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.
Highlights
Sedation and analgesia are commonly required to relieve anxiety and pain in mechanically ventilated patients
The results of this study showed that remifentanil was associated with significant reductions in mean duration of mechanical ventilation and extubation time
The points representing the evaluated studies in the three funnel plots were concentrated at the top showed that the studies had high precision and large sample sizes. The results of this meta-analysis suggested that the use of remifentanil was associated with a reduction in the duration of mechanical ventilation when compared with other opioids, findings that were supported by the results of subgroup of studies in which analgesia and sedation were administered and subgroup of studies in which remifentanil was compared with fentanyl; the subgroups of studies in which analgesia alone was administered and studies in which remifentanil was compared with morphine or sufentanil indicated the presence of no differences
Summary
Sedation and analgesia are commonly required to relieve anxiety and pain in mechanically ventilated patients. Opioids are commonly used in the ICU for analgesia, and the accumulation of opioid agents may cause respiratory depression, leading to prolongation of time to weaning and extubation. 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%) [3, 4]. Alfentanil and sufentanil undergo hepatic metabolism, and continuous infusion results in accumulation and prolongation of effect [5]. Those pharmacodynamic and pharmacokinetic profiles have disadvantages in terms of rapid weaning and extubation
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