypass were randomly assigned to receive patient-controlled analgesia with remifentanil or sufentanil during the first 24 h postoperatively. Pain intensity during patient-controlled analgesia was assessed using 4 different pain rating scales.

Results

patients given remifentanil had lower Visual Analog Scale scores at 24 h compared to those given sufentanil ( p = 0.002). The Numeric Rating Scale at 24 h was also significantly lower in patients using remifentanil ( p = 0.004). The Faces Pain Scale scores at 4, 18, and 24 h were significantly lower in patients using remifentanil compared to those using sufentanil ( p = 0.045, 0.036, and 0.011, respectively). No significant differences between groups were seen in the pain intensity assessed by the Behavior Rating Scale at any time point during the first 24 h postoperatively.

Conclusion

our study showed that both remifentanil and sufentanil patient-controlled analgesia can provide acceptable analgesia after coronary artery bypass. The difference between their efficacies was inconspicuous until 24 h postoperatively. Remifentanil seems to result in better pain relief at 24 h postoperatively.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Remifentanil apnea: Case report and review of the literature

Remifentanil is an opioid analgesic frequently used in intensive care patients because of its rapid onset of action, potency, and ultra-short duration. If an excessive dose is given, it leads to rapid, short lasting, potentially life-threatening side effects such as apnea, bradycadia, hypotension, and rigidity, following rapid peak serum levels. We report a 36-year-old woman developing apnea with bradycardia and hypotension, following an infusion in the central venous catheter lumen that had been used for remifentanil till tracheal extubation. The patient was immediately ventilated with bag-valve-mask and improved within 8 minutes. She became fully awake, heart rate and blood pressure returned to normal, and oxygen saturation improved to 100%. Acute care physicians, intensivists, anesthesiologists, and critical care nurses should be aware of this clinical problem in order prevent it as much as possible and to initiate immediate resuscitative measures.

Continuous infusion of two doses of remifentanil immediately after laparoscopic-assisted vaginal hysterectomy

Background

We evaluated the effect and safety of the immediate postoperative continuous infusion of remifentanil at two doses in patients undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) with alfentanil-based patient-controlled analgesia (PCA).

Methods

The study enrolled 50 ASA physical status 1 or 2 patients scheduled to undergo LAVH. Anesthesia was maintained with sevoflurane-remifentanil-air. At the last skin suture, the sevoflurane was discontinued, and patients were randomized to receive remifentanil 0.05 µg/kg/min (group I) or 0.1 µg/kg/min (group II). PCA was started at the time of eye opening and response to a verbal command. In the recovery room, we monitored the mean arterial blood pressure (MAP), heart rate (HR), respiratory rate (RR), SpO₂, and bispectral index (BIS) at 5-minute intervals. Thirty minutes after starting PCA, the remifentanil was discontinued. Pain was assessed using a visual analog scale (0 = no pain; 100 = the worst possible pain) at 0, 5, 10, and 30 minutes after stopping the remifentanil infusion.

Results

The eye opening time, BIS, MAP, and HR did not differ significantly between the two groups, and pain scores were similar between the two groups. Respiratory depression (SpO₂ < 90% or RR < 8/min) did not occur in group I but did occur in three patients in group II.

Conclusions

Continuous remifentanil infusion (0.05 µg/kg/min) immediately postoperatively with alfentanil-based PCA had a similar effect as a 0.1 µg/kg/min infusion with respect to pain control without side effects. However, special attention must be given to respiratory depression.

[Intravenous remifentanyl for labor analgesia]

BACKGROUND

Intravenous remifentanil may be the preferred analgesic when regional techniques are contraindicated.

OBJECTIVE

To perform a systematic review on the use of remifentanil for analgesia in labor.

METHODS

We searched MEDLINE (January 1995-August 2007) for studies on obstetric analgesia with remifentanil.

RESULTS

We found 32 references representing the use of remifentanil in 257 women in labor. In most cases, patients reported relief of pain and a high level of satisfaction, with no severe side effects in mothers or neonates. When compared with meperidine and nitrous oxide in clinical trials, remifentanil provided better analgesia with fewer adverse effects.

CONCLUSION

Analgesia with intravenous remifentanil is more effective and safer than other alternatives to regional analgesic techniques in obstetrics. Nevertheless, the optimum system for infusing the drug must b e established and further studies of maternal and fetal safety should be carried out.

Comparison of remifentanil and fentanyl for postoperative pain control after abdominal hysterectomy

PURPOSE

In this randomized, double-blind study, we investigated the analgesic efficacy and side effects of continuous constant-dose infusions of remifentanil after total abdominal hysterectomy and compared it to fentanyl.

MATERIALS AND METHODS

Fifty-six adult female patients scheduled for elective total abdominal hysterectomy were enrolled in this study. Patients were randomly assigned to two groups according to fentanyl (group F, n=28) or remifentanil (group R, n=28) for postoperative analgesia. Patients in group F were given fentanyl intravenously with an infusion rate of fentanyl 0.5 microg/kg/hr; group R was given remifentanil with an infusion rate of remifentanil 0.05 microg/kg/min for 2 days. Pain intensity at rest, occurrence of postoperative nausea and vomiting (PONV), dizziness, pruritus, and respiratory depression were assessed 1 hr after arrival at the post-anesthesia care unit, at 6; 12; 24; and 48 hr post-operation and 6 hr post-infusion of the study drug. Pain was evaluated by using visual analogue scale (VAS; 0-10). The time that patients first requested analgesics was recorded as well as additional analgesics and antiemetics.

RESULTS

There were no significant differences in VAS, time to first postoperative analgesics, and additional analgesics between the 2 groups. The incidences and severities of PONV and opioid related side effects were not different between the groups; however, there were 3 episodes (10.7%) of serious respiratory depression in group R.

CONCLUSION

Continuous infusion technique of remifentanil did not reveal any benefits compared to fentanyl. Furthermore, it is not safe for postoperative analgesia in the general ward.

The effects of single-dose tramadol on post-operative pain and morphine requirements after coronary artery bypass surgery

AIM

To investigate the effects of a single dose of tramadol administered prior to extubation on post-operative pain and morphine consumption after coronary artery bypass surgery.

METHODS

Patients were randomized post-operatively into two groups (group T, n= 30; group P, n= 30). The technique of anaesthesia was standardized for all patients. The patients in group T received intravenous tramadol, 1 mg/kg, and the patients in group P received 2 ml of saline 0.9%, both approximately 1 h before extubation. After extubation, all patients were allowed to use the morphine patient-controlled analgesia (PCA) device for 24 h post-operatively. Post-operative data were recorded in the cardiac intensive care unit at 30 min, 1 h, 2 h, 4 h, 12 h and 24 h after extubation by the same anaesthesiologist, who had no knowledge of the groups, and the side-effects were also evaluated.

RESULTS

In group P, the visual analogue scale (VAS) scores were found to be higher 30 min (P < 0.01), 1 h (P < 0.01), 2 h (P < 0.01) and 4 h (P < 0.05) after extubation. The patient comfort scores were higher in group T 30 min (P < 0.01), 1 h (P < 0.05), 2 h (P < 0.01) and 4 h (P < 0.01) after extubation. The total morphine consumption was higher in group P at all evaluation times (P < 0.01), and the numbers of PCA demands and boluses were also higher in group P (P < 0.01).

CONCLUSIONS

The study demonstrated that a single dose of tramadol administered prior to extubation following coronary artery bypass surgery is associated with a decrease of up to 25% in morphine consumption, a decrease in the VAS scores and an improvement in patient comfort within the first 4 h post-operatively.