Remifentanil

Remifentanil is a prescription medication used as induction of anesthesia, maintenance anesthesia, conscious analgesia, and immediate post-op analgesia. 

• Remifentanil is available under the following different brand names: Ultiva

Adult and pediatric dosage

Powder for injection: Schedule II

• 1mg/vial
• 2mg/vial
• 5mg/vial

Anesthesia, Induction

Adult dosage

• 0.5-1 mcg/kg/min IV until after intubation; may give an initial dose of 1 mcg/kg if intubation to occur less than 8 min after the start of infusion

Anesthesia, Maintenance

Adult dosage

• 0.25-0.5 mcg/kg/min IV; may bolus with 0.5-1 mcg/kg every 2-5 min in response to light anesthesia or transient episodes of intense surgical stress

Pediatric dosage

• Children birth-2 months of age: With Nitrous Oxide: 0.4 mcg/kg/min IV
• Range: 0.4-1 mcg/kg/min, may give supplemental dose 1 mcg/kg IV
• Children 1-12 years of age: with Halothane, sevoflurane, isoflurane: 0.25 mcg/kg/min IV
• Range: 0.05-1.3 mcg/kg/min IV, may give supplemental dose 1 mcg/kg over 30-60 sec IV 

Conscious Analgesia

Adult dosage

• 1 mcg/kg IV bolus, followed by 0.05-0.2 mcg/kg/min IV

Analgesia, Immediate Post-Op Period

Adult dosage

• 0.025-0.2 mcg/kg/min IV

Dosage Considerations – Should be Given as Follows: 

• See “Dosages”.

Common side effects of Remifentanil include:

• slow breathing, 
• slow heart rate, 
• muscle stiffness, and
• low blood pressure

Serious side effects of Remifentanil include:

• hives, 
• difficult breathing, 
• swelling of the face, lips, tongue, or throat, 
• slow breathing with long pauses, 
• blue colored lips, 
• difficult to wake up, 
• shallow breathing, 
• breathing that stops during sleep, 
• fast or slow heart rate, 
• stiff muscles, 
• low blood pressure, 
• severe weakness, 
• lightheadedness, 
• agitation, 
• hallucinations, 
• fever, 
• fast heart rate, 
• muscle stiffness, 
• twitching, 
• loss of coordination, 
• nausea, and
• diarrhea

Rare side effects of Remifentanil include:

• none 

If your medical doctor is using this medicine to treat your pain, your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor, health care provider, or pharmacist first

• Remifentanil has severe interactions with the following drug:
  • alvimopan
• Remifentanil has serious interactions with at least 25 other drugs. 
• Remifentanil has moderate interactions with at least 45 other drugs. 
• Remifentanil has minor interactions with the following drug:
  • benazepril

This information does not contain all possible interactions or adverse effects. Visit the RxList Drug Interaction Checker for any drug interactions. Therefore, before using this drug, tell your doctor or pharmacist of all the drugs you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist. Check with your physician if you have health questions or concerns.

Contraindications

• Epidural or intrathecal administration
• Known hypersensitivity to fentanyl analogs 

Effects of drug abuse

• None

Short-Term Effects

• See “What Are Side Effects Associated with Using Remifentanil?”

Long-Term Effects

• See “What Are Side Effects Associated with Using Remifentanil?”

Cautions

• In patients who may be susceptible to intracranial effects of CO2 retention (e.g., those with evidence of increased intracranial pressure or brain tumors), therapy may reduce respiratory drive, and resultant CO2 retention can further increase intracranial pressure; monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy; opioids may obscure the clinical course in a patient with a head injury; avoid the use in patients with impaired consciousness or coma
• Profound sedation, respiratory depression, coma, and death may result from concomitant administration with benzodiazepines or other CNS depressants (e.g., non-benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol); because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate
• Cases of serotonin syndrome, a potentially life-threatening condition, reported with concomitant use of serotonergic drugs; this may occur within the recommended dosage range; the onset of symptoms generally occurs within several hours to a few days of concomitant use, but may occur later than that; discontinue therapy immediately if serotonin syndrome is suspected
• Muscle rigidity occurring during induction of can be treated by decreasing rate or discontinuing infusion of drug or by administering a neuromuscular blocking agent; neuromuscular blocking agents used should be compatible with the patient's cardiovascular status
• Bradycardia may occur; monitor heart rate during dosage initiation and titration; responsive to ephedrine or anticholinergic drugs
• Therapy may cause severe hypotension including orthostatic hypotension and syncope in ambulatory patients; there is increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics); monitor patients for signs of hypotension after initiating or titrating dosage; in patients with circulatory shock, therapy may cause vasodilation that can further reduce cardiac output and blood pressure; avoid therapy in patients with circulatory shock
• Not to be administered into same IV tubing with blood due to potential inactivation by nonspecific esterases in blood products
• Therapy may increase the frequency of seizures in patients with seizure disorders and other clinical settings associated with seizures; monitor patients for worsened seizure control during therapy
• May cause spasm of the sphincter of Oddi; opioids may cause increases in serum amylase; monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms
• Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients because they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients; monitor closely
• Continuous infusions should be administered only by an infusion device
• Clear IV tubing after discontinuation of remifentanil
• It May be associated with apnea and respiratory depression, skeletal muscle rigidity
• Should not be administered in same IV tubing as blood
• Intraoperative awareness in some patients under 55 years old when admin. with propofol infusion is less than 75 mcg/kg/min

Pregnancy and Lactation

• Prolonged use of opioid analgesics during pregnancy may cause neonatal opioid withdrawal syndrome; available data in pregnant women are insufficient to inform a drug-associated risk for major birth defects and miscarriage

Labor or delivery

• Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates; an opioid antagonist, such as naloxone, must be available for reversal of opioid-induced respiratory depression in neonates; drug is not recommended for use in women during and immediately before labor, when the use of shorter-acting analgesics or other analgesic techniques are more appropriate; opioid analgesics can prolong labor through actions that temporarily reduce strength, duration, and frequency of uterine contractions; however, this effect is not consistent and may be offset by an increased rate of cervical dilatation, which tends to shorten labor; monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression

Lactation

• The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for therapy; capsules and any potential adverse effects on the breastfed infant from therapy or underlying maternal condition
• Monitor infants exposed to the drug through breast milk for excess sedation and respiratory depression; withdrawal symptoms can occur in breastfed infants when maternal administration of an opioid analgesic is stopped, or when breast-feeding is stopped