Remifentanil, although not licensed for analgesia and sedation in ventilated patients under 18 years, has been used increasingly in paediatric intensive care units (PICU). We audited remifentanil use in mechanically ventilated patients in a tertiary 20-bed PICU between 2005 and 2007.
There were 43 patients with a median age of 53.7 months (interquartile range 6.1–153.3), who received remifentanil at a maximum infusion rate of 0.5 μg/kg per minute (0.2–0.9) for 2.0 days (0.5–5.0). Cardiac (10), respiratory (8), neurosurgical (7), ENT (6) and general surgical (5) patients received remifentanil most commonly. 30 patients were within the recommended dose range (0.10–0.75 μg/kg per minute). Seven patients received more than the maximum dose and were more likely to receive concomitant sedative and/or analgesic agents (p<0.01). Remifentanil was the sole analgesic/sedative drug in 15 cases, all of which received an infusion for <1 day. 29 and 10 cases received remifentanil for <3 and >3 days, respectively, with concomitant drugs more likely to be started in the latter (p<0.01). Three cases had significant withdrawal following ⩾8 days infusion, who received higher (⩾1.00 μg/kg per minute) infusion rates (p<0.01) and more (⩾4) analgesic/sedative drugs (p<0.01), compared with those without any adverse effects. For a 10 kg infant the cost of 3-day infusions of midazolam (100 μg/kg per hour), morphine (20 μg/kg per hour) and remifentanil (0.10 μg/kg per minute) would be £74, £3 and £18, respectively.
Remifentanil usage is increasing in PICU, with our current guidelines for dosage and duration generally not being upheld. There is a significant risk of withdrawal from remifentanil, particularly in those patients who receive high infusion rates for longer.