Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.
Department of Anesthesiology, St. Mary's Hospital, Kurume, Fukuoka, Japan.
BMC Anesthesiol. 2022 Oct 21;22(1):323. doi: 10.1186/s12871-022-01871-7.
Fentanyl is selected to manage pain in critical care patients on mechanical ventilation in the intensive care unit (ICU). However, the usefulness of fentanyl compared with other opioids is unknown. This study examined the evidence for using fentanyl to improve the clinical outcomes of ICU patients, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.
We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases in June 2021. Two independent assessors reviewed studies to identify randomized, controlled trials (RCTs) that compared the intravenous administration of fentanyl and other opioids in mechanically ventilated patients in the ICU. The study quality was assessed using the GRADE system and Cochrane methodology. The primary outcome was mortality. The secondary outcomes were the duration of mechanical ventilation, duration of the ICU stay, incidence of severe adverse events, and incidence of delirium. We integrated outcome data using a random-effects model and showed absolute values and certainty of evidence in the GRADE evidence profile.
Seven RCTs met the study inclusion criteria with 534 patients (251 were treated with fentanyl and 283 with other opioids, including 242 with remifentanil and 41 with morphine). Among 191 participants from 2 RCTs, fentanyl was not associated with mortality (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.24 to 2.60; low-quality evidence). Regarding the secondary outcomes, fentanyl did not shorten the duration of mechanical ventilation (mean difference, 0.49 h; 95% CI, - 0.90 to 1.88; moderate-quality evidence) or the duration of the ICU stay (mean difference, 7.04 h; 95% CI, - 3.27 to 17.35; moderate-quality evidence) compared with other opioids. Fentanyl did not increase the incidence of severe adverse events (RR, 0.98; 95% CI, 0.50 to 1.90; low-quality evidence) or delirium (RR, 1.27; 95% CI, 0.79 to 2.04; low-quality evidence).
Although fentanyl is a frequently administered opioid in the ICU, patients' outcomes are not different between fentanyl use and use of other opioids. However, the GRADE evaluation provides little certainty to support the results of this systematic review. Therefore, further large RCTs are required to confirm our conclusions.
PROSPERO, CRD42019130648 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130648 ).
芬太尼被选作重症监护病房（ICU）机械通气患者的镇痛药物。然而，与其他阿片类药物相比，芬太尼的有效性尚不清楚。本研究使用 Grading of Recommendations Assessment, Development, and Evaluation（GRADE）系统，考察了使用芬太尼改善 ICU 患者临床结局的证据。
我们于 2021 年 6 月检索了 MEDLINE、Cochrane 对照试验中心注册库和 Igaku Chuo Zasshi 数据库。两名独立评估员对研究进行了回顾，以确定比较 ICU 中接受机械通气的患者静脉注射芬太尼和其他阿片类药物的随机对照试验（RCT）。使用 GRADE 系统和 Cochrane 方法评估研究质量。主要结局为死亡率。次要结局为机械通气时间、ICU 入住时间、严重不良事件发生率和谵妄发生率。我们使用随机效应模型整合了结局数据，并在 GRADE 证据概要中展示了绝对数值和证据确定性。
有 7 项 RCT 符合纳入标准，共纳入 534 例患者（251 例接受芬太尼治疗，283 例接受其他阿片类药物治疗，包括 242 例接受瑞芬太尼治疗和 41 例接受吗啡治疗）。在 2 项 RCT 中的 191 名参与者中，芬太尼与死亡率无关（风险比 [RR]，0.79；95%置信区间 [CI]，0.24 至 2.60；低质量证据）。关于次要结局，与其他阿片类药物相比，芬太尼并未缩短机械通气时间（平均差，0.49 小时；95%CI，-0.90 至 1.88；中等质量证据）或 ICU 入住时间（平均差，7.04 小时；95%CI，-3.27 至 17.35；中等质量证据）。芬太尼并未增加严重不良事件（RR，0.98；95%CI，0.50 至 1.90；低质量证据）或谵妄（RR，1.27；95%CI，0.79 至 2.04；低质量证据）的发生率。
尽管芬太尼是 ICU 中常用的阿片类药物，但使用芬太尼和使用其他阿片类药物的患者结局并无差异。然而，GRADE 评估对支持本系统评价结果的证据确定性提供的帮助较少。因此，需要进一步的大型 RCT 来证实我们的结论。
PROSPERO，CRD42019130648（https://www.crd.york.ac.uk/prospero/display_record.php？RecordID=130648）。
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