Adjunctive remifentanil infusion in deeply sedated and paralyzed ICU patients during fiberoptic bronchoscopy procedure: a prospective, randomized, controlled study

Hervé Quintard, Isabelle Pavlakovic, Jean Mantz, Carole Ichai, Hervé Quintard, Isabelle Pavlakovic, Jean Mantz, Carole Ichai

Abstract

Background: Even with an adequate pain assessment, critically ill patients under sedation experience pain during procedures in the intensive care unit (ICU). We evaluated the effects of adjunctive administration of Remifentanil, a short-acting drug, in deeply sedated patient on variation of Bispectral Index (BIS) during a fiberoptic bronchoscopy.

Methods: A prospective, randomized, blinded, placebo-controlled study was conducted in 18-bed ICU. Patients needing a tracheal fibroscopy under deep sedation (midazolam (0.1 mg/kg per hour) fentanyl (4 μg/kg per hour)) and neuromuscular blocking (atracurium 0.5 mg/kg) were included in the study. A continuous monitoring of BIS, arterial pressure, and heart rate were realized before, during, and after the fiberoptic exam. An adjunctive continuous placebo or Remifentanil infusion was started just before the fiberoptic exam with a target effect-site concentration of 4 ng/ml using a Base Primea pump.

Results: Mean arterial pressure and heart rates were comparable between the placebo and Remifentanil groups at all times of the procedure. We did not observe differences in the variation of BIS values between the two groups during procedure. We described no change in BIS values relative to the placebo group in this population.

Conclusions: In deeply sedated and paralyzed patients, receiving analgesic support based on a scale score an additional administration of short-acting analgesic drug, such as Remifentanil, seems not to be necessary for acute pain control.

Trial registration: NCT00162591.

Figures

Figure 1
Figure 1
Study design.
Figure 2
Figure 2
Mean heart rate (±SD) recorded each minute during procedure.
Figure 3
Figure 3
Mean arterial pressure (±SD) recorded each minute during procedure.
Figure 4
Figure 4
Box plot of BIS variation during procedure with mean (box plot) with median, interquartile (25th–75th), minimum and maximum values and outliers. C10 10 mn after the myorelaxant injection.
Figure 5
Figure 5
Maximum BIS variation during fiberoptic bronchoscopy (mean ± SD).

References

    1. Kalfon P, Mimoz O, Auquier P, Loundou A, Gauzit R, Lepape A, Laurens J, Garrigues B. Pottecher T. Malledant Y: Development and validation of a questionnaire for quantitative assessment of perceived discomforts in critically ill patients. Intensive Care Med; 2010.
    1. Novaes MA, Knobel E, Bork AM, Pavao OF, Nogueira-Martins LA, Ferraz MB. Stressors in ICU: perception of the patient, relatives and health care team. Intensive Care Med. 1999;25(12):1421–1426. doi: 10.1007/s001340051091.
    1. Chanques G, Viel E, Constantin JM, Jung B, de Lattre S, Carr J, Cisse M, Lefrant JY, Jaber S. The measurement of pain in intensive care unit: comparison of 5 self-reported intensity scales. Pain. 2010;151(3):711–721. doi: 10.1016/j.pain.2010.08.039.
    1. Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J. Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study. Anesthesiology. 2009;111(6):1308–1316. doi: 10.1097/ALN.0b013e3181c0d4f0.
    1. Payen JF, Bru O, Bosson JL, Lagrasta A, Novel E, Deschaux I, Lavagne P, Jacquot C. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29(12):2258–2263. doi: 10.1097/00003246-200112000-00004.
    1. Brocas E, Dupont H, Paugam-Burtz C, Servin F, Mantz J, Desmonts JM. Bispectral index variations during tracheal suction in mechanically ventilated critically ill patients: effect of an alfentanil bolus. Intensive Care Med. 2002;28(2):211–213. doi: 10.1007/s00134-001-1189-y.
    1. Breen D, Wilmer A, Bodenham A, Bach V, Bonde J, Kessler P, Albrecht S, Shaikh S. Offset of pharmacodynamic effects and safety of remifentanil in intensive care unit patients with various degrees of renal impairment. Crit Care. 2004;8(1):R21–R30. doi: 10.1186/cc2399.
    1. Battershill AJ, Keating GM. Remifentanil: a review of its analgesic and sedative use in the intensive care unit. Drugs. 2006;66(3):365–385. doi: 10.2165/00003495-200666030-00013.
    1. Dershwitz M, Hoke JF, Rosow CE, Michalowski P, Connors PM, Muir KT, Dienstag JL. Pharmacokinetics and pharmacodynamics of remifentanil in volunteer subjects with severe liver disease. Anesthesiology. 1996;84(4):812–820. doi: 10.1097/00000542-199604000-00008.
    1. Casey E, Lane A, Kuriakose D, McGeary S, Hayes N, Phelan D, Buggy D. Bolus remifentanil for chest drain removal in ICU: a randomized double-blind comparison of three modes of analgesia in post-cardiac surgical patients. Intensive Care Med. 2010;36(8):1380–1385. doi: 10.1007/s00134-010-1836-2.
    1. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999;27(7):1325–1329. doi: 10.1097/00003246-199907000-00022.
    1. Sauder P, Andreoletti M, Cambonie G, Capellier G, Feissel M, Gall O. Sédation et analgésie en réanimation(nouveau né exclu), Ann FrAnesthRéanim 20084ème conférence de consensus commune: sédation et analgésie en réanimation. 2007.
    1. Chastre J, Trouillet JL, Vuagnat A, Joly-Guillou ML, Clavier H, Dombret MC, Gibert C. Nosocomial pneumonia in patients with acute respiratory distress syndrome. Am J RespirCrit Care Med. 1998;157(4 Pt 1):1165–1172.
    1. Stevens JB, Wheatley L. Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. AnesthAnalg. 1998;86(1):45–49.
    1. McAtamney D, O’Hare R, Hughes D, Carabine U, Mirakhur R. Evaluation of remifentanil for control of haemodynamic response to tracheal intubation. Anaesthesia. 1998;53(12):1223–1227. doi: 10.1046/j.1365-2044.1998.00601.x.
    1. O’Hare R, McAtamney D, Mirakhur RK, Hughes D, Carabine U. Bolus dose remifentanil for control of haemodynamic response to tracheal intubation during rapid sequence induction of anaesthesia. Br J Anaesth. 1999;82(2):283–285. doi: 10.1093/bja/82.2.283.
    1. Guignard B, Menigaux C, Dupont X, Fletcher D, Chauvin M. The effect of remifentanil on the bispectral index change and hemodynamic responses after orotracheal intubation. AnesthAnalg. 2000;90(1):161–167.
    1. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J RespirCrit Care Med. 1994;149(3 Pt 1):818–824.
    1. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–1477. doi: 10.1056/NEJM200005183422002.
    1. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM. et al.Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–1116. doi: 10.1056/NEJMoa1005372.
    1. Glass PS, Bloom M, Kearse L, Rosow C, Sebel P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology. 1997;86(4):836–847. doi: 10.1097/00000542-199704000-00014.
    1. Manyam SC, Gupta DK, Johnson KB, White JL, Pace NL, Westenskow DR, Egan TD. When is a bispectral index of 60 too low?: Rational processed electroencephalographic targets are dependent on the sedative-opioid ratio. Anesthesiology. 2007;106(3):472–483. doi: 10.1097/00000542-200703000-00011.
    1. Karamchandani K, Rewari V, Trikha A, Batra RK. Bispectral index correlates well with Richmond agitation sedation scale in mechanically ventilated critically ill patients. J Anesth. 2010;24(3):394–398. doi: 10.1007/s00540-010-0915-4.
    1. Weatherburn C, Endacott R, Tynan P, Bailey M. The impact of bispectral index monitoring on sedation administration in mechanically ventilated patients. Anaesth Intensive Care. 2007;35(2):204–208.
    1. Gelinas C, Tousignant-Laflamme Y, Tanguay A, Bourgault P. Exploring the validity of the bispectral index, the Critical-Care Pain Observation Tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: a pilot study. Intensive Crit Care Nurs. 2011;27(1):46–52. doi: 10.1016/j.iccn.2010.11.002.

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