[Level concept of analgesic dosing in intensive care medicine with sufentanil].
OBJECTIVE
The efficacy of a 3-level regimen of analgesia and sedation was investigated in a clinical setting. Level 1 consisted of continuous administration of sufentanil, in level 2 continuous administration of midazolam and level 3 continuous administration of midazolam and clonidine was added according to patients' needs.


METHODS
Sufentanil at 1 microgram/kg/h was given initially. Later it was adjusted to patients' requirements in accordance with the Ramsay score (group 1). Long-term intubated patients received in addition midazolam 0.05 mg/kg/h (group 2). If needed, clonidine 1 microgram/kg/h was added (group 3). Mean drug requirements were investigated during controlled ventilation and during assisted ventilation with spontaneous breathing > 25% of total minute ventilation. In group 1 arterial paCO2 was measured to estimate drug-induced respiratory depression. Values given are median and ranges.


RESULTS
With the 3-level-regimen of analgesia and sedation a Ramsay score of 2-3 was achieved in all intensive-care patients. In group 1 (n = 109; 36.7%) paCO2 values were similar at all times. Patients on controlled ventilation needed sufentanil 0.6 (0.075-2.5) microgram/kg/h, on assisted ventilation 0.4 (0.05-2.5) microgram/kg/h. Patients of group 2 (n = 113; 38.1%) had on controlled ventilation a higher requirement of sufentanil 1.2 (0.09-2.7) micrograms/kg/h, in addition Midazolam 0.05 (0.002-0.56) mg/kg/h was given. On assisted ventilation with spontaneous breathing > 25% sufentanil 0.9 (0.05-2.6) microgram/kg/h plus midazolam 0.04 (0.002-0.38) mg/kg/h was sufficient. Group 3 (n = 75; 25.2%) had on controlled ventilation a higher requirement of sufentanil with 1.5 (0.09-4.0) micrograms/kg/h and midazolam 0.05 (0.005-0.52) mg/kg/h, in addition clonidine 1.1 (0.12-2.88) micrograms/kg/h was given. On assisted ventilation with spontaneous breathing > 25% requirement of sufentanil with 1.1 (0.15-2.6) micrograms/kg/h and of midazolam with 0.05 (0.002-0.22) mg/kg/h was slightly lower, whereas more clonidine was needed with 1.3 (0.12-2.88) micrograms/kg/h.


CONCLUSIONS
Continuous infusion of sufentanil only for analgesia and sedation is suitable for intensive-care patients with a short stay in the ICU. Respiratory depression during spontaneous breathing is not significant. The supplementary administration of midazolam and clonidine according to the presented regimen was shown to be of advantage for patients with a longer stay in ICU.
Wappler
F
F
Abteilung für Anästhesiologie, Universitäts-Krankenhaus Eppendorf, Hamburg. wappler@uke.uni-hamburg.de
Scholz
J
J
Prause
A
A
Möllenberg
O
O
Bause
H
H
Schulte am Esch
J
J
D015760:Alfentanil / Q000493:pharmacokinetics / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000493:pharmacokinetics / Q000627:therapeutic use; D002245:Carbon Dioxide / Q000097:blood; D003000:Clonidine / Q000008:administration & dosage / Q000627:therapeutic use; D003422:Critical Care; D004305:Dose-Response Relationship, Drug; D005283:Fentanyl / Q000493:pharmacokinetics / Q000627:therapeutic use; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000627:therapeutic use; D007262:Infusions, Intravenous; D007440:Intubation; D008874:Midazolam / Q000008:administration & dosage / Q000627:therapeutic use; D009020:Morphine / Q000493:pharmacokinetics / Q000627:therapeutic use; D012119:Respiration; D012121:Respiration, Artificial; D012189:Retrospective Studies; D017409:Sufentanil / Q000008:administration & dosage* / Q000493:pharmacokinetics / Q000627:therapeutic use; D013565:Sympatholytics / Q000008:administration & dosage / Q000627:therapeutic use
D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D013565:Sympatholytics; D002245:Carbon Dioxide; D015760:Alfentanil; D009020:Morphine; D017409:Sufentanil; D003000:Clonidine; D008874:Midazolam; D005283:Fentanyl
Stufenkonzept zur Analgosedierung in der Intensivmedizin mit Sufentanil.