Fentanyl注射劑在加護病房的使用角色

(1)

386

Fentanyl

1

NSAIDs meperidine

( ) morphine

( )

fentanyl

fentanyl morphine

( Fentanyl ) ( Analgesia )

( Continuous IV infusion ) ( Respiratory depression )

( Visual analog scale VAS )

(

)

¹

NSAIDs ( nonsteroidal anti- inflammatory drugs )

meperidine

morphine

( fentanyl )

(2)

2

SUPPORT

3

( Visual analog scale VAS ) ( Verbal descriptor scale VDS) ( Numeric rating scale NRS ) ( Wong/Baker Pain Scale

⁴

) VAS

3 ( Wong/Baker Pain Scale )

VAS VDS NRS

propofol midazolam

VAS VDS NRS

Wong/Baker Pain Scale 2

catecholamine glucagon cortisol vaso- pressin

5

Fentanyl

fentanyl meperidine

1 9 5 0 s J a n s s e n

Pharmaceutica 1960s

(VAS) 10

(VDS) 6

(NRS) 10

6 (Wong/Baker Pain Scale)

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morphine meperidine

6

fentanyl

morphine 133

⁷

IM, IV, neuraxial, tran- sdermal, transmucosal inhalation

⁸

fentanyl 5 80%

( )

⁸

9

( 1 ) I V 3 ~ 5 I M

7~8

(2) IV 30~60 IM 1~2

(3) 80~86%

(4) cytochrome P450

3A4 4

( 5 ) 2 1 9 ( I V )

85% 9 %

( ) f e n t a n y l

m o r p h i n e 1 0 0 0 . 6

n g / m l 1 . 7

ng/ml

¹⁰

1~3 ng/ml

¹¹

1~2 ng/ml

VAS 1~3

^12-13

14

( )

fentanyl

(4)

fentanyl

2 ng/ml

8

( )

fentanyl 0.6-2 ng/ml

⁸

N i m m o 0 . 5 ug/kg/h 1.5 ug/kg/h

0.56-0.61 1.62-1.79 ng/ml

¹⁵

Duthie 1.48 ug/kg/h 1.56 ug/kg/h

1.4-2.0 0.5-2.3 ng/ml

^16-17

Holley 25 50 100 125 ug/h

0.51-0.53 0.87-0.94 1.37-1.42 1.90-1.97 ng/ml

¹⁸

( )

fentanyl ( IV

bolus ) ( continuous IV infusion )

1-2 u g / k g ( 3 - 5 ) 1 . 5 - 2 . 5 u g / k g / h ( )

GFR=10~50 ( ml/min ) 75%

GFR<10 ( ml/min ) 50%

fentanyl

Fentanyl Morphine

fentanyl morphine

f e n -

tanyl morphine

morphine 3~5

fentanyl morphine

1. ( VAS 2 ) 2. dopamine,

norepinephrine fentanyl

m o r p h i n e

25-100 ug ( 3-5 )

5-10 6

300 ug

1.5-2.5 ug/kg/h

VA S 4

( ) 2 VAS 4

VAS 2

1 0 10%

fentanyl

1.Hynes-Gay P, Leo M, Molino-Carmona S, et al. Optimizing se- dation and analgesia in mechanically ventilated patients--an evidence-based approach. Dynamics 2003; 14: 10-3.

2.Pasero C. Pain in the critically ill patient. Journal of Peria- nesthesia Nursing 2003; 18: 422-5.

3.Desbiens NA, Wu AW, Broste SK, et al. Pain and satisfaction fentanyl morphine(IV)

morphine fentanyl 10mg/1cc/amp 0.5mg/10cc/amp

30 3-5

2-4 30-60

2-4 2-5

10 mg 0.1 mg

+++ ++++

+++ +

+++ ++

+++ +

/amp 16 98

(5)

from the SUPPORT research investigations. Critical Care Medicine 1996; 24: 1953-61.

4.Hamill-Ruth RJ, Marohn ML. Evaluation of pain in the critically ill patient. Critical Care Clinics 1999; 15: 35-54.

5.Cammarano WB, Drasner K, Katz JA. Pain control, sedation and use of muscle relaxants. In: Hall JB, Schmidt GA, Wood LDH.

Principle of critical care. 2nd ed. New York: International McGraw Hill; 1998; 87-109.

6.Stanley TH. The history and development of the fentanyl series.

J Pain Symptom Manage 1992; 7: S3-7.

7.Hug CC Jr. Pharmacokinetics of new synthetic narcotic anal- gesics. In: Estafanous FG. Opioids in Anesthesia. 1st ed.

Stoneham, UK, Butterworth; 1984; 50-69.

8.Peng PW, Sandler AN. A review of the use of fentanyl analge- sia in the management of acute pain in adults. Anesthesiology 1999; 90: 576-99.

9.MICROMEDEX® Health Series. 2005.

10.Nimmo WS, Todd JG. Fentanyl by constant rate i.v. infusion for postoperative analgesia. Br J Anaesth 1985; 57: 250-4.

11.Duthie DJR, McLaren AD, Nimmo WS. Pharmacokinetics and fentanyl during constant rate i.v. infusion for the relief of pain after surgery. Br J Anaesth 1986; 58: 950-6.

12.Salomaki TE, Laitinen JO, Nuutinen LS. A randomized double- blind comparison of epidural versus intravenous fentanyl infu- sion for analgesia after thoracotomy. Anesthesiology 1991; 75:

790-5.

comparison of epidural versus intravenous fentanyl infusion for analgesia after cesarean section. Anesthesiology 1990; 72: 981- 6.

14.Loper KA, Ready B, Downey M, et al. Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery.

Anesth Analg 1990; 70: 72-5.

15.Beckett AH, Casey AF. Synthetic analgesics, stereochemical considerations. J Pharm Pharmacol 1954; 6: 986-1001.

16.Duthie DJR, McLaren AD, Nimmo WS. Pharmacokinetics and fentanyl during constant rate i.v. infusion for the relief of pain after surgery. Br J Anaesth 1986; 58: 950-6.

17.Duthie DJR, Rowbotham DJ, Wyld R, Henderson PD, Nimmo WS. Plasma fentanyl concentrations during transdermal deli- very of fentanyl to surgical patients. Br J Anaesth 1988; 60: 614- 8.

18.Holley FO, Van Steennis C. Postoperative analgesia with fen- tanyl: Pharmacokinetics and pharmacodynamics of constant- rate iv and transdermal delivery. Br J Anaesth 1988; 60: 608-13.

19.Liu LL, Gropper MA. Postoperative analgesia and sedation in the adult intensive care unit: a guide to drug selection. Drugs 2003; 63: 755-67.

20.Mularski RA. Pain management in the intensive care unit.

Critical Care Clinics 2004; 20: 381-401.

The Role of Fentanyl Injection in Intensive Care Unit

Yu-Ping Lin, Chien-Wei Hsu

¹

, Pi-Lai Tseng, and Derek K.T. Lee

Pain-control service is always inadequate in intensive care units (ICU) of Taiwan. Adverse drug reactions are the main reason to under-prescribe analgesics, as nonsteroidal anti-inflammatory drugs lead to gastrointesti- nal bleeding and nephrotoxicity; meperidine-related seizures; morphine has unstable hemodynamics and addic- tives problems. However, lots of invasive procedures are necessary for critical illness patients. The possibility to induce the complication (e.g. acute myocardial infarction, immunosuppression, insulin resistance) maybe in- crease, and the outcome will prolong the hospital stay even death if we could not provide adequate pain-control.

In the developed country, fentanyl injection is the first-line analgesic in ICU. Fentanyl has lots of advantages more than morphine in safety, efficacy and convenience to improve healthcare quality. It is worthy to learn and apply in ICU of Taiwan. ( J Intern Med Taiwan 2005; 16: 211-215 )

Department of Pharmacy,

¹

Division of Intensive Care,

Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan