Drugs
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Review Comparative Study
Remifentanil : a review of its analgesic and sedative use in the intensive care unit.
Remifentanil (Ultiva), a 4-anilidopiperidine derivative of fentanyl, is an ultra-short-acting micro-opioid receptor agonist indicated to provide analgesia and sedation in mechanically ventilated intensive care unit (ICU) patients. Analgesia-based sedation with remifentanil is a useful option for mechanically ventilated patients in the ICU setting. Its unique properties (e.g. organ-independent metabolism, lack of accumulation, rapid offset of action) set it apart from other opioid agents. ⋯ Moreover, it allows fast and predictable extubation, as well as being associated with a shorter duration of mechanical ventilation and quicker ICU discharge than comparators in some studies. In addition, remifentanil is generally well tolerated in this patient population. Thus, remifentanil is a welcome addition to the currently available pharmacological agents employed in the management of mechanically ventilated ICU patients.
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Wegener's granulomatosis (WG) is the most common pulmonary granulomatous vasculitis and was a uniformly fatal disease prior to the identification of efficacious pharmacological regimens. The pathogenesis of WG remains elusive but proteinase 3-specific anti-neutrophil cytoplasmic antibodies may be involved. Histologically, WG is defined by the triad of small vessel necrotising vasculitis, 'geographic' necrosis and granulomatous inflammation. ⋯ Recent investigation has focussed on other immunomodulatory agents (tumour necrosis factor-alpha inhibitors [infliximab and etanercept] and anti-CD20 antibodies [rituximab]) for treating patients with WG. However, the current data are conflicting and difficult to interpret. As a result, these newer agents cannot be recommended for routine use until vigorous clinical study confirms their efficacy.
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Remifentanil is a relatively new synthetic opioid, which is not licensed worldwide for neonates and infants. Because of its unique pharmacokinetic properties with a short recovery profile, it could be the ideal opioid for neonates and infants, who are especially sensitive to respiratory depression by opioids. Therefore, we conducted a MEDLINE search on all articles dealing with the use of remifentanil in this important subgroup of patients. ⋯ In approximately 300 neonates and infants, remifentanil proved to be an effective and safely used opioid for this indication. However, very limited data exist on remifentanil for analgesia and sedation of mechanically ventilated paediatric intensive care patients. Further research with remifentanil in neonates and infants should focus on this group of patients because remifentanil, with its very short context-sensitive half-life, could result in shorter extubation times compared with commonly used opioids such as morphine or fentanyl.
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Patient-controlled analgesia (PCA) is a delivery system with which patients self-administer predetermined doses of analgesic medication to relieve their pain. Since its introduction in the early 1980s, the daily management of postoperative pain has been extensively optimised. The use of PCA in hospitals has been increasing because of its proven advantages over conventional intramuscular injections. ⋯ Serious complications occur rarely with these catheters. With the introduction of an Acute Pain Service, management of postoperative pain can be improved. This will also help to minimise adverse effects related to PCA and to avoid lethal mishaps.
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Tramadol is a synthetic, centrally acting opioid analgesic. An extended-release tablet formulation of tramadol (tramadol ER) allows gradual release of the active drug, permitting once-daily administration. Tramadol ER administered once daily is equivalent in bioavailability to immediate-release tramadol administered four times daily, with prolonged absorption and lower peak plasma concentrations. ⋯ In a flexible-dose trial in patients with osteoarthritis of the knee, the mean reduction from baseline in pain intensity scores over 12 weeks was significantly greater in recipients of tramadol ER than in placebo recipients. In a fixed-dose trial in patients with osteoarthritis of the knee and/or hip, the mean improvements from baseline in the pain and physical function subscale scores of the Western Ontario and McMaster Universities Osteoarthritis Index over 12 weeks were significantly greater in tramadol ER than placebo recipients. Common adverse events reported in patients with moderate to moderately severe chronic pain treated with tramadol ER 100-300 mg once daily were dizziness (excluding vertigo), nausea, constipation, somnolence and flushing.