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
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
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Breslin DS et al. Sevoflurane--nitrous oxide anaesthesia supplemented with remifentanil: effect on recovery and cognitive function Anaesthesia 2001; 56: 1149.
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.
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GlaxoSmithKline. Remifentanil HCl (Ultiva) Summary of Product Characteristics, June 2005.
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References continued
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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: 7218.
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: 6239.
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.
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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.
