Properties of remifentanil Intra-operative control



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How to use remifentanil in general anaesthesia


How to use remifentanil in general anaesthesia

  • Properties of remifentanil

  • Intra-operative control

  • Recovery

  • Reconstitution

  • Dosing protocol for general anaesthesia

  • Hypnotic sparing effects in general anaesthesia

  • Post-operative pain management

  • Summary

  • References

  • Prescribing information



Properties of remifentanil



Intra-operative control

  • Remifentanil is suitable for use in many different types of surgery1–5

  • Remifentanil’s fast onset and short duration of action enables rapid titration to effect6

  • Remifentanil offers a unique approach to the management of surgical patients by providing:

    • More effective control of intra-operative responses than alfentanil or fentanyl7,8
    • More effective at maintaining haemodynamic stability than alfentanil or fentanyl5,9
    • Control in difficult-to-treat patients with renal or hepatic impairment, with no initial dose adjustment needed10-12


Recovery

  • Remifentanil provides fast, clear-headed recovery1–3

  • Recovery with remifentanil is more rapid than with fentanyl or alfentanil2,3

  • Remifentanil facilitates rapid extubation and reduces the need for ICU admission1–5

  • Remifentanil enables early post-operative neurological assessment1–3

  • Post-operative pain can be effectively managed6



Reconstitution

  • Available as lyophilised powder for reconstitution in 1mg, 2mg and 5mg vials

  • To reconstitute add recommended diluent to powder in vial and shake well

  • After reconstitution, further dilute to recommended dilution

  • 50µg/ml is the recommended dilution for adults



Dosing protocol for general anaesthesia – induction

  • Remifentanil is indicated as an analgesic agent for use during induction and/or maintenance of general anaesthesia under close supervision1

  • Induction of anaesthesia in adults:*

    • Remifentanil: continuous infusion 0.5–1µg/kg/min1
    • Mackey et al used an infusion rate of 0.5µg/kg/min for 2 minutes prior to intubation2
    • Warner et al used an infusion rate of 0.5–1µg/kg/min for 1 minute prior to intubation3
    • Isoflurane: starting dose 0.5 MAC1
    • Propofol: starting dose 100μg/kg/min1
  • Details of infusion rates required for target dosages according to patient weight are supplied in the corresponding factsheet

  • *When given by bolus injection at induction remifentanil should be administered over not less than 30 seconds1



Dosing protocol for general anaesthesia – maintenance

  • Maintenance of anaesthesia in adult ventilated patients:

  • The administration of remifentanil should be individualised based on the patient’s response

    • During anaesthesia, the rate of administration can be titrated:
      • upward in 25–100% increments every 2–5 minutes
      • downward in 25–50% decrements every 2–5 minutes
    • When used with isoflurane: starting rate 0.25µg/kg/min (range 0.05–2µg/kg/min)*
    • When used with propofol: starting rate 0.25µg/kg/min (range 0.05–2µg/kg/min)*


Dosing protocol for general anaesthesia – summary



Hypnotic sparing effects in general anaesthesia

  • Remifentanil significantly reduces the amount of hypnotic agent required to maintain anaesthesia1

  • The doses of the following agents used in anaesthesia have been reduced by up to 75% when used concurrently with remifentanil:

      • Isoflurane1
      • Thiopentone1
      • Propofol1
      • Temazepam1
      • Sevoflurane2
  • Starting doses of hypnotics are detailed on the corresponding factsheet



Hypnotic sparing effects in general anaesthesia

  • It is appropriate to maintain a low concentration of hypnotic agent and titrate remifentanil to produce adequate anaesthesia1-3



MAC Reduction of Isoflurane with Remifentanil

  • Adapted from Lang E et al., Anesthesiol 1996; 85: 721–28.



Post-operative pain management

  • Due to the very rapid offset of action of remifentanil, no residual opioid activity will be present within 5–10 minutes after discontinuation, regardless of duration of infusion

  • Post-operative analgesia, including choice of agent, dose and time of administration must be planned well in advance of remifentanil discontinuation

    • Analgesics should be administered prior to discontinuation of remifentanil
    • Sufficient time must be allowed to reach the maximum effect of the longer-acting analgesic
    • The choice of analgesic should be appropriate for the patient’s surgical procedure and the level of post-operative care


Post-operative pain management

  • The dosage and timing of administration of the alternative long-acting analgesic agent should be considered to allow therapeutic effects to become established1

  • Minkowitz et al. achieved adequate post-operative pain management with a 150 or 200μg/kg bolus of morphine sulphate administered 30 minutes before the end of surgery2

  • Muñoz et al. used 150μg/kg morphine and showed a reduction in the number of patients requiring morphine in the post-anaesthesia care unit, when morphine had been given more than 40 minutes before the end of surgery3



Special precautions for use

  • Due to the very rapid offset of action of remifentanil, post-operative analgesia must be planned well in advance of remifentanil discontinuation

  • Care should be taken to avoid inadvertent administration of remifentanil remaining in IV lines and cannulae

  • Muscle rigidity induced by remifentanil must be treated in the context of the patient's clinical condition with appropriate supporting measures including ventilatory support.

  • Remifentanil should only be used in areas where facilities for monitoring and dealing with respiratory depression are available

  • Hypotension and bradycardia may be managed by reducing the rate of infusion of remifentanil or the dose of concurrent anaesthetics or by using IV fluids, vasopressor or anticholinergic agents as appropriate



Summary



References

  • Bekker A et al. The recovery of cognitive function after remifentanil-nitrous oxide anesthesia is faster than after an isoflurane-nitrous oxide-fentanyl combination in elderly patients Anesth Analg 2000; 91: 117–22.

  • Breslin DS et al. Sevoflurane--nitrous oxide anaesthesia supplemented with remifentanil: effect on recovery and cognitive function Anaesthesia 2001; 56: 1149.

  • Demirbilek S et al. The effects of remifentanil and alfentanil-based total intravenous anesthesia (TIVA) on the endocrine response to abdominal hysterectomy J Clin Anesth 2004; 16: 358–63.

  • Dershwitz M et al. Pharmacokinetics and pharmacodynamics of remifentanil in volunteer subjects with severe liver disease. Anesthesiology 1996; 84: 812–20.

  • Dershwitz M et al. The pharmacokinetics and pharmacodynamics of remifentanil in volunteers with severe hepatic or renal dysfunction. J Clin Anesthesia 1996; 8: 88S–90S.

  • Eberhart L et al. Fast-track eligibility, costs and quality of recovery after intravenous anaesthesia with propofol-remifentanil versus balanced anaesthesia with isoflurane-alfentanil Eur J Anaesthesiol 2004; 21: 107–14.

  • Egan TD Remifentanil pharmacokinetics and pharmacodynamics. A preliminary appraisal. Clin Pharmacokinet 1995; 29: 80–94.

  • Fish W et al. Comparison of sevoflurane and total intravenous anaesthesia for daycase urological surgery Anaesthesiology 1999; 54: 1002–6.

  • GlaxoSmithKline. Remifentanil HCl (Ultiva) Summary of Product Characteristics, June 2005.

  • Howie MB et al. A randomised double-blinded multicenter comparison of remifentanil versus fentanyl when combined with isoflurane/propofol for early extubation in coronary artery bypass graft surgery. Anesth Analg 2001; 92: 1084-1093.

  • Kallar SK et al. A single, blind, comparative study of the safety and efficacy of remifentanil and alfentanil for outpatient anaesthesia. Anesthesiol 1994; 81: A32.



References continued

  • Kovac A et al. Remifentanil versus alfentanil in a balanced anesthetic technique for total abdominal hysterectomy J Clin Anesth 1997; 9: 532–41.

  • Lane M et al. The use of remifentanil in the critically ill Care Crit Ill 2002: 18: 144-45.

  • Lang E et al. Reduction of isoflurane minimal alveolar concentration by remifentanil Anesthesiology 1996; 85: 7218.

  • Mackey J. et al. Effectiveness of remifentanil versus traditional fentanyl-based anesthetic in high-risk outpatient surgery J Clin Anesth 2000; 12: 427–32.

  • Milne S et al. Propofol sparing effect of remifentanil using closed-loop anaesthesia Br J Anaesth 2003; 90: 6239.

  • Minkowitz H. Postoperative pain management in patients undergoing major surgery after remifentanil vs. fentanyl anesthesia. Multicentre Investigator Group. Can J Anesth 2000; 47: 522–8.

  • Muñoz H et al. Effect of timing of morphine administration during remifenanil-based anaesthesia on early recovery from anaesthesia and postoperative pain. Br J Anaesth 2002; 88: 814-8.

  • Park G et al. Reducing the demand for admission to intensive care after major abdominal surgery by a change in anaesthetic practice and the use of remifentanil Eur J Anaes 2000; 17: 111–9.

  • Schuttler J et al. A comparison of remifentanil and alfentanil in patients undergoing major abdominal surgery. Anaesthesia 1997; 52: 307–317.

  • Sneyd J et al. Comparison of propofol/remifentanil and sevoflurane/remifentanil for maintenance of anaesthesia for elective intracranial surgery Br J Anaesth 2005; 94: 778–83.

  • Sneyd J et al. Remifentanil and fentanyl during anaesthesia for major abdominal and gynaecological surgery. An open, comparative study of safety and efficacy Eur J Anaesthesiol 2001; 18: 605–14.

  • Warner DS. Experience with remifentanil in neurosurgical patients Anesth Analg 1999; 89: S33-9.

  • Wilhelm W et al. Recovery and neurological examination after remifentanil-desflurane or fentanyl-desflurane anaesthesia for carotid artery surgery. Br J Anaesth 2001; 86: 44–9.



Prescribing information



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