Conscious sedation with remifentanil and midazolam during brief painful procedures in children

Area of Science:

• Pediatric Anesthesiology
• Pharmacology
• Critical Care Medicine

Background:

• Brief, painful procedures in children often require effective analgesia and sedation.
• Remifentanil, an ultra-short-acting opioid, possesses favorable pharmacokinetic properties for procedural sedation.
• Midazolam is commonly used for procedural sedation in pediatric patients.

Purpose of the Study:

• To evaluate the efficacy and safety of combining remifentanil and midazolam for analgesia and sedation during brief, painful pediatric procedures.
• To assess pharmacokinetic advantages of remifentanil in this setting.

Main Methods:

• Prospective observational study in a university hospital setting.
• Seventeen children (aged 2-12 years) undergoing 20 procedures received intravenous midazolam (0.05 mg/kg) and remifentanil (1 microg/kg), followed by a remifentanil infusion (0.1 microg x kg(-1) x min(-1)).
• Doses were titrated every 5 minutes, monitoring sedation, analgesia, and adverse events.

Main Results:

• The combination was successful in 17 of 20 procedures, with a mean successful remifentanil dose of 0.4 +/- 0.2 microg x kg(-1) x min(-1).
• Mean discharge readiness time was 9.5 +/- 4.3 minutes.
• Four children experienced hypoxemia (resolved with stimulation), and one required positive-pressure ventilation. Continuous stimulation helped avoid hypoxemia in 10 of 13 patients.

Conclusions:

• Remifentanil and midazolam facilitate rapid discharge after pediatric procedures.
• However, this combination is associated with a significant incidence of life-threatening respiratory depression, even at subtherapeutic doses.
• Careful monitoring and potential interventions like continuous stimulation are crucial when using this regimen.