Short-term use of remifentanil during endotracheal extubation for prophylactic analgesia in neurosurgical patients after craniotomy (SURE after Craniotomy Study): a study protocol and statistical analysis plan for a randomised controlled trial

Abstract

IntroductionAcute pain is common during the endotracheal extubation period, and is related to complications and adverse outcomes. Patients with delayed extubation after craniotomy are vulnerable to pain and complications of extubation. However, pain control during extubation is still inadequate. Remifentanil, a new opioid with rapid onset and short duration of action, provides adequate analgesia during procedures with minimal effect of respiratory depression.Methods and analysisThe study is a prospective, randomised, double-blinded, controlled parallel-group design. Patients with delayed extubation after intracranial surgery are screened daily. Adult patients ready for extubation are enrolled and assigned randomly to one of the two treatment study groups, labelled as the ‘Remi group’ or ‘Saline group’. Patients in the Remi group receive an intravenous bolus dose of remifentanil 0.5 μg/kg over 60 s followed by a continuous infusion 0.05 μg/kg/min for 20 min. Patients in the Saline group receive an intravenous infusion of 0.9% sodium chloride at a volume and rate equal to that of remifentanil. Pain intensity is measured by the visual analogue scale (VAS) pain score. Adverse events during drug infusion are documented and reported. Patients will be followed up until hospital discharge, death or 60 days after the trial intervention on a first come, first served basis. Details of the incidence of reintubation and reoperation within 72 h after extubation, length of stay in the intensive care unit and hospital and mortality are collected. The primary end point is the incidence of severe pain (defined as a VAS pain score more than 5 cm) during the periextubation period (defined as the period of time from immediately before extubation to 20 min after extubation).Ethics and disseminationThe study was approved by the Institutional Review Board (IRB) of the Beijing Tiantan Hospital, Capital Medical University. The study findings will be disseminated through peer-reviewed publications and conference presentations.Trial registration numberClinicalTrials (NCT): ChiCTR-PRC-13003879.

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“…However, the dosage of propofol, which could provide effective sedation and hypnosis for tolerance endotracheal tube and have little effect on hemodynamic responses, is far below the above usage. Remifentanil, a potent synthetic selective μ-opioid receptor agonist with a rapid onset and short duration of action, can provide sedation and analgesia during the placement of the endotracheal tube, and can cause blunt reflex responses (21). Lee et al reported that the infusion of 1 μg/kg remifentanil, which is in accordance with ours, could lead to a decrease in blood pressure and HR in an acceptable safely range (22).…”

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“…Prophylactic analgesia is a form of analgesia that blocks the transmission, conduction, and establishment of peripheral injurious impulses to the center and reduces the peripheral and central sensitization caused by noxious stimulus afferents[ 20 ]. As a long-acting, non-accumulative opioid, oxycodone can provide suitable prophylactic analgesia.…”

Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients

“…After completing the SBT, patients were disconnected from the ventilator, either breathing through a T-tube circuit with humidified oxygen or extubated as decided by the clinical team using a screen checklist (Table S2) (36,37). Reconnection to the ventilator support was solely decided by the clinical team, who were unaware of the physiological (36).…”

“…After completing the SBT, patients were disconnected from the ventilator, either breathing through a T-tube circuit with humidified oxygen or extubated as decided by the clinical team using a screen checklist (Table S2) (36,37). Reconnection to the ventilator support was solely decided by the clinical team, who were unaware of the physiological (36). Failed ventilator liberation was defined as the need for invasive ventilator support within 48 h after the SBT, independent of the presence of an artificial airway (tracheostomy or endotracheal tube).…”