Case Report: Requirement of Supplemental Morphine During Sedation With Propofol in a Critically Ill Patient Undergoing Hemodiafiltration

Francesco Imperatore, MD, Paolo Francesco Marsilia, MD, Francesco Munciello, MD, Giovanni Liguori, MD, Luigi Maria Borrelli, MD, Gianluca Gatta, MD, Antonio Martino, MD, Luigi Occhiochiuso, MD

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Abstract and Introduction

Objective: Propofol has been shown to produce a predictable and easily attainable level of sedation in postcardiac, head-injured, general trauma patients. The commencement of hemodiafiltration itself has not been shown to significantly influence the requirement for propofol. We report on a patient who underwent binephrectomy complicated by sepsis-induced adult respiratory distress syndrome (ARDS).
Design: Case report.
Setting: Largest nonteaching hospital in Southern Italy.
Patients/Subjects: An 18-year-old male underwent a surgical procedure for splenectomy and right nephrectomy for severe abdominal trauma. On the 10th postoperative day, the patient was admitted into our intensive care unit (ICU) for acute respiratory and renal failure due to ARDS and left renal infarction.
Interventions: Continuous venovenous hemodiafiltration was carried out through a double-lumen cannula. Sedation was initially achieved with propofol up to standard doses into a nonfemoral venous site. Because the optimal level of sedation was not achieved, the initial propofol infusion rate was increase to 3.5 mg/kg, and then an intravenous bolus of morphine (.01 mg/kg) was administered twice daily.
Results: The administration of morphine was fundamental to achieving an optimal level of sedation. ARDS resolved and, 10 days later, the patient was transferred to the surgical unit, then discharged home after 14 days.
Conclusion: Hemodiafiltration was found to influence the clinical requirement for propofol. The optimal level of sedation is achieved with the addition of morphine.

Sedation is frequently required for critically ill patients.[1] Propofol has been shown to produce a predictable and easily attainable level of sedation in postcardiac, head-injured, general trauma patients.[2] The commencement of hemodiafiltration itself has not been found to significantly influence the requirement for propofol.[3] Moreover, hemodiafiltration removes just 1% to 3% of the total amount of morphine used for sedation.[4]

We report on a patient who underwent binephrectomy complicated by sepsis-induced adult respiratory distress syndrome (ARDS). Optimal sedation during continuous venovenous hemodiafiltration (CVVHDF) was not successfully achieved through the intravenous infusion of propofol, but with the addition of supplemental doses of morphine.

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