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Remifentanil use in emergency department patients: initial experience
  1. Alfred Sacchetti1,
  2. Jennifer Jachowski2,
  3. Josephine Heisler1,
  4. Teena Cortese1
  1. 1Departments of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, New Jersey, USA
  2. 2Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  1. Correspondence to Professor Alfred Sacchetti, Department of Emergency Medicine, Our Lady of Lourdes Medical Center, 1600 Haddon Avenue, Camden, NJ 08103, USA; sacchetti1011{at}gmail.com

Abstract

Introduction This study examines the use of remifentanil, an ultra-short-acting opioid, in emergency department (ED) patients.

Methods Chart review of ED patients receiving remifentanil for procedural sedation in an urban general ED.

Results 50 patients over a 28-month period with a mean age of 30.6 years (±2.6) were reviewed. Procedures performed included: abscess drainage (13); fracture care (9); thoracostomy (8); lumbar puncture (7); shoulder reduction (3); cardioversion (3) and others (7). Six (12%) cases received additional rescue medications. All procedures were successfully completed in the ED. No complications were recorded but 21 (42%) were admitted for underlying pathology.

Conclusion Remifentanil is a safe and effective medication for ED use.

  • Analgesia pain control
  • cardiac care
  • emergency department
  • paediatrics
  • procedural sedation
  • remifentanil
  • ventilation
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Remifentanil is a synthetic opioid analgesic similar in potency to fentanyl but with a much shorter duration of action. This study examines the use of remifentanil in emergency department (ED) patients.

Methods

Our Lady of Lourdes Medical Center is an urban community hospital with 57 000 annual ED visits performing approximately 160 emergency physician-directed sedations annually.

Patients receiving remifentanil for procedural sedation and analgesia in the ED were identified through the department's electronic medical records. The decision to use remifentanil was completely at the discretion of the treating emergency physician and no attempt was made to direct the staff to use remifentanil. Credentialling for remifentanil was covered in the emergency physician's existing credentialling for procedural sedation and analgesia. A structured review was conducted to abstract patients' ages, procedures, medication use, complications, outcomes and dispositions.

The study was approved by the hospital institutional review board.

Results

Fifty patients were identified from 6 January 2009 to 15 May 2011. Patient ages ranged from 16 months to 74 years, with a mean of 30.6 years (±2.6) and 13 patients were less than 18 years of age. Procedures performed are presented in table 1. For all cases in this study, 1 mg remifentanil was placed in 50 cc of normal saline and infused at 0.16 μg/kg per minute (10 μg/kg per hour) beginning 3–5 min before the procedure. Six (12%) cases received rescue medications, propofol (two), lorazepam (two), midazolam (two), while four (8%) received bolus doses of 1 μg/kg immediately before the procedure and four (8%) patients were pretreated with 0.5 mg lorazepam. Seven patients were assigned an American Society of Anesthesiologists (ASA) score of 2, while the remaining 43 had ASA scores of 1. All sedation was directed by the attending emergency physician. All procedures were successfully completed in the ED and no patient required any respiratory or cardiovascular support. Twenty-nine (58%) patients were discharged, 21 (42%) were admitted for their underlying pathology.

Table 1

ED procedures performed

Discussion

Remifentanil is a semisynthetic μ-receptor opioid that possesses strong analgesic properties with few cardiovascular effects. It is metabolised by blood and tissue esterases, with a pharmacological half-life of only 3–6 min and a clinical duration of action of 5–10 min.1–4

Unlike with propofol, simple intermittent boluses produce minimal clinical effects and those that are produced rapidly dissipate. In contrast, the use of a continuous infusion provides profound analgesia limited to the duration of the drug's administration.

One interesting observation in our early experience with remifentanil was that it was not effective in extremely anxious patients. Even repeated supplemental boluses of 1–2 μg/kg were unable to produce cooperation for a procedure in such patients, adult or paediatric. Pretreatment with a low dose of an anxiolytic such as lorazepam completely eliminated this problem. This effect has not been described in other reports on this drug.

Remifentanil produces true moderate sedation with patients awake and able to respond to verbal stimuli. Unlike propofol and the benzodiazepines, remifentanil alone does not produce skeletal muscle relaxation, making it less attractive for major joint reductions as a single agent.5 ,6

The largest advantage of remifentanil is its brief duration of action. In our experience the time from the cessation of an infusion until full recovery is generally 5 min, limiting the nursing time spent monitoring and more quickly freeing up stretchers and equipment.

Since the introduction of remifentanil, propofol and ketamine have remained the principal procedural sedation agents in our ED. However, in certain patients, particularly those requiring brief painful procedures, remifentanil is increasingly being employed.

Conclusion

Remifentanil is an effective procedural sedation agent in ED patients and may find a role in brief painful ED procedures.

References

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Footnotes

  • Competing interests None.

  • Ethics approval This study was approved by the Institutional Review Board of Our Lady of Lourdes Medical Center, Camden, NJ, USA, which is the ethics committee for our institution.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement If anyone is interested we will be glad to provide a blinded copy of the data base we used to collect the information for this study. To obtain this data please contact: Alfred Sacchetti at sacchetti1011@gmail.com.

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