Research

Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: a randomised trial [ISRCTN47583497]

Des Breen¹ , Andreas Karabinis² , Manu Malbrain³ , Rex Morais⁴ , Sven Albrecht⁵ , Inge-Lise Jarnvig⁶ , Pauline Parkinson⁷ and Andrew JT Kirkham⁸

¹Consultant in Anaesthesia and Intensive Care, Royal Hallamshire Hospital, Sheffield, UK

²Director of Intensive Care Unit, Genimatas General Hospital, Athens, Greece

³Director of Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, Antwerpen, Belgium

⁴Consultant Anaesthetist, Intensive Care Unit, Dubai Hospital, Dubai, United Arab Emirates

⁵Deputy Director, Universität Erlangen-Nürnberg, Klinik für Anästhesiologie, Erlangen, Germany

⁶Senior Registrar, Intensive Care Unit, Righospitalet, Copenhagan, Denmark

⁷Clinical Scientist, Neurosciences Medicines Development Centre, GlaxoSmithKline, Greenford, Middlesex, UK

⁸Clinical Development Director, Neurosciences Medicines Development Centre, GlaxoSmithKline, Greenford, Middlesex, UK

author email corresponding author email

Critical Care 2005, 9:R200-R210doi:10.1186/cc3495

Published:	15 March 2005

See related commentary http://ccforum.com/content/9/3/247

Abstract

Introduction

This randomised, open-label, multicentre study compared the safety and efficacy of an analgesia-based sedation regime using remifentanil with a conventional hypnotic-based sedation regime in critically ill patients requiring prolonged mechanical ventilation for up to 10 days.

Methods

One hundred and five randomised patients received either a remifentanil-based sedation regime (initial dose 6 to 9 μg kg^-1 h^-1 (0.1 to 0.15 μg kg^-1 min^-1) titrated to response before the addition of midazolam for further sedation (n = 57), or a midazolam-based sedation regime with fentanyl or morphine added for analgesia (n = 48). Patients were sedated to an optimal Sedation–Agitation Scale (SAS) score of 3 or 4 and a pain intensity (PI) score of 1 or 2.

Results

The remifentanil-based sedation regime significantly reduced the duration of mechanical ventilation by more than 2 days (53.5 hours, P = 0.033), and significantly reduced the time from the start of the weaning process to extubation by more than 1 day (26.6 hours, P < 0.001). There was a trend towards shortening the stay in the intensive care unit (ICU) by 1 day. The median time of optimal SAS and PI was the same in both groups. There was a significant difference in the median time to offset of pharmacodynamic effects when discontinuing study medication in patients not extubated at 10 days (remifentanil 0.250 hour, comparator 1.167 hours; P < 0.001). Of the patients treated with remifentanil, 26% did not receive any midazolam during the study. In those patients that did receive midazolam, the use of remifentanil considerably reduced the total dose of midazolam required. Between days 3 and 10 the weighted mean infusion rate of remifentanil remained constant with no evidence of accumulation or of a development of tolerance to remifentanil. There was no difference between the groups in SAS or PI score in the 24 hours after stopping the study medication. Remifentanil was well tolerated.

Conclusion

Analgesia-based sedation with remifentanil was well tolerated; it reduces the duration of mechanical ventilation and improves the weaning process compared with standard hypnotic-based sedation regimes in ICU patients requiring long-term ventilation for up to 10 days.