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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com

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lunes, 9 de mayo de 2016

Fentanyl infusions for sedation

Resultado de imagen de PulmCrit
PulmCrit - May 9, 2016 - By Josh Farkas
"Introduction
We keep changing how we sedate intubated patients. Etomidate infusions were trendy for a while, until it was noticed that they suppressed adrenal function. Then benzodiazepine infusions were popular, until research showed they increase delirium and prolong intubation. Currently fentanyl infusions are en vogue.
I’ve been using fentanyl infusions as the backbone of my sedative strategy, in keeping with the 2013 SCCM guidelines. This generally works well for patients who can be extubated quickly. However, for patients who remain on the ventilator for longer periods of time, it often leads to problems involving tolerance and withdrawal.
Hence the question: What is the evidence supporting fentanyl infusions in the ICU? Is this a safe approach to patients requiring sedation for longer periods of time (for example, over one week)?
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  • There is little evidence to support the use of prolonged fentanyl infusions for sedation in the ICU (e.g. longer than 10 days).
  • Over time, fentanyl infusions are often up-titrated to levels that correspond to an enormous opioid dose (e.g. 200 mcg/hour fentanyl is equivalent to 960 mg oxycodone daily). Opioid doses this high might actually exacerbate pain (opioid-induced hyperalgesia).
  • When used for long periods of time, fentanyl infusions may cause drug accumulation and tolerance, with subsequent opioid withdrawal.
  • It is possible that the combination of a low-dose ketamine infusion with PRN opioid boluses could achieve effective analgesia with fewer side-effects."