Remifentanil hydrochloride
Remifentanil hydrochloride (Ultiva)
Remifentanil hydrochloride
((rem-ih- FEN-tah-nil))
Pregnancy Category: C Ultiva (Rx) (C-II)

Classification: Narcotic analgesic

See Also: See also Narcotic Analgesics.

Action/Kinetics: Narcotic analgesic that binds with mu-opioid receptors. Depresses respiration in a dose-dependent manner and causes muscle rigidity. Rapidly metabolized by nonspecific blood and tissue esterases; not metabolized appreciably by the liver or lung. Onset: 1 min. Peak effect: 1 min. t 1/2, elimination: 3-10 min. Recovery: Within 5-10 min.

Uses: As an analgesic during the induction and maintenance of general anesthesia and for continuation as an analgesic in the immediate postoperative period. It is also an analgesic component of monitored anesthesia care. Maintenance of general anesthesia in pediatric clients, aged 1-12 years.

Contraindications: Epidural or intrathecal use due to the presence of glycine in the formulation. Hypersensitivity to fentanyl analogues. Use as the sole agent in general anesthesia because LOC cannot be ensured and due to a high incidence of apnea, muscle rigidity, and tachycardia.

Special Concerns: Use with caution in obese clients and during lactation. Respiratory depression and other narcotic effects may be seen in newborns whose mothers are given remifentanil shortly before delivery. Geriatric clients are twice as sensitive as younger clients to the effects of the drug. Not studied in children less than 2 years of age. Possible intraoperative awareness in clients less than 55 years old when given with propofol infusion rates of 75 or less mcg/kg/min.

Side Effects: GI: N&V;, constipation, abdominal discomfort, xerostomia, gastroesophageal reflux, dysphagia, diarrhea, heartburn, ileus. CNS: Shivering, fever, dizziness, headache, agitation, chills, warm sensation, anxiety, involuntary movement, prolonged emergence from anesthesia, tremors, disorientation, dysphoria, nightmares, hallucinations, paresthesia, nystagmus, twitch, sleep disorder, seizures, amnesia. CV: Hypotension, bradycardia, tachycardia, hypertension, atrial and ventricular arrhythmias, heart block, ECG change consistent with myocardial ischemia, syncope. Musculoskeletal: Muscle rigidity, muscle stiffness, musculoskeletal chest pain, delayed recovery from neuromuscular block. Respiratory: Respiratory depression, apnea, hypoxia, cough, dyspnea, bronchospasm, laryngospasm, rhonchi, stridor, nasal congestion, pharyngitis, pleural effusion, hiccoughs, pulmonary edema, rales, bronchitis, rhinorrhea. Dermatologic: Pruritus, rash, urticaria, erythema, sweating, flushing, pain at IV site. GU: Urine retention, oliguria, dysuria, urine incontinence. Hematologic: Anemia, lymphopenia, leukocytosis, thrombocytopenia. Metabolic: Abnormal liver function, hyperglycemia, electrolyte disorders. Miscellaneous: Decreased body temperature, anaphylactic reaction visual disturbances, postoperative pain.

Laboratory Test Alterations: CPK-MB levels.

Overdose Management: Symptoms: Apnea, chest-wall rigidity, seizures, hypoxemia, hypotension, bradycardia. Treatment: Discontinue administration, maintain a patent airway, initiate assisted or controlled ventilation with oxygen, and maintain adequate CV function. A neuromuscular blocking agent or a mu-opiate receptor antagonist may be used to treat muscle rigidity. IV fluids, vasopressors, and other supportive measures are indicated to treat hypotension. Bradycardia or hypotension may also be treated with atropine or glycopyrrolate. IV naloxone is used to treat respiratory depression or muscle rigidity. Reversal of the opioid effects may lead to acute pain and sympathetic hyperactivity.

Drug Interactions: Remifentanil is synergistic with other anesthetics. Doses of thiopental, propofol, isoflurane, and midazolam have been reduced by up to 75% with the coadministration of remifentanil.

How Supplied: Powder for injection: 1 mg, 2 mg, 5 mg

Dosage
?Continuous IV Infusion Only Induction of anesthesia through intubation.
0.5-1 mcg/kg/min given with a hypnotic or volatile agent. If endotracheal intubation is to occur less than 8 min after the start of the infusion of remifentanil, the initial dose of 1 mcg/kg may be given over 30 to 60 sec.
Maintenance of nitrous oxide (66%) anesthesia.
The dose of remifentanil is 0.4 mcg/kg/min (range of 0.1-2 mcg/kg/min). A supplemental IV bolus dose of 1 mcg/kg may be given.
Maintenance of isoflurance (0.4 to 1.5 MAC) or propofol (100-200 mcg/kg/min) anesthesia.
The dose of remifentanil is 0.25 mcg/kg/min (range of 0.05-2 mcg/kg/min). A supplemental IV bolus dose of 1 mcg/kg may be given.
Continuation as an analgesic into the immediate postoperative period.
0.1 mcg/kg/min (range of 0.025-0.2 mcg/kg/min). The infusion rate may be adjusted every 5 min in 0.025-mcg/kg/min increments to balance the client's level of analgesia and respiratory rate.
Analgesic component of monitored anesthesia care.
Single IV dose: 1 mcg/kg administered over 30 to 60 sec and given 90 sec before the local anesthetic. If remifentanil is given with midazolam (2 mg), the dose is 0.5 mcg/kg. Continuous IV infusion: 0.1 mcg/kg beginning 5 min before the local anesthetic. After the local anesthetic, the dose of remifentanil is 0.05 mcg/kg/min (range 0.025-0.2 mcg/kg/min) at 5-min intervals in order to balance the level of analgesia and respiratory rate. If remifentanil is given with midazolam (2 mg), the dose is 0.025 mcg/kg/min (range 0.025-0.2 mcg/kg/min).