Remifentanil In Icu @ Mri
-
Upload
university-of-manchester -
Category
Health & Medicine
-
view
2.552 -
download
1
description
Transcript of Remifentanil In Icu @ Mri
Remifentanil in ICU @ Manchester Royal Infirmary
Daniel Conway
Consultant in Critical Care
Manchester Royal Infirmary
Sedation & Analgesia on ICU – an uncomfortable paradigm
Traditional analgesics will accumulate over time + metabolites
Painful procedures, general discomfort should be treated
Excess sedation extends length of stay and may worsen PTSD symptoms
Inadequate sedation or analgesia may worsen PTSD symptoms
Moving Away from Sedation
• Early detection of neurological problems– Stroke / bleeds / hypoxia– Delirium
• Early extubation before tracheostomy• ‘Fast track’ major surgery with regional
analgesia• Withdrawal and weaning• Reduced ICU length of stay
Shorter Acting Agents
• Propofol Carsson, Kress Crit Care Med 2006
– Rapid offset due to redistribution– Hypotension & ? acidosis
• Alfentanil– Minimal metabolites– Less accumulation than morphine & fentanyl
• Remifentanil– Esterase metabolism– Rapid offset
Remifentanil Pharmacokinetics
• Rapid offset 6-8 minutes
• Independent of Renal / Hepatic Function
• Independent of BMI
• Titratable– Analgesia– Respiratory depression
Stable context sensitive t1/2
Egan Anaesthesiology 1993;79: 881-92
Hypnotic or Narcotic ????
Hypnotic or Narcotic ????
BDZ & Propofol• GABA agonist• Anxiolytic / amnesic• Prolong Ventilation• Cause delirium• Contribute to long
term cognitive dysfunction
Opioids & α2 agonists
• Hypotensive• Analgesic• Withdrawal phenomena• Less delirium ?• Long term cognition?
Remifentanil on ICU?
• Neurological examination
• Analgesia for procedures
• Patients with hepatic and renal impairment
• Fast track extubations– Surgical– Short stay medical eg overdose
• All Patients who require analgesia ????
Remifentanil on general ICU Breen D, Karabinis A et al Crit Care 2005
• Open Label RCT remi v midaz/ morph fent
• 105 patients in 15 ICU’s
• Exclusions: NMBA, surgery, epidural, sensit
• Remi dose 0.2 mcg/kg/min
• Time to extubation, LOS on ICU
• SAS, Pain Index, mAP, 6 day follow up
Remifentanil on ICU Breen D, Karabinis A et al Crit Care 2005
• ↓ Midaz dose
• Similar Sedation & Pain scores
• ↑ Vomiting with remi
• Non-sig ↓ in ICU LOS with remi
Remifentanil on ICU Breen D, Karabinis A et al Crit Care 2005
• Re-intubations 7/25 remi v 2/12 hypnotic
Head Injury
Remifentanil With Head Injury Karabinis A et al Crit Care (2004)
• Analgesia based v hypnotic regime – Remifentanil v Fentanyl v Morphine– Midazolam or propofol also used
Remifentanil 15mcg/kg/hr (0.25mcg/kg/min)
• 161 patients in 17 hospitals open label RCT
• LOS, SAS, mAP, HR, ICP and CPP
• Time to extubation
Remifentanil With Head Injury
Karabinis A et al Crit Care 2004
• Similar mAP HR• No difference in ICP or
CPP• ↓ Propofol requirement• Optimal sedation
– 95% of time – remi– 99% of time -
fentanyl
Improved time to neurological assessment with remi
Karabinis A et al Crit Care 2004
Hypnotic v Analgesic sedationPark, Lane B J Anaes 2007
• 12 wk hypnotic based drugs
• 12 wk analgesics (predominantly remi)
• All ventilated patients
• Excluded if NMBA
• Looked at Mortality / LOS / dreams memory
• Looked at drug use
Hypnotic v Analgesic sedationPark, Lane B J Anaes 2007
• 111 Hyp and 96 Ana patients
• Age 58 v 56
• APACHE II 16.5 v 18.1
• ICU Mortality 23% v 26%
• Hosp Mortality 31% v 35%
• Time on Vent 37h v 71h n/s
• LoS ICU 67 v 118
Hypnosis v AnalgesiaPark, Lane BJA 2007
• 37% of patients could be managed with remifentanil alone
• 40-50% experienced dreams or hallucinations which most found unpleasant
• 5 accidental extubations in analgesic (3 on remi) vs 2 in hypnotic
• Remi reduced propofol requirements
Remifentanil on ICU: Tolerance, Side Effects and Withdrawal
It’s an opioid !• Tolerance with prolonged infusion Vinik An Anal 98
• Side Effects– Bradycardia and Hypotension– Nausea/Vomiting/Ileus– Respiratory Depression
• Withdrawal phenomena Apitzsch Anaesthetist 99
Remifentanil and GlycineBonnet MP, Benhamou D et al Int Care Med 07
• Glycine: inhibitory neurotransmitter
• Remi powder has 3mg glycine for each mg remi
• 72 hour infusion, toxic levels NOT reached
• Correlation between remi rate and glycine levels
• Glycine accumulation with ↓ Creat CL
Remifentanil in Manchester
Implementing Remifentanil @ MRI
• Consultants Agree Patient Group
• Pharmacist produces guidelines
• Nurse Education Practitioner
• Regular Meetings
• Audit use month on month
• Guidelines modified
Remifentanil on ICU @ MRI
• Indication– Analgesia and sedation– Head injury / early extubation– Hepatic and Renal Impairment
• Contra-indications– Spont Vent or NIV or paralysed– Opioid intolerance– Bolus administration
Remifentanil Guideline MRI
• Duration 3 Days max
• Constitution– 100μg/ml in 50 ml N/Sal or 5%Dex
• Withdrawal– Stop infusion if no further analgesia– Reduce by 25% every 15min if alt analgesic
Start Anxiolysis propofol or midazolam
Patient needs analgesia/sedation
Patient needs further analgesia/sedation
Not For Remifentanil
Patient paralysed/ encephalopathic
6mcg/kg/h Remifentanil
Increase Remifentanil 1.5 mcg/kg/h
At 12mcg/kg/h Remifentanil
Patient still needs analgesia/sedation
If remains in pain increase remifentanil 15mcg/kg/h + propofol or midazolam AND D/W Doctor
Case Study 1
• 72 yr man, alcoholic liver disease• Urinary obstruction and sepsis• Acute on chronic renal failure• Agitated & Hypoxic ?? needs CVVH, • Ventilated 40 hours• Renal function improves without CVVH• Remifentanil and propofol stopped • Extubated & sent to ward next day
Case Study 2
• 38 yr woman, Tracheal reconstruction surgery. Surgeons want sedated 48hrs
• Remifentanil peri-op
• Taken back to theatre day 1
• Remifentanil & propofol continued 48 h
• Controlled titration of remifentanil until patient awake and not agitated / coughing
Summary: Remifentanil on ICU
• Short acting opioid for analgesia & sedation
• Useful in renal patients
• May facilitate early extubation
• Take care when stopping infusions
• Staff training was essential
• Start Pain Scores
nfusion rates of remifentanil by body weight using a 100μg/mL solution Body
weight (kg)
6 μg/kg/h(mL/h)
9 μg/kg/h (mL/h)
12 μg/kg/h (mL/h)
15 μg/kg/h (mL/h)
40 2.4 3.6 4.8 6.0
45 2.7 4.1 5.4 6.8
50 3.0 4.5 6.0 7.5
55 3.3 5.0 6.6 8.3
60 3.6 5.4 7.2 9.0
65 3.9 5.9 7.8 9.8
70 4.2 6.3 8.4 10.5
75 4.5 6.8 9.0 11.0
80 4.8 7.2 9.6 12.0
85 5.1 7.7 10.2 12.8
90 5.4 8.1 10.8 13.5
95 5.7 8.6 11.4 14.3
100 6.0 9.0 12.0 15.0
105 6.3 9.5 12.6 15.8
110 6.6 9.9 13.2 16.5
115 6.9 10.4 13.8 17.3
120 7.2 10.8 14.4 18.0
• Key messages In neurotrauma patients requiring intensive care for up to 5 days, analgesia-based sedation using remifentanil compared with a standard hypnotic-based technique provided the following:
• • a significant reduction in the mean time taken to wake the patient for assessment of neurological function;• a significantly reduced mean between-patient variability in the time to wake-up, making the performance of this assessment more predictable;• a significantly shorter time to extubation than with a hypnotic-based regimen using morphine as the analgesic;• no clinical differences in pain and sedation scores;• a trend towards reduced dosing with propofol;• comparable haemodynamic and cerebral haemodynamic stability;• higher user satisfaction rating by physicians and nurses;• a similar safety profile.