Monday, August 6, 2018

Remifentanil for mechanically ventilated patients

Q: Remifentanil has been advocated for use in mechanically ventilated patients for analgesia. What are the three main characteristics of this drug which make it superior to other continuous analgesia infusions in ICU? 


Remifentanil has been advocated for off-label use in ICU for mechanically ventilated patients
1 as a continuous infusion over fentanyl or morphine because of it's few characteristics which include.

1. ultrashort duration of action with the onset of action in 1-3 minutes, peak effect in 3-5 minutes and total duration of up to 10 minutes.

2. In patients with severe multiorgan failure, it has an advantage as its effect does not depend on renal or hepatic metabolism.

3. In patients with hemodynamic instability or bronchospasm, it has the advantage to release little histamine.

But, it should be used with caution in awake patients as may cause respiratory depression, and in patients with bradycardia. Also, if used with serotonergic agents, it may cause Serotonin syndrome. Also, it can elevate the intra-cranial pressure. 4



1. Dahaba AA, Grabner T, Rehak PH, et al. Remifentanil versus morphine analgesia and sedation for mechanically ventilated critically ill patients: a randomized double blind study. Anesthesiology 2004; 101:640.

2. Tan JA, Ho KM. Use of remifentanil as a sedative agent in critically ill adult patients: a meta-analysis. Anaesthesia 2009; 64:1342.

3.. Barr J, Fraser GL, Puntillo K, et al, “Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit,” Crit Care Med, 2013, 41(1):263-306.

4.  Warner DS, Hindman BJ, Todd MM, et al, “Intracranial Pressure and Hemodynamic Effects of Remifentanil Versus Alfentanil in Patients Undergoing Supratentorial Craniotomy,” Anesth Analg, 1996, 83(2):348-53. 

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