Adult Dosing
Anesthesia induction
- 0.5-1 mcg/kg/min IV as a continuous infusion
- An initial dose of 1 mcg/kg may be given over 30-60 secs
- Give with muscle relaxant to avoid chest wall rigidity
Anesthesia maintenance
- With nitrous oxide 66%
- 0.4 mcg/kg/min IV
- Range 0.1-2 mcg/kg/min
- Supplemental bolus doses of 1 mcg/kg may be given
- With isoflurane (0.4-1.5 MAC)/propofol (100-200 mcg/kg/min)
- 0.25 mcg/kg/min IV
- Range 0.05-2 mcg/kg/min
- Supplemental bolus doses of 1 mcg/kg may be given
Analgesia in immediate postoperative period
- 0.1 mcg/kg/min IV
- Range: 0.025-0.2 mcg/kg/min
Monitored anesthesia care (remifentanil alone)
- Single IV dose: 1 mcg/kg/min IV given 90 seconds before local anesthetic
- Continuous IV infusion:
- 0.1 mcg/kg/min IV beginning 5 min before local anesthetic
- Then 0.05 mcg/kg/min after local anesthetic (range 0.025-0.2 mcg/kg/min)
Monitored anesthesia care (remifentanil + midazolam)
- Single IV dose: 0.5 mcg/kg/min IV given 90 seconds before local anesthetic
- Continuous IV infusion:
- 0.05 mcg/kg/min IV beginning 5 min before local anesthetic
- Then 0.025 mcg/kg/min after local anesthetic (range 0.025-0.2 mcg/kg/min)
Coronary artery bypasses surgery
- Induction of anesthesia: 1 mcg/kg/min IV
- Maintenance of anesthesia: 1 mcg/kg/min IV. Range: 0.125-4 mcg/kg/min
- Continuation of analgesic into ICU: 1 mcg/kg/min IV. Range : 0.05-1 mcg/kg/min
Pediatric Dosing
Anesthesia maintenance
- Birth-2 months:
- With nitrous oxide 70%: 0.4 mcg/kg/min; Range: 0.4-1 mcg/kg/min IV. Supplemental doses of 1 mcg/kg may be given
- 1-12 yrs of age:
- With halothane/sevoflurane/isoflurane: 0.25 mcg/kg/min IV; Range: 0.05-1.3 mcg/kg/min. Supplemental doses of 1 mcg/kg may be given
[Outline]
- Remifentanil is a schedule II controlled drug substance produces drug dependence of the morphine type and exhibits potential for being abused
- Administer continuous infusion by an infusion device. Use IV bolus administration only during the maintenance of general anesthesia. Administer single doses over 30 to 60 seconds in nonintubated patients
- Interruption of an infusion results in rapid offset of effect. Rapid dissipation of respiratory depressant and analgesic effects has occurred on discontinuation of this drug at recommended doses. Discontinuation of an infusion should be preceded by the establishment of adequate postoperative analgesia
- Upon discontinuations clear the IV tubing to prevent the inadvertent administration at a later point in time. Appearance of respiratory depression, apnea, and muscle rigidity has occurred on administration of additional fluids or medications through the uncleared IV tubing
- Only persons specifically trained in the use of anesthetic drugs and the management of the respiratory effects of potent opioids, including respiratory and cardiac resuscitation of patients in the age group being treated should administer this drug. Such training includes the establishment and maintenance of a patient airway and assisted ventilation
- Avoid using this drug in diagnostic or therapeutic procedures outside the monitored anesthesia care setting. Continuously monitor patients receiving anesthesia care by persons not involved in the conduct of the surgical or diagnostic procedure. Monitor oxygen saturation on a continuous basis
- Keep ready resuscitative and intubation equipment, oxygen, and an opioid antagonist
- Manage respiratory depression in spontaneously breathing patients by decreasing the rate of the infusion by 50% or by temporarily discontinuing the infusion
- Skeletal muscle rigidity is related to the dose and speed of administration. Chest wall rigidity (inability to ventilate) after single doses of >1 mcg/kg administered over 30-60 seconds, or after infusion rates >0.1 mcg/kg/min has occurred. Single doses <1mcg/kg causes chest wall rigidity when given concurrently with a continuous infusion
- Manage muscle rigidity in the context of the patients clinical condition. Treat muscle rigidity occurring during the induction of anesthesia by the administration of a neuromuscular blocker and the concurrent induction medications
- Treat muscle rigidity in spontaneously breathing patients by stopping or decreasing the rate of administration. Resolution of muscle rigidity after discontinuing the infusion occurs within minutes. Administer a rapid onset neuromuscular blocker or naloxone in the case of life-threatening muscle rigidity
- Administer into the same IV tubing with blood due to potential inactivation by nonspecific esterases in blood products
- Continually monitor vital signs and oxygenation
- Bradycardia has occurred and is responsive to ephedrine or anticholinergic drugs, such as atropine and glycopyrrolate
- Hypotension has occurred and is responsive to decreased in the administration of this drug or to IV fluids or catecholamine (ephedrine, epinephrine, norepinephrine, etc.) administration
- Intraoperative awareness has occurred in patients <55 yrs of age when this drug has been administered with propofol infusion rates of
75 mcg/kg/min - Within 5-10 mins after the discontinuation of this drug residual analgesic activity is diminished
- Maintain standard monitoring in the postoperative period to ensure adequate recovery without stimulation
- Administer other analgesics prior to the discontinuation of this drug for patients undergoing surgical procedures where postoperative pain is generally anticipated
- Avoid using as a sole agent for induction of anesthesia as loss of consciousness cannot be assured and high incidence of apnea, muscle rigidity, and tachycardia exists
Cautions: Use cautiously in
- Hypotension
- Bradycardia
- Severe pulmonary disease
- Increased ICP
- Head trauma
- Cardiac disease
- Adrenal insufficiency
- Undiagnosed abdominal pain
- Hypothyroidism
- Alcoholism
- Debilitated, geriatric or severely ill patients
- Elderly patients
Pregnancy Category:C
Breastfeeding: Safety unknown; as the half-life of remifentanil is extremely short; it is unlikely to cause any adverse effects in the breastfed newborn if used in mother for labor analgesia or a surgical procedure. As no information is available on the use of remifentanil during breastfeeding, prefer an alternate drug if the mother requires prolong administration of remifentanil during the early postpartum period. Immediately contact a physician if the baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, breathing difficulties, or limpness. This information is based upon LactMed database (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 12 February 2011. Manufacturer advises caution.
