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Use of a remifentanil PCA for a patient with multiple rib fractures

London, UK

To the Editor:

A 48-yr-old woman, weighing 55 kg, fell off her horse and was admitted to our High Dependency Unit with fractures of L1–L3 transverse processes, fractured left second to eighth ribs and hemopneumothorax requiring a chest drain and regular chest physiotherapy.

The patient was given regular oral paracetamol 1 g six hourly and tramadol 50 mg at six hourly intervals and started on a morphine patient-controlled analgesia (PCA) pump, programmed to give 1 mg boluses with a five-minute lockout time. However, the patient complained of bad dreams, paranoia, drowsiness and nausea while using it. In view of this the morphine in the PCA was changed to remifentanil on the fourth day. A concentration of 25 µg•mL^-1 was prepared and administered as a PCA pump with boluses of 25 µg (approximately 0.5 µg•kg^-1) using a five-minute lockout time. On day six a continuous infusion of 50 µg•hr^-1 (approximately 1 µg•kg^-1•hr^-1) was added as a background infusion to the PCA. The patient reported feeling less nauseated, and claimed the bad dreams and paranoia had stopped. The daily mean sedation and nausea scores improved while on the remifentanil PCA.

No bradycardias or desaturations were observed in our patient. We suggest that the use of remifentanil as a PCA be considered in patients where rapid control of analgesia is required, e.g., for chest physiotherapy, and the accumulative sedative and respiratory depressant effects of longer-acting opiates are undesirable.

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