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Case Reports
. 2025 Feb 22;17(2):e79435.
doi: 10.7759/cureus.79435. eCollection 2025 Feb.

Safe Sedation and Analgesia Management With Remifentanil in Pediatric ICU Patients: A Report of Two Cases

Mana Tamaki  1 , Takahiro Hirai  2 , Tasuku Fujii  2 , Shogo Suzuki  2 , Takahiro Tamura  3
Affiliations
Case Reports

Safe Sedation and Analgesia Management With Remifentanil in Pediatric ICU Patients: A Report of Two Cases

Mana Tamaki et al. Cureus. .

Abstract

Although remifentanil (RF) is not approved for use in the ICU for children, its short half-life and titratability may provide advantages in children requiring high doses of sedatives and analgesics during prolonged mechanical ventilation. This report presents two pediatric cases in which RF was administered for sedation and analgesia, enabling successful extubation without adverse effects. In Case 1, a four-year-old girl with multiple atypical teratoid rhabdoid tumors required mechanical ventilation due to impaired consciousness. RF was initiated at 0.22 μg/kg/min and titrated up to 0.48 μg/kg/min on the day before extubation, allowing the reduction of other sedatives. She received RF for a total of 16 hours (5.66 mg) before it was discontinued, and extubation was successfully performed 70 minutes later. In Case 2, a three-year-old girl with a severe neck abscess required prolonged intubation following surgical drainage. RF was started at 0.1 μg/kg/min and increased to 0.2 μg/kg/min on the day before extubation, facilitating the tapering of other sedatives. She received RF for a total of 23 hours (4.4 mg) before discontinuation, and extubation was successfully performed 25 minutes later. Throughout RF administration, hemodynamic stability was maintained, with no occurrences of hypotension, bradycardia, desaturation, hepatic or renal dysfunction, muscle rigidity, or hyperalgesia. No additional catecholamines were required, and no signs of withdrawal symptoms were observed. These findings suggest that RF may be a safe and effective option for sedation and analgesia in pediatric patients undergoing prolonged mechanical ventilation.

Keywords: analgesia; intensive care unit; pediatric; remifentanil; sedation.

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Unapproved New Drug Evaluation Committee issued approval TF23003. The Unapproved New Drug Evaluation Committee approved the off-label use of remifentanil for pediatric patients on March 20, 2023. The targeted patients are pediatric patients undergoing mechanical ventilation in intensive care settings. Furthermore, this study has been approved by our hospital's Bioethics Review Committee (approval number: 2024-0305). Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. MR FLAIR and CT images of the brain in Case 1.
Axial (A) and coronal (B) MR FLAIR images showing a mass lesion with mild heterogeneous hyperintensity in the left temporal lobe and lateral ventricle (red arrow); (C) CT image showing narrowing of the lateral ventricles (yellow arrow) and intratumoral hemorrhage (white arrow). MR: magnetic resonance; CT: computed tomography; FLAIR: fluid-attenuated inversion recovery
Figure 2
Figure 2. Clinical course of Case 1.
RASS: Richmond Agitation-Sedation Scale; MDZ: midazolam; DEX: dexmedetomidine
Figure 3
Figure 3. Clinical course of Case 2.
RASS: Richmond Agitation-Sedation Scale; MDZ: midazolam; DEX: dexmedetomidine
See this image and copyright information in PMC

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