Cost-consequence analysis of remifentanil-based analgo-sedation vs. conventional analgesia and sedation for patients on mechanical ventilation in the Netherlands

Abstract

IntroductionHospitals are increasingly forced to consider the economics of technology use. We estimated the incremental cost-consequences of remifentanil-based analgo-sedation (RS) vs. conventional analgesia and sedation (CS) in patients requiring mechanical ventilation (MV) in the intensive care unit (ICU), using a modelling approach.MethodsA Markov model was developed to describe patient flow in the ICU. The hourly probabilities to move from one state to another were derived from UltiSAFE, a Dutch clinical study involving ICU patients with an expected MV-time of two to three days requiring analgesia and sedation. Study medication was either: CS (morphine or fentanyl combined with propofol, midazolam or lorazepam) or: RS (remifentanil, combined with propofol when required). Study drug costs were derived from the trial, whereas all other ICU costs were estimated separately in a Dutch micro-costing study. All costs were measured from the hospital perspective (price level of 2006). Patients were followed in the model for 28 days. We also studied the sub-population where weaning had started within 72 hours.ResultsThe average total 28-day costs were €15,626 with RS versus €17,100 with CS, meaning a difference in costs of €1474 (95% CI -2163, 5110). The average length-of-stay (LOS) in the ICU was 7.6 days in the RS group versus 8.5 days in the CS group (difference 1.0, 95% CI -0.7, 2.6), while the average MV time was 5.0 days for RS versus 6.0 days for CS. Similar differences were found in the subgroup analysis.ConclusionsCompared to CS, RS significantly decreases the overall costs in the ICU.Trial RegistrationClinicaltrials.gov NCT00158873.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

“…Providing a calm and reassuring environment, with attention to day-night cycles, restriction of noise, use of appropriate music, and/or the reassuring presence of friends and family may decrease agitation and anxiety [89]. These environmental measures are especially important when a dominant-hemisphere lesion causes aphasia and attempts at verbal communication generate agitated behaviors.…”

“…Complications associated with under-sedation include ventilator dysynchrony, patient injury, agitation, anxiety, device removal, and elevated ICP [76][77][78][79][80][81][82][83][84][85][86][87][88][89]. Adequate sedation is paramount in all therapeutic algorithms for the treatment of increased ICP [80,81], since psychomotor restlessness, pain, and autonomic stress all adversely affect ICP, CBF, CPP, and the cerebral metabolic rate for oxygen metabolism (CMRO 2 ).…”

Dexmedetomidine: a unique clinical profile in ICU sedation

“…This is because mechanical ventilation increases ICU costs compared with patients not on ventilation, 13,14 and most patients on ventilation require sedation. 15 Dexmedetomidine offers a distinct mechanism of action and has a unique clinical profile compared with current alternatives.…”

Sedation in Intensive Care: A review of the State-of-the-Art

“…Эффективность обезболива ния оценивают специальными шкалами оценки уровня боли, типа визуальной аналоговой шкалы (VAS) или О б з о р ы Behavioural Pain Scale (BPS) для пациентов, которые не могут адекватно самостоятельно оценить уровень боли [43,44]. Существуют противоречивые данные о преиму ществе наркотических анальгетиков с более коротким периодом полувыведения, например, ремифентанила перед фентанилом: в одном исследовании найдено суще ственное сокращение времени ИВЛ, седации и нахожде ния в ОРИТ [45], в то время как другие исследователи его не находят [46].…”

“…Каждая клиника прини мает свой протокол, не противоречащий национально му, но учитывающий местные особенности. Введение такого протокола снижает время, проведенное пациен том на ИВЛ, реанимационный койко день, госпиталь ную летальность и общие затраты на лечение [4,5,8,20,21,33,34,36,38,39,40,41,45,72].…”