Could remifentanil reduce duration of mechanical ventilation in comparison with other opioids for mechanically ventilated patients? A systematic review and meta-analysis

Abstract

BackgroundSedation and analgesia are commonly required to relieve anxiety and pain in mechanically ventilated patients. Fentanyl and morphine are the most frequently used opioids. Remifentanil is a selective μ-opioid receptor that is metabolized by unspecific esterases and eliminated independently of liver or renal function. Remifentanil has a rapid onset and offset and a short context-sensitive half-life regardless of the duration of infusion, which may lead to reductions in weaning and extubation. We aimed to compare the efficacy and safety of remifentanil to that of other opioids in mechanically ventilated patients.MethodsWe conducted a search to identify relevant randomized controlled studies (RCTs) in the PubMed, Embase, Cochrane Library and SinoMed databases that had been published up to 31 December 2016. The results were analysed using weighted mean differences (WMDs) and 95% confidence intervals (CIs).ResultsTwenty-three RCTs with 1905 patients were included. Remifentanil was associated with reductions in the duration of mechanical ventilation (mean difference -1.46; 95% CI -2.44 to -0.49), time to extubation after sedation cessation (mean difference -1.02; 95% CI -1.59 to -0.46), and ICU-LOS (mean difference -0.10; 95% CI -0.16 to -0.03). No significant differences were identified in hospital-LOS (mean difference -0.05; 95% CI -0.25 to 0.15), costs (mean difference -709.71; 95% CI -1590.98 to 171.55; I2 88%), mortality (mean difference -0.64; 95% CI -1.33 to 0.06; I2 87%) or agitation (mean difference -0.71; 95% CI -1.80 to 0.37; I2 93%).ConclusionsRemifentanil seems to be associated with reductions in the duration of mechanical ventilation, time to extubation after cessation of sedation, and ICU-LOS. No significant differences were identified between remifentanil and other opioids in terms of hospital-LOS, costs, mortality or agitation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1789-8) contains supplementary material, which is available to authorized users.

Early prediction of extubation failure in patients with severe pneumonia: a retrospective cohort study

“…Overuse and accumulation of opioid agents have been elucidated to be associated with increased adverse events, such as respiratory depression, iatrogenic withdrawal syndrome, and prolongation of time to extubation and weaning [36,37]. In our study, we also found that the use of both fentanyl and midazolam were significantly increased in patients with extubation failure, and the mean dose of fentanyl >1.135 mg/d was an independent predictor in predicting extubation failure.…”

Sedation During Neurocritical Care

“…The unique pharmacokinetics of remifentanil may lead to reductions in time to weaning and extubation and, accordingly, may be associated with reductions in mechanical ventilation time, length of ICU stay ( ICU-LOS), and costs. 31 In line with previous findings, no intravenous sedative agent has shown superiority over others, a prognostic improvement, or a decrease in mortality. 33 The results of our review highlight the need for studies designed to evaluate superiority and potential improvements in outcome.…”

“…Opioids are commonly used in the ICU for analgesia, and the accumulation of opioid agents may cause respiratory depression, thus leading to prolongation of time to weaning and extubation. 31 Studies have found the most frequently used opioids to be fentanyl (30-35%), morphine (15-33%), and sufentanil (25-40%), the specific proportions of which differ in the results of different surveys, with remifentanil being less commonly used (10%). 32 However, the use of opioids may not be ideal in mechanically ventilated critically ill patients.…”

Effects of sedatives and opioids on trigger and cycling asynchronies throughout mechanical ventilation: an observational study in a large dataset from critically ill patients

“…Sedation is associated with deleterious side effects. Deep sedation is associated with worse short- and long-term outcomes [11–14]. Forgoing or minimizing sedatives during MV is increasingly recommended [15–17].…”