Dahaba Ashraf A, Grabner Tanja, Rehak Peter H, List Werner F, Metzler Helfried
Department of Anaesthesiology and Intensive Care Medicine, Graz University, Austria.
Anesthesiology. 2004 Sep;101(3):640-6. doi: 10.1097/00000542-200409000-00012.
The rapid onset and offset of action of remifentanil could make it quickly adjustable to the required level of sedation in critically ill patients. The authors hypothesized that the efficacy of a remifentanil-based regimen was greater than that of a morphine-based regimen.
Forty intent-to-treat patients were randomly allocated to receive a blinded infusion of either remifentanil 0.15 microg x kg(-1) x min(-1) or morphine 0.75 microg x kg(-1) x min(-1). The opioid infusion was titrated, in the first intent, to achieve optimal sedation defined as Sedation Agitation scale of 4. A midazolam open-label infusion was started if additional sedation was required.
The mean percentage hours of optimal sedation was significantly longer in the remifentanil group (78.3 +/- 6.2) than in the morphine group (66.5 +/- 8.5). This was achieved with less frequent infusion rate adjustments (0.34 +/- 0.25 changes/h) than in the morphine group (0.42 +/- 0.22 changes/h). The mean duration of mechanical ventilation and extubation time were significantly longer in the morphine group (18.1 +/- 3.4 h, 73 +/- 7 min) than in the remifentanil group (14.1 +/- 2.8 h, 17 +/- 6 min), respectively. Remifentanil mean infusion rate was 0.13 +/- 0.03 microg x kg(-1) x min(-1), whereas morphine mean infusion rate was 0.68 +/- 0.28 microg x kg(-1) x min(-1). More subjects in the morphine group (9 of 20) than in the remifentanil group (6 of 20) required midazolam. The incidence of adverse events was low and comparable across the two treatment groups.
A remifentanil-based regimen was more effective in the provision of optimal analgesia-sedation than a standard morphine-based regimen. The remifentanil-based regimen allowed a more rapid emergence from sedation and facilitated earlier extubation.
瑞芬太尼起效迅速且作用消退快，这使其能在危重症患者中迅速调整至所需的镇静水平。作者推测以瑞芬太尼为基础的方案的疗效优于以吗啡为基础的方案。
40例意向性治疗患者被随机分配接受瑞芬太尼0.15微克·千克⁻¹·分钟⁻¹或吗啡0.75微克·千克⁻¹·分钟⁻¹的盲法输注。首先，对阿片类药物输注进行滴定，以达到定义为镇静 - 躁动评分4分的最佳镇静状态。如果需要额外的镇静，则开始咪达唑仑开放标签输注。
瑞芬太尼组达到最佳镇静的平均小时百分比（78.3±6.2）显著长于吗啡组（66.5±8.5）。与吗啡组（0.42±0.22次/小时）相比，瑞芬太尼组实现这一目标时输注速率调整频率更低（0.34±0.25次/小时）。吗啡组机械通气的平均持续时间和拔管时间（分别为18.1±3.4小时，73±7分钟）显著长于瑞芬太尼组（14.1±2.8小时，17±6分钟）。瑞芬太尼的平均输注速率为0.13±0.03微克·千克⁻¹·分钟⁻¹，而吗啡的平均输注速率为0.68±0.28微克·千克⁻¹·分钟⁻¹。吗啡组（20例中的9例）比瑞芬太尼组（20例中的6例）需要更多患者使用咪达唑仑。不良事件的发生率较低，且在两个治疗组之间相当。
与标准的以吗啡为基础的方案相比，以瑞芬太尼为基础的方案在提供最佳镇痛 - 镇静方面更有效。以瑞芬太尼为基础的方案能使患者更快地从镇静状态中苏醒，并促进更早拔管。
