Remifentanil: An update

Current Opinion in Anaesthesiology

Volumn 16, Issue 4, 2003, Pages 367-372

  Servin, Frédérique S ^a  

^a BICHAT HOSPITAL   (France)

Author keywords

Anaesthesia; Opioids; Pharmacodynamics; Pharmacokinetics; Remifentanil

Indexed keywords

ANALGESIC AGENT; ANESTHETIC AGENT; ETOMIDATE; HYPNOTIC AGENT; KETAMINE; MU OPIATE RECEPTOR AGONIST; N METHYL DEXTRO ASPARTIC ACID RECEPTOR BLOCKING AGENT; NEUROMUSCULAR BLOCKING AGENT; OPIATE AGONIST; PROPOFOL; REMIFENTANIL; SEVOFLURANE; THIOPENTAL;

ADULT; ANALGESIA; ANESTHESIA; BRAIN BLOOD FLOW; CARDIOVASCULAR EFFECT; CENTRAL NERVOUS SYSTEM; CHILD; CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; CONTROLLED STUDY; CROSSOVER PROCEDURE; DOUBLE BLIND PROCEDURE; DRUG EFFECT; DRUG POTENTIATION; ENDOTRACHEAL INTUBATION; HEART CATHETERIZATION; HEART SURGERY; HEMODYNAMIC PARAMETERS; HUMAN; NEUROMUSCULAR BLOCKING; NEUROSURGERY; OBSTETRIC ANESTHESIA; PEDIATRIC ANESTHESIA; PHARMACODYNAMICS; POSTOPERATIVE PAIN; PRIORITY JOURNAL; RANDOMIZED CONTROLLED TRIAL; RESPIRATION DEPRESSION; REVIEW; SIDE EFFECT; SYSTEMIC VASCULAR RESISTANCE; VASODILATATION;

EID: 0041624287     PISSN: 09527907     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.aco.0000084479.59960.3f     Document Type: Review

References (69)

1. Glass PS. Remifentanil: a new opioid. J Clin Anesth 1995; 7:558-563.
2. Davis PJ, Stiller RL, Wilson AS, et al. In vitro remifentanil metabolism: the effects of whole blood constituents and plasma butyrylcholinesterase. Anesth Analg 2002; 95:1305-1307. In vitro, remifentanil metabolism is independent from plasma cholinesterase activity.
3. Dahaba AA, Oettl K, von Klobucar F, et al. End-stage renal failure reduces central clearance and prolongs the elimination half life of remifentanil. Can J Anaesth 2002; 49:369-374. The remifentanil concentrations achieved during infusion in renal failure patients are increased when compared with normal patients because of a reduction in clearance.
4. Crankshaw DP, Chan C, Leslie K, Bjorksten AR. Remifentanil concentration during target-controlled infusion of propofol. Anaesth Intens Care 2002; 30:578-583. During propofol co-administration, the remifentanil concentrations achieved during the early phases of infusion are increased.
5. Bouillon T, Bruhn J, Radu-Radulescu L, et al. Non-steady state analysis of the pharmacokinetic interaction between propofol and remifentanil. Anesthesiology 2002; 97:1350-1362. This excellent study has defined the nature and extent of the pharmacokinetic interactions between propofol and remifentanil. Remifentanil did not alter propofol pharmacokinetics. In contrast, the co-administration of propofol decreased the central volume of distribution and distributional clearance of remifentanil, thus explaining the early increase in concentration described by Crankshaw et al. [4•]. This effect was not concentration-dependent in the examined concentration range of propofol.
6. Mertens MJ, Engbers FH, Burm AG, Vuyk J. Predictive performance of computer-controlled infusion of remifentanil during propofol/remifentanil anaesthesia. Br J Anaesth 2003; 90:132-141. The performance of published pharmacokinetic parameter sets in predicting remifentanil concentrations in surgical patients has been calculated in young fit patients; the models published by Egan (Anesthesiology 1993; 1997 and 1998) performed best.
7. Elliott P, O'Hare R, Bill KM, et al. Severe cardiovascular depression with remifentanil. Anesth Analg 2000; 91:58-61.
8. Sebel PS, Hoke JF, Westmoreland C, et al. Histamine concentrations and hemodynamic responses after remifentanil. Anesth Analg 1995; 80:990-993.
9. Unlugenc H, Itegin M, Ocal I, et al. Remifentanil produces vasorelaxation in isolated rat thoracic aorta strips. Acta Anaesthesiol Scand 2003; 47:65-69. In isolated rat thoracic aorta strips, remifentanil induces vasodilation mainly through an endothelium-dependent mechanism.
10. Lorenz IH, Kolbitsch C, Hinteregger M, et al. Remifentanil and nitrous oxide reduce changes in cerebral blood flow velocity in the middle cerebral artery caused by pain. Br J Anaesth 2003; 90:296-299. Pain generates increases in regional cerebral blood flow, measured by transcranial Doppler sonography in conscious volunteers, which are attenuated by remifentanil.
11. Abdallah C, Karsli C, Bissonnette B. Fentanyl is more effective than remifentanil at preventing increases in cerebral blood flow velocity during intubation in children. (Le fentanyl est plus efficace que le remifentanil a prevenir des augmentations de la vitesse circulatoire cerebrale pendant l'intubation chez les enfants). Can J Anaesth 2002; 49:1070-1075. In the clinical setting, increases in cerebral blood flow created by a potent stimulus are more efficiently blunted by fentanyl than by remifentanil. This study does not take into account the pharmacokinetic differences between the two drugs.
12. Muncaster AR, Sleigh JW, Williams M. Changes in consciousness, conceptual memory, and quantitative electroencephalographical measures during recovery from sevoflurane- and remifentanil-based anesthesia. Anesth Analg 2003; 96:720-725. At the end of an anaesthesia associating remifentanil and sevoflurane, after a period of sevoflurane washout, most patients remained unconscious with remifentanil alone and had no recall (explicit or implicit) of the period. This study adds new information to the debate about the risk of intraoperative awareness, and outlines the potential interest of entropy as a measure of depth of anaesthesia in the presence of opioids.
13. Bruhn J, Bouillon TW, Radulescu L, et al. Correlation of approximate entropy, bispectral index, and spectral edge frequency 95 (SEF95) with clinical signs of 'anesthetic depth' during coadministration of propofol and remifentanil. Anesthesiology 2003; 98:621-627. The interest of entropy is further detailed in this paper, the main topic of which is not remifentanil.
14. Kofke WA, Attaallah AF, Kuwabara H, et al. The neuropathologic effects in rats and neurometabolic effects in humans of large-dose remifentanil. Anesth Analg 2002; 94:1229-1236. Like other μ opioids, remifentanil is neurotoxic in the animal, and may also be so in humans when prolonged infusions are given.
15. Allen JS, Campbell JA, Cariello NF, et al. Genetic toxicology of remifentanil, an opiate analgesic. Terat Carcin Mutagen 2003; Suppl.:137-149. This study shows that remifentanil is not genotoxic.
16. Nieuwenhuijs DJ, Olofsen E, Romberg RR, et al. Response surface modeling of remifentanil-propofol interaction on cardiorespiratory control and bispectral index. Anesthesiology 2003; 98:312-322. At concentrations clinically useful in sedation and monitored anaesthesia care, the pharmacodynamic interactions between propofol and remifentanil on the hypnotic state or on the haemodynamic status are weak. In contrast, the synergistic interaction on the ventilatory drive is major. The authors use the most recent pharmacodynamic modeling tools to characterize these interactions precisely.
17. Olofsen E, Sleigh JW, Dahan A. The influence of remifentanil on the dynamic relationship between sevoflurane and surrogate anesthetic effect measures derived from the EEG. Anesthesiology 2002; 96:555-564. The authors modeled the influence of remifentanil on the dynamics of sevoflurane using three parameters derived from the electroencephalogram: 95% spectral edge frequency, canonical univariate parameter, and bispectral index. Remifentanil accelerates sevofiurane blood-brain equilibration without affecting its hypnotic potency, possibly through its vasodilatating effect.
18. Koitabashi T, Johansen JW, Sebel PS. Remifentanil dose/electroencephalogram bispectral response during combined propofol/regional anesthesia. Anesth Analg 2002; 94:1530-1533.
19. Puri GD. Other stimuli add to effect of remifentanil on BIS. Anesth Analg 2003; 96:632.
20. Munoz HR, Cortinez LI, Altermatt FR, Dagnino JA. Remifentanil requirements during sevoflurane administration to block somatic and cardiovascular responses to skin incision in children and adults. Anesthesiology 2002; 97:1142-1145. Children require higher (more than double) remifentanil blood concentrations than adults to blunt the response to skin incision.
21. Milne SE, Kenny GN, Schraag S. Propofol sparing effect of remifentanil using closed-loop anaesthesia (dagger). Br J Anaesth 2003; 90:623-629. When propofol is administered by a closed loop system to an Auditory Evoked Potential (AEP) endpoint, the propofol requirements are reduced by remifentanil co-administration.
22. De Castro V, Godet G, Mencia G, et al. Target-controlled infusion for remifentanil in vascular patients improves hemodynamics and decreases remifentanil requirement. Anesth Analg 2003; 96:33-38. In elderly sick vascular patients, remifentanil TCI performs better than manually controlled continuous infusion, with less haemodynamic consequences of anaesthesia. The overall remifentanil consumption is reduced by TCI. This may be partly due to the fact that the remifentanil model used in this study incorporates age as a covariate.
23. Erhan E, Ugur G, Alper I, et al. Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol. Eur J Anaesthesiol 2003; 20:37-43. To reduce the somatic response to tracheal intubation adequately, the initial remifentanil bolus should be at least 2 μg/kg, and more efficiently 4 μg/kg.
24. Erhan E, Ugur G, Gunusen I, et al. Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade. (Le propofol, mais non le thiopental ou l'etomidate, combine au remifentanil, permet des conditions d'intubation satisfaisantes en l'absence de blocage neuromusculaire). Can J Anaesth 2003; 50:108-115. Remifentanil provides good intubating conditions in the absence of muscle relaxants when associated with propofol, but not in every patient if thiopental or etomidate are chosen for the induction of anaesthesia.
25. Troy AM, Huthinson RC, Easy WR, Kenney GN. Tracheal intubating conditions using propofol and remifentanil target-controlled infusions. Anaesthesia 2002; 57:1204-1207. To obtain good intubating conditions in the absence of muscle relaxants in the majority of patients, a remifentanil predicted concentration of at least 8 ng/ml is necessary.
26. Habib AS, Parker JL, Maguire AM, et al. Effects of remifentanil and alfentanil on the cardiovascular responses to induction of anaesthesia and tracheal intubation in the elderly. Br J Anaesth 2002; 88:430-433. If remifentanil and alfentanil provide good haemodynamic conditions in the absence of muscle relaxants, this technique should be used with caution in elderly patents for fear of significant hypotension.
27. Johnson KB, Swenson JD, Egan TD, et al. Midazolam and remifentanil by bolus injection for intensely stimulating procedures of brief duration: experience with awake laryngoscopy. Anesth Analg 2002; 94:1241-1243. When a patient is at risk of difficult intubation, it may be appropriate to ascertain the difficulties by an 'awake' laryngoscopy using an easily reversible sedation technique. Remifentanil may be useful in this setting.
28. Puchner W, Egger P, Puhringer F, et al. Evaluation of remifentanil as single drug for awake fiberoptic intubation. Acta Anaesthesiol Scand 2002; 46:350-354. To provide appropriate intubating conditions and optimal safety for the patient in a difficult case, remifentanil was used for its efficiency and reversibility during fiberoptic intubation.
29. Guignard B, Bossard AE, Coste C, et al. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology 2000; 93:409-417.
30. Gustorff B, Nahlik G, Hoerauf KH, Kress HG. The absence of acute tolerance during remifentanil infusion in volunteers. Anesth Analg 2002; 94:1223-1228. This carefully designed randomized, placebo-controlled, double-blinded, cross-over study in 20 volunteers receiving a 3 h remifentanil infusion failed to demonstrate any development of rapid opioid tolerance. The validity of such results in the clinical setting where both the painful stimuli and the opioid requirements are much larger remains to be ascertained.
31. Kissin I, Bright CA, Bradley Jr EL. Acute tolerance to continuously infused alfentanil: the role of cholecystokinin and N-methyl-D-aspartate-nitric oxide systems. Anesth Analg 2000; 91:110-116.
32. Guignard B, Coste C, Costes H, et al. Supplementing desflurane-remifentanil anesthesia with small-dose ketamine reduces perioperative opioid analgesic requirements. Anesth Analg 2002; 95:103-108. The authors, who had first reported the risk of acute tolerance during remifentanil high-dose infusion in the clinical setting, provide a way to alleviate this problem through ketamine administration.
33. Jaksch W, Lang S, Reichhalter R, et al. Perioperative small-dose S(+)-ketamine has no incremental beneficial effects on postoperative pain when standard-practice opioid infusions are used. Anesth Analg 2002; 94:981-986. The opioid-sparing effect of ketamine was not reproduced in this randomized, double-blinded clinical trial. Was it because the authors used S+ ketamine and not the racemic mixture? The authors reject this hypothesis and rather favour their careful consistently administered continuous perioperative opioid analgesia.
34. Luginbuhl M, Gerber A, Schnider TW, et al. Modulation of remifentanil-induced analgesia, hyperalgesia, and tolerance by small-dose ketamine in humans. Anesth Analg 2003; 96:726-732. This well desgined randomized, double-blinded, placebo-controlled crossover study investigated the effect of remifentanil combined with small concentrations of ketamine on different experimental pain models in 14 healthy volunteers. Ketamine coadministration enhanced opioid analgesia without increasing sedation and reduced respiratory depression. Opioid-induced hyperalgesia and tolerance were not affected by ketamine and depended on the type of nociceptive stimulus.
35. Ozkose Z, Yalcin Cok O, Tuncer B, et al. Comparison of hemodynamics, recovery profile, and early postoperative pain control and costs of remifentanil versus alfentanil-based total intravenous anesthesia (TIVA). J Clin Anesth 2002; 14:161-168. Remifentanil and alfentanil were compared in lumbar discectomies in a randomized, double-blind study (thus precluding intraoperative adaptation of the doses).
36. Vanacker B, Van Geldre L. A randomized study of the efficacy and recovery of remifentanil-based and alfentanil anaesthesia with desflurane or sevoflurane for gynecological surgery. Acta Anaesthesiol Belg 2002; 53:21-26. Remifentanil allowed better intraoperative control over surgical stimuli. Recovery was similar in all patient groups.
37. Eltzschig HK, Schroeder TH, Eissler BJ, et al. The effect of remifentanil or fentanyl on postoperative vomiting and pain in children undergoing strabismus surgery. Anesth Analg 2002; 94:1173-1177. Fentanyl was associated with lower pain scores, and in the remifentanil group, vomiting episodes were significantly less frequent.
38. Alper I, Erhan E, Ugur G, Ozyar B. Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery. Eur J Anaesthesiol 2003; 20:61-64. Early recovery was shorter after remifentanil but pain scores were higher.
39. Mukherjee K, Seavell C, Rawlings E, Weiss A. A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and conditions of surgery. Anaesthesia 2003; 58:176-180. Intraoperative conditions were better with remifentanil, with less early postoperative nausea and vomiting and higher pain scores in the recovery room.
40. Puchner W, Obwegeser J, Puhringer FK. Use of remifentanil for awake fiberoptic intubation in a morbidly obese patient with severe inflammation of the neck. Acta Anaesthesiol Scand 2002; 46:473-476.
41. Gaszynski T, Gaszynski W, Strzelczyk J. General anaesthesia with remifentanil and cisatracurium for a superobese patient. Eur J Anaesthesiol 2003; 20:77-78.
42. Fernandez A, Jerez A, Falcone N. Anaesthetic management in a case of a type IV laryngotracheo-oesophageal cleft. Paediatr Anaesth 2003; 13:270-273.
43. Gande AR, Ambler JJ, Haw MP, Gill RS. Remifentanil for phaeochromocytoma resection. Anaesthesia 2003; 58:196-197.
44. Cafiero T, Burrelli R, Gargiulo G, Mastronardi P. Tracheal intubation in a case of idiopathic pulmonary fibrosis using remifentanil and propofol without muscle relaxants [In Italian]. Minerva Anestesiol 2002; 68:867-871.
45. Tokarz A, Gaszynski T, Gaszynski W, Arkuszewski P. General anaesthesia with remifentanil and propofol for a patient with centronuclear (myotubular) myopathy. Eur J Anaesthesiol 2002; 19:842-844.
46. Durmus M, Turkoz A, Togal T, et al. Remifentanil and acute intermittent porphyria. Eur J Anaesthesiol 2002; 19:839-840.
47. Gardner SV, Evans NR. The ProSeal laryngeal mask in myasthenia gravis. Anaesth Intens Care 2002; 30:671-674.
48. Dill-Russell PC, Ng L, Ravalia A. Use of a remifentanil PCA for a patient with multiple rib fractures. Can J Anaesth 2002; 49:757.
49. Breslin DS, Fading PA, Mirakhur RK. The use of remifentanil in the anaesthetic management of patients undergoing adrenalectomy: a report of three cases. Anaesthesia 2003; 58:356-362.
50. Myles PS, Hunt JO, Fletcher H, et al. Remifentanil, fentanyl, and cardiac surgery: a double-blinded, randomized, controlled trial of costs and outcomes. Anesth Analg 2002; 95:805-812. A double-blinded, randomized trial involving 77 cardiac surgical patients randomly allocated to receive remifentanil or fentanyl (small or moderate doses). Remifentanil did not significantly reduce the duration of tracheal intubation nor did it increase the total hospital costs associated with cardiac surgery. Low-dose fentanyl was associated with significantly more postoperative myocardial infarctions and a longer length of hospital stay.
51. Gerlach K, Uhlig T, Huppe M, et al. Remifentanil-clonidine-propofol versus sufentanil-propofol anesthesia for coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2002; 16:703-708. Patients in the remifentanil-clonidine group were extubated earlier and had lower plasma epinephrine and norepinephrine levels.
52. Reddy P, Feret BM, Kulicki L, et al. Cost analysis of fentanyl and remifentanil in coronary artery bypass graft surgery without cardiopulmonary bypass. J Clin Pharm Ther 2002; 27:127-132. Remifentanil is associated with an increased likelihood of extubation in the operating theatre. However, length of stay and total hospital costs remain unchanged.
53. Straka Z, Brucek P, Vanek T, et al. Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia. Ann Thorac Surg 2002; 74:1544-1547.
54. Bowler I, Djaiani G, Abel R, et al. A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery. J Cardiothorac Vasc Anesth 2002; 16:709-714. The association of remifentanil and intrathecal morphine gives satisfying results, but what of the association of spinal puncture and full heparinization?
55. Foubert L, Reyntjens K, De Wolf D, et al. Remifentanil infusion for cardiac catheterization in children with congenital heart disease. Acta Anaesthesiol Scand 2002; 46:356-360. Remifentanil provides an interesting alternative to more traditional anaesthetic. techniques in this situation.
56. Tijero T, Ingelmo I, Garcia-Trapero J, Puig A. Usefulness of monitoring brain tissue oxygen pressure during awake craniotomy for tumor resection: a case report. J Neurosurg Anesthesiol 2002; 14:149-152.
57. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy - evolution of a technique that facilitates awake neurological testing. Br J Anaesth 2003; 90:161-165. An elegant solution for a tricky procedure.
58. Debailleul AM, Bortlein ML, Touzet G, Krivosic-Horber R. Particularités anesthésiques de la neurochirurgie stéréotaxique. Ann Fr Anesth Reanim 2002; 21:170-178. A good review of the requirements of anaesthesia for stereotaxic procedures.
59. Herrick IA, Craen RA, Blume WT, et al. Sedative doses of remifentanil have minimal effect on ECoG spike activity during awake epilepsy surgery. J Neurosurg Anesthesiol 2002; 14:56-58. The use of remifentanil seems promising in epilepsy surgery.
60. Kan RE, Hughes SC, Rosen MA, et al. Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology 1998; 88:1467-1474.
61. Owen MD, Poss MJ, Dean LS, Harper MA. Prolonged intravenous remifentanil infusion for labor analgesia. Anesth Analg 2002; 94:918-919. Remifentanil in labour: a solution when regional anaesthesia is contraindicated?
62. Olufolabi AJ, Booth JV, Wakeling HG, et al. A preliminary investigation of remifentanil as a labor analgesic. Anesth Analg 2000; 91:606-608.
63. Saunders TA, Glass PS. A trial of labor for remifentanil. Anesth Analg 2002; 94:771-773. The drug is important, but also the dosing scheme!
64. Volmanen P, Akural EI, Raudaskoski T, Alahuhta S. Remifentanil in obstetric analgesia: a dose-finding study. Anesth Analg 2002; 94:913-917. A careful clinical description of remifentanil patient-controlled analgesia in labour.
65. Thurlow JA, Laxton CH, Dick A, et al. Remifentanil by patient-controlled analgesia compared with intramuscular meperidine for pain relief in labour. Br J Anaesth 2002; 88:374-378.
66. Bell GT, Dickson U, Arana A, et al. Remifentanil vs fentanyl/morphine for pain control during paediatric cardiac surgery. Paediatr Anaesth 2002; 12:817. This paper illustrates the difficulties of implementing a new technique in the paediatric setting.
67. Chambers N, Lopez T, Thomas J, James MF. Remifentanil and the tunnelling phase of paediatric ventriculoperitoneal shunt insertion. A double-blind, randomised, prospective study. Anaesthesia 2002; 57:133-139. Remifentanil allows intraoperative control over the adrenergic response without modifying recovery.
68. Degoute CS, Ray MJ, Gueugniaud PY, Dubreuil C. Remifentanil induces consistent and sustained controlled hypotension in children during middle ear surgery. (Le remifentanil induit de l'hypotension constante et prolongee chez des enfants pendant une operation de l'oreille moyenne). Can J Anaesth 2003; 50:270-276. An anaesthestic technique that provides good surgical conditions without delaying recovery.
69. Friesen RH, Veit AS, Archibald DJ, Campanini RS. A comparison of remifentanil and fentanyl for fast track paediatric cardiac anaesthesia. Paediatr Anaesth 2003; 13:122-125. A randomized study.