Opioid and sedative infusions are commonly used to provide analgesia and sedation for adults receiving invasive mechanical ventilation (IMV) in the intensive care unit (ICU). Although remifentanil‑based analgo‑sedation is clinically feasible and may shorten ventilation and ICU durations, the economic consequences of choosing remifentanil over alternatives such as fentanyl remain unclear. This systematic review aimed to identify, synthesise and critically appraise published economic evaluations that compared remifentanil‑based sedation with fentanyl‑based or other comparators in mechanically ventilated adult ICU patients.
The authors searched Ovid MEDLINE, Ovid Embase and the Cochrane Library for full‑text, original English‑language economic evaluations published between 1997 and 2023. Reporting quality of included studies was assessed using the 24‑item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Screening and selection outcomes were reported as the number of records identified, duplicates removed, full texts reviewed and studies meeting inclusion criteria.
A total of 169 records were identified through database searches; after duplicate removal 103 records remained. Eight articles underwent full‑text review. Only two single‑centre economic evaluations met the inclusion criteria, and together they included 285 patients. The two studies differed substantially in multiple methodological aspects, including the specific outcomes assessed, which cost components were included, the analytical perspective adopted and the time horizon used for the economic analysis. Details on study settings, patient populations, and exact costing methods were reported in the original articles; the systematic review summarised these differences and their implications for comparability.
Reporting quality assessed by the CHEERS checklist varied between the two included evaluations. The study by Muellejans et al. was rated as having good reporting quality (59% of CHEERS items met). The study by Al et al. achieved a higher rating of very good (81% of CHEERS items met). The review reported these scores but did not alter the primary study findings; instead, it used the assessment to contextualise confidence in the economic results and to highlight reporting gaps.
Both included studies reported shorter durations of invasive mechanical ventilation and reduced ICU length of stay in patients managed with remifentanil‑based analgo‑sedation compared with the comparator. These consistent clinical signals across the two single‑centre evaluations suggest potential clinical benefits in terms of time on ventilatory support and ICU occupancy when remifentanil is used for analgo‑sedation.
Despite similar clinical findings for ventilation and ICU duration, the economic conclusions were inconsistent between the two studies. Al et al. reported that remifentanil may reduce overall costs. In contrast, Muellejans et al. found total costs to be similar between remifentanil and comparator groups; this was attributed principally to the higher acquisition cost of remifentanil offsetting savings from shorter resource use. The review emphasised that the studies differed in which costs were measured and in analytical perspective and horizon, limiting direct comparison and pooled economic interpretation.
The systematic review identified a very limited evidence base: only two single‑centre studies with a combined sample of 285 patients met inclusion criteria. The included studies displayed substantial heterogeneity in methodology, outcome selection, cost components and time horizons. Reporting completeness also varied. These limitations reduce confidence in generalisability and in any overarching conclusion about the cost‑effectiveness or value for money of remifentanil in mechanically ventilated ICU populations.
The review concluded that evidence on the economic impact of remifentanil for analgo‑sedation in mechanically ventilated adult ICU patients is limited and heterogeneous. Given the high costs associated with intensive care, the authors recommend that future economic evaluations be high quality, reflect contemporary clinical practice, measure costs comprehensively and apply appropriate time horizons. Such studies are needed to determine whether remifentanil provides good value for money compared with fentanyl or other sedation strategies in the ICU.
Keywords appearing in the review include ICU, cost‑effectiveness, economic evaluation, intensive care, opioids and remifentanil. The review emphasises methodological rigor and comprehensive cost measurement as necessary to resolve current uncertainty about the economic implications of remifentanil use in mechanically ventilated adults.