Efficacy of target controlled infusion of remifentanil with spontaneous ventilation for procedural sedation and analgesia (Remi TCI PSA): A double center prospective observational study

Cyrus Motamed, MD; Romain Roubineau, MD; Jean-Pol Depoix, MD; Frédérique Servin, MD; Geraldine Roche, CRNA; Valérie Billard, MD

doi:10.5055/jom.2021.0615

Authors

Cyrus Motamed, MD
Romain Roubineau, MD
Jean-Pol Depoix, MD
Frédérique Servin, MD
Geraldine Roche, CRNA
Valérie Billard, MD

DOI:

https://doi.org/10.5055/jom.2021.0615

Keywords:

remifentanil, target controlled infusion, sedation procedural, monitoring

Abstract

Objective: Remifentanil, a rapid onset rapid offset synthetic opioid and potent analgesic, is often used for procedural conscious sedation in spontaneous ventilation, especially when delivered in target controlled infusion (TCI), which allows precise titration. We assessed efficacy, tolerance, and adverse events related with the use of remifentanil TCI during various procedures.

Design: Prospective, observational.

Setting: Two teaching hospitals.

Patients: We enrolled 434 patients undergoing procedures suitable for conscious sedation.

Interventions: The following procedures considered suitable were included: interventional radiology, gastrointestinal (GI) endoscopy, interventional cardiology, and peripheral dermatology. Sedation options were determined during the preoperative anesthesia assessment.

Main outcome measures: Demographics were recorded as well as success rate, remifentanil dosage, pain scores, respiratory or cardiovascular events, and patient and operator satisfaction.

Results: The procedure was successful in 429 patients (99 percent), canceled in four patients because of agitation, apnea, desaturation, and converted to general anesthesia in two for major pain. The maximal remifentanil target was around 2-3 ng/ml for most procedures, but it was 3-5 ng/ml for GI endoscopy and urology. A total of 172 patients (40 percent) had bradypnea < 8 min−1, but only 26 (6 percent) had hypoxemia < 90 percent. Eighteen patients (4 percent) required mandibular luxation, and twelve needed face mask ventilation. There were no major cardiovascular adverse events.

Conclusions: Remifentanil TCI is a suitable protocol for procedural sedation, but respiratory depression is a permanent concern. This risk requires equipped environment and competent medical personnel on hand to adjust the target before hypoxemia occurs. Respiratory rate monitoring, based on capnography or thoracic impedance is of a great help in anticipating this threat.

Author Biographies

Cyrus Motamed, MD

Department of Anaesthesia, Gustave Roussy Cancer Centre, Villejuif, France

Romain Roubineau, MD

Department of Anaesthesia, Bichat Claude Bernard University Hospital, Paris, France

Jean-Pol Depoix, MD

Department of Anaesthesia, Bichat Claude Bernard University Hospital, Paris, France

Frédérique Servin, MD

Department of Anaesthesia, Bichat Claude Bernard University Hospital, Paris, France

Geraldine Roche, CRNA

Department of Anaesthesia, Gustave Roussy Cancer Centre, Villejuif, France

Valérie Billard, MD

Department of Anaesthesia, Gustave Roussy Cancer Centre, Villejuif, France

References

Hinkelbein J, Lamperti M, Akeson J, et al.: European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol. 2018; 35: 6-24.

De Robertis E, Longrois D, Fuchs-Buder T: Safety and quality of procedural sedation and analgesia practice for adult patients throughout Europe: A step forward. Eur J Anaesthesiol. 2018; 35: 1-3.

Burkle H, Dunbar S, Van AH: Remifentanil: A novel, short-acting, mu-opioid. Anesth Analg. 1996; 83: 646-651.

Servin FS, Billard V: Remifentanil and other opioids. In: Schuttler J, Schwildden H, eds. Modern Anesthetics. Berlin: Springer; Collection Handb Exp Pharmacol, 2008; 182: 283-311.

Lallo A, Billard V, Bourgain JL: A comparison of propofol and remifentanil target-controlled infusions to facilitate fiberoptic nasotracheal intubation. Anesth Analg. 2009; 108: 852-857.

Rudner R, Jalowiecki P, Kawecki P, et al.: Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy. Gastrointest Endosc. 2003; 57: 657-663.

Singh PM, Borle A, Goudra BG: Use of computer-assisted drug therapy outside the operating room. Curr Opin Anaesthesiol. 2016; 29: 506-511.

Schnider TW, Minto CF, Struys MM, et al.: The safety of target-controlled infusions. Anesth Analg. 2016; 122: 79-85.

Kisilewicz M, Rosenberg H, Vaillancourt C: Remifentanil for procedural sedation: A systematic review of the literature. Emerg Med J. 2017; 34: 294-301.

Morue HI, Raj-Lawrence S, Saxena S, et al.: Placebo versus low-dose ketamine infusion in addition to remifentanil target-controlled infusion for conscious sedation during oocyte retrieval: A double-blinded, randomised controlled trial. Eur J Anaesthesiol. 2018; 35: 667-674.

Barends CRM, Driesens MK, van AK, et al.: Moderate-to-deep sedation using target-controlled infusions of propofol and remifentanil: Adverse events and risk factors: A retrospective cohort study of 2937 procedures. Anesth Analg. 2019; 131: 1173-1183.

Minto CF, Schnider TW, Egan TD, et al.: Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil—I: Model development. Anesthesiology. 1997; 86: 10-23.

Moerman AT, Herregods LL, De Vos MM, et al.: Manual versus target-controlled infusion remifentanil administration in spontaneously breathing patients. Anesth Analg. 2009; 108: 828-834.

Egan TD: Target-controlled drug delivery: progress toward an intravenous “vaporizer” and automated anesthetic administration. Anesthesiology. 2003; 99: 1214-1219.

Steib A, Hausberger D, Robillart A, et al.: [Anaesthetic considerations for interventional radiology]. Ann Fr Anesth Reanim. 2006; 25: 615-625.

Dahaba AA, Lischnig U, Kronthaler R, et al.: Bispectralindex-guided versus clinically guided remifentanil/propofol analgesia/sedation for interventional radiological procedures: An observer-blinded randomized study. Anesth Analg. 2006; 103: 378-384, table.

Yamamoto M, Meguro K, Mouillet G, et al.: Effect of local anesthetic management with conscious sedation in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2013; 111: 94-99.

Husser O, Fujita B, Hengstenberg C, et al.: Conscious sedation versus general anesthesia in transcatheter aortic valve replacement: The German aortic valve registry. JACC Cardiovasc Interv. 2018; 11: 567-578.

Patel PA, Ackermann AM, Augoustides JGT, et al.: Anesthetic evolution in transcatheter aortic valve replacement: Expert perspectives from high-volume academic centers in Europe and the United States. J Cardiothorac Vasc Anesth. 2017; 31: 777-790.

Sathananthan J, Webb JG, Lauck SB, et al.: Impact of local anesthesia only versus procedural sedation using the Vancouver clinical pathway for TAVR: Insights from the 3M TAVR study. JACC Cardiovasc Interv. 2019; 12: 1000-1001.

Bhatt HV, Syros G, Greco M, et al.: Ablation therapy for atrial fibrillation: Implications for the anesthesiologist. J Cardiothorac Vasc Anesth. 2015; 29: 1341-1356.

Gaitan BD, Trentman TL, Fassett SL, et al.: Sedation and analgesia in the cardiac electrophysiology laboratory: A national survey of electrophysiologists investigating the who, how, and why? J Cardiothorac Vasc Anesth. 2011; 25: 647-659.

Leslie K, Allen ML, Hessian EC, et al.: Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: A prospective cohort study. Br J Anaesth. 2017; 118: 90-99.

Early DS, Lightdale JR, Vargo JJ, et al.: Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018; 87: 327-337.

Moerman AT, Struys MM, Vereecke HE, et al.: Remifentanil used to supplement propofol does not improve quality of sedation during spontaneous respiration. J Clin Anesth. 2004; 16: 237-243.

Smits GJ, Kuypers MI, Mignot LA, et al.: Procedural sedation in the emergency department by Dutch emergency physicians: A prospective multicentre observational study of 1711 adults. Emerg Med J. 2017; 34: 237-242.

Pattinson KT: Opioids and the control of respiration. Br J Anaesth. 2008; 100: 747-758.

Barcroft J, Roberts F: The dissociation curve of haemoglobin. J Physiol. 1909; 39: 143-148.

Litman RS: Conscious sedation with remifentanil during painful medical procedures. J Pain Symptom Manage. 2000; 19: 468-471.

Motamed C, Weil G, Deschamps F, et al.: Remifentanil target-controlled infusion: A safe rescue protocol for unexpected severe postoperative pain. J Opioid Manag. 2014; 10: 284-288.

Gilmore T, Saccheti A, Cortese T: Buprenorphine/naloxone inhibition of remifentanil procedural sedation. Am J Emerg Med. 2012; 30: 1655.

Motamed C, Bourgain JL: Trend of analgesic consumption and pain scores in the post anesthetic care unit (A 9-year survey in surgical cancer patients). Bull Cancer. 2011; 98: E90-E94.

Chalumeau-Lemoine L, Stoclin A, Billard V, et al.: Flexible fiberoptic bronchoscopy and remifentanil target-controlled infusion in ICU: A preliminary study. Intensive Care Med. 2013; 39: 53-58.

Sacchetti A, Jachowski J, Heisler J, et al.: Remifentanil use in emergency department patients: Initial experience. Emerg Med J. 2012; 29: 928-929.

Godwin SA, Burton JH, Gerardo CJ, et al.: Clinical policy: Procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014; 63: 247-258.

Lamperti M: Adult procedural sedation: An update. Curr Opin Anaesthesiol. 2015; 28: 662-667.

Garnier M, Bonnet F: Management of anesthetic emergencies and complications outside the operating room. Curr.Opin. Anaesthesiol. 2014; 27: 437-441.

De Castro V, Godet G, Mencia G, et al.: Target-controlled infusion for remifentanil in vascular patients improves hemodynamics and decreases remifentanil requirement. Anesthesia Analgesia 2003; 96: 33-38, table.