Remifentanil-based analgesia and sedation facilitates more rapid and predictable time to neurological assessments

Introduction

Predictable pharmacokinetics and organ-independent elimination allows remifentanil hydrochloride (Remi) to be easily titrated to provide optimal analgesia with rapid dissipation of effects even after prolonged infusions in critically ill patients. Remi-based analgesia and sedation supplemented with propofol (P) or midazolam (Mid) was compared with a hypnotic-based technique using fentanyl (Fent) or morphine (Morph) in combination with P or Mid for up to 5 days in 161 mechanically ventilated neurotrauma patients.

Methods

Open-label treatment with Remi, Fent or Morph was randomised 2:1:1. Remi infusion was started at 9 μg/kg/hour and titrated to effect. Supplemental P (days 1–3) or Mid (days 4–5) was introduced at a Remi infusion rate of 18 μg/kg/hour to provide optimal sedation (SAS 1–3) and analgesia (none/mild pain). Fent or Morph were administered with P or Mid according to routine practice. Study drugs were reduced/stopped for daily scheduled assessments of neurological function.

Results

From an observed case analysis (on log-transformed data), the overall mean neurological assessment time (unpaired t test) and between-subject variability (F test) around the assessment time were significantly reduced in the Remi group compared with Fent and Morph. Table 1 presents the median (range) time from reducing analgesia/sedation until neurological assessment (hours).

Table 1

Conclusion

The time to assessment of neurological function can be achieved significantly faster and more predictably when using remifentanil-based analgesia and sedation.