Analgesia-first sedation in critically ill adults: A U.S. pilot, randomized controlled trial

Chung

Int J of Nursing Practice

et al. 2021

Aim: This study aimed to assess the effects of daily sedation interruption on the mechanical ventilation duration and relevant outcomes in mechanically ventilated patients in the intensive care unit (ICU).Background: Previously, three meta-analyses on the association of daily sedation interruption with the mechanical ventilation duration have reported conflicting findings, and these did not support current guideline recommendations that daily sedation interruption can be routinely used in mechanically ventilated adult ICU patients.Design: This was a systematic review and meta-analysis of randomized controlled studies.

Section: Resultsmentioning

confidence: 99%

Effects of daily sedation interruption in intensive care unit patients undergoing mechanical ventilation: A meta‐analysis of randomized controlled trials

Chung

Int J of Nursing Practice

et al. 2021

Critical Care Research and Practice

“…American (compared to European) trials have not found analgosedation improves outcome [ 28 ]. Opioid-induced coma is associated with longer ventilation and greater mortality [ 29 ] and ICU opioid use is associated with greater delirium [ 30 ]. In the face of the ongoing opioid epidemic, clinicians are prescribing fewer opioids and more non-opioid analgesics [ 31 – 33 ].…”

Section: Discussionmentioning

confidence: 99%

Naloxegol to Prevent Constipation in ICU Adults Receiving Opioids: A Randomized Double-Blind Placebo-Controlled Pilot Trial

Duprey

Allison

Garpestad

et al. 2022

Self Cite

Background. Constipation is frequent in critically ill adults receiving opioids. Naloxegol (N), a peripherally acting mu-receptor antagonist (PAMORA), may reduce constipation. The objective of this trial was to evaluate the efficacy and safety of N to prevent constipation in ICU adults receiving opioids. Methods and Patients. In this single-center, double-blind, randomized trial, adults admitted to a medical ICU receiving IV opioids (≥100 mcg fentanyl/day), and not having any of 17 exclusion criteria, were randomized to N (25 mg) or placebo (P) daily randomized to receive N (25mg) or placebo (P) and docusate 100 mg twice daily until ICU discharge, 10 days, or diarrhea (≥3 spontaneous bowel movement (SBM)/24 hours) or a serious adverse event related to study medication. A 4-step laxative protocol was initiated when there was no SBM ≥3 days. Results. Only 318 (20.6%) of the 1542 screened adults during the 1/17–10/19 enrolment period met all inclusion criteria. Of these, only 19/381 (4.9%) met all eligibility criteria. After 7 consent refusals, 12 patients were randomized. The study was stopped early due to enrolment futility. The N (n = 6) and P (n = 6) groups were similar. The time to first SBM (N 41.4 ± 31.7 vs. P 32.5 ± 25.4 hours, P = 0.56) was similar. The maximal daily abdominal pressure was significantly lower in the N group (N 10 ± 4 vs. P 13 ± 5, P = 0.002). The median (IQR) daily SOFA scores were higher in N (N 7 (4, 8) vs. P 4 (3, 5), P < 0.001). Laxative protocol use was similar (N 83.3% vs. P 66.6%; P = 0.51). Diarrhea prevalence was high but similar (N 66.6% vs. P 66.6%; P = 1.0). No patient experienced opioid withdrawal. Conclusions. Important recruitment challenges exist for ICU trials evaluating the use of PAMORAs for constipation prevention. Despite being underpowered, our results suggest time to first SBM with naloxegol, if different than P, may be small. The effect of naloxegol on abdominal pressure, SOFA, and the interaction between the two requires further research.

“…17,18 Remifentanil appears to be a good choice for analgesia-based sedation; however, ICU reports are mainly from Europe, and fentanyl remains the mainstream opioid in North America. 19 Although remifentanil has a short half-life and is thus more easily titrated than other opioids, the tachyphylaxis and hyperalgesia associated with prolonged infusion limit its use in the ICU to short durations. In the present study, the length of ICU stay and MV were relatively short.…”

Section: Discussionmentioning

confidence: 99%

Remifentanil provides an increased proportion of time under light sedation than fentanyl when combined with dexmedetomidine for mechanical ventilation

et al. 2021

Objective To compare the effects of remifentanil versus fentanyl during light sedation with dexmedetomidine in adults receiving mechanical ventilation (MV) in the intensive care unit. Methods In this retrospective cohort study, we compared the use of remifentanil versus fentanyl in adults receiving MV with dexmedetomidine sedation. The primary outcome was the proportion of time under light sedation (Richmond Agitation–Sedation Scale score between −1 and 0) during MV. Results We included 94 patients and classified 58 into the remifentanil group and 36 into the fentanyl group. The mean proportion of time under light sedation during MV was 66.6% ± 18.5% in the remifentanil group and 39.9% ± 27.3% in the fentanyl group. In the multivariate analysis with control for confounding factors, patients in the remifentanil group showed a significantly higher proportion of time under light sedation than patients in the fentanyl group (mean difference: 24.3 percentage points; 95% confidence interval: 12.9–35.8). Conclusions Remifentanil use might increase the proportion of time under light sedation in patients receiving MV compared with fentanyl administration.