Remifentanil (Intravenous)

Remifentanil is known under the US brand name Ultiva and is used after surgery or medical procedures to reduce or prevent pain.

Overview

Remifentanil is a drug used to relieve and prevent pain during and after medical procedures including surgery. It's also used with other medications (e.g. propofol, isoflurane, midazolam, Diprivan, thiopental) just before or during an operation to help improve the effectiveness of the anesthetic.

This drug belongs to a group of medicines known as narcotic analgesics (pain medicines). They work by acting on the brain or central nervous system (CNS) to relieve pain. This drug can only be administered under the supervision of a trained doctor or trained healthcare professional. It is only available via prescription from your doctor and is available in the dosage forms of powder for solution and solution.

Conditions treated

  • Additional Local Anesthesia
  • Acute Pain Following an Operation
  • Additional Agent to Induce General Anesthesia

Type of medicine

  • Powder for solution
  • Narcotic analgesic

Side Effects

Along with its intended effects, the use of remifentanil can produce some unwanted side effects. Not all these side effects may be present at one time, but if they are, you may need medical attention.

Inform a doctor or healthcare professional urgently if you suffer from any of the following side effects whilst taking remifentanil:

More common side effects

  • Chest pain or discomfort
  • Troubled or difficult breathing
  • Confusion
  • Faintness, dizziness, or lightheadedness when getting up suddenly from a sitting or lying position
  • Blurred vision
  • Dizziness, lightheadedness or fainting
  • Irregular, fast or slow, or shallow breathing
  • Muscle stiffness or tightness
  • Shortness of breath
  • Blue or pale lips, fingernails, or skin
  • Slow or irregular heartbeat
  • Unusual weakness or tiredness
  • Sweating

Less common side effects

  • Chills
  • Fast, pounding, or heartbeat or pulse
  • A decrease in cardiac output
  • Bluish lips or skin
  • A feeling of warmth
  • Headache
  • Fever
  • Vomiting or nausea
  • Not breathing
  • Feeling nervous
  • Pain after surgery
  • Pounding in the ears
  • Pain in the shoulders, jaw, arm or neck
  • Problems with bleeding or clotting
  • Shivering
  • Redness of the neck, face, arms, and occasionally, upper chest

Rare side effects

  • Black, tarry stools
  • Stomach or abdominal pain
  • Bleeding gums
  • Blood in the urine or stools
  • Congestion
  • Body pains or aches
  • Crawling, burning, itching, numbness, prickling, "pins and needles", or tingling feelings
  • A cough or hoarseness
  • Coughing that sometimes produces a pink frothy sputum
  • A cough producing mucus
  • Coughing up blood
  • Difficult, fast, or noisy breathing
  • Decreased frequency or amount of urine
  • Difficulty with swallowing
  • Dry mouth
  • Disorientation
  • Dysphoria
  • Soreness or dryness of the throat
  • Eye pain
  • Fruit-like breath odor
  • Flushed, dry skin
  • General feeling of illness
  • Itching, hives, or skin rash
  • Hiccups
  • Increased blood pressure
  • Increased menstrual flow or vaginal bleeding
  • Increased hunger
  • Increased sweating
  • Lower back or side pain
  • Loss of appetite
  • Muscle pain or cramps
  • Noisy breathing
  • Nervousness
  • Increased thirst
  • Increased urination
  • Nosebleeds
  • Difficult or painful urination
  • Numbness or tingling in the hands, feet, or lips
  • Pale skin
  • Pinpoint red spots on the skin
  • Paralysis
  • Prolonged bleeding from cuts
  • Swelling, puffiness of the eyelids or around the eyes, face, lips, or tongue
  • Red or dark brown urine
  • Rapid heartbeat
  • Black, red or tarry stools
  • Runny nose
  • Shakiness in the arms, legs, hands, or feet
  • Seizures
  • Small clicking, bubbling, or rattling sounds in the lungs
  • Stuffy nose
  • Listening with a stethoscope
  • Swelling of the ankles and legs
  • Tender, swollen glands in the neck
  • Swelling of the face, fingers, or lower legs
  • Tightness in the chest
  • Unexplained weight loss
  • Troubled breathing with exertion
  • Vomiting
  • Unusual bruising or bleeding
  • Voice changes
  • Weight gain
  • Weakness and heaviness of the legs

Some side effects don't require any medical attention. You will find these usually disappear once your body begins to adjust to the medication. If they are giving you bother, you should contact a healthcare professional or your doctor for advice on ways to prevent or minimise the side effects.

Less common side effects

  • Blurred or loss of vision
  • Anxiety
  • Disturbed color perception
  • Difficulty having a bowel movement
  • Double vision
  • Hyperventilation
  • Halos around lights
  • Night blindness
  • Pain at the injection site
  • Over bright appearance of lights
  • Tunnel vision
  •  Restlessness
  • Trouble with sleeping

Rare side effects

  • Burning while urinating
  • Welts or hives
  • Heartburn
  • Loss of bladder control
  • Nightmares
  • Loss of memory
  • Problems with memory
  • Severe constipation
  • Hearing, seeing, or feeling things that are not there
  • Severe vomiting
  • Uncontrolled eye movements
  • Trouble with urinating

Remember you can report all side effects to the FDA on 1-800-FDA-1088.

Dosage

The final dosage of any medication will depend on a variety of factors. This includes your age, weight and height, the severity of your condition, any medications you are currently taking, any medical conditions you are currently suffering from and your response to the first dose.

Typical Adult Dose for Anesthesia

Induction of anesthesia:

0.5 - 1 mcg/kg/min via continuous IV infusion. An initial dose of 1 mcg/kg over a 30 to 60 second period may be administered.

If the endotracheal intubation is to occur less than eight minutes after the start of the induction infusion, an initial IV dose should be administered.

Maintenance of anesthesia:

  • With Nitrous Oxide at 66%. A continuous IV infusion at 0.4 mcg/kg/min
  • With Isoflurane Propofol at 100 to 200 or 0.4 to 1.5 MAC mcg/kg/min: A continuous IV infusion at 0.25 mcg/kg/min
  • IV bolus of 1 mcg/kg in a 30 to 60 second period may be used every two to five minutes as needed in response to transient episodes of intense surgical stress or light anesthesia.

Postoperative

Use continuous IV infusion at 0.1 mcg/kg/min. To balance the respiratory rate and level of analgesia, you should adjust infusion rate every five minutes in 0.025 mcg/kg/min increments. A maximum rate of 0.2 mcg/kg/min should be maintained.

  • Dosing needs to be tailored to individual response
  • Patients should be closely monitored for respiratory depression, especially with initiation and following all dose increases. The dose should be adjusted as necessary.
  • Continuous IV infusions should be given via a calibrated infusion device.
  • Due to the rapid offset of action, no residual analgesic activity will be present five to ten minutes after discontinuation. If some degree of pain is expected then alternative analgesics should be given prior to the discontinuation.

Typical Adult Dose for Pain

Induction of anesthesia: 0.5 to 1 mcg/kg/min via a continuous IV infusion. An initial dose of 1 mcg/kg over a 30 to 60 second period may be given. If endotracheal intubation occurs less than eight minutes after the start of the induction infusion, an initial IV dose should be administered.

Maintenance of anesthesia:

  • With Nitrous Oxide at 66%. A continuous IV infusion at 0.4 mcg/kg/min
  • With Isoflurane at Propofol at 100 to 200 mcg/kg/min or 0.4 to 1.5 MAC. Alternatively, a continuous IV infusion at 0.25 mcg/kg/min can be given.
  • An IV bolus of 1 mcg/kg over a 30 to 60 second time period may be used every two to five minutes as necessary in response to transient episodes of intense surgical stress or light anesthesia.

Postoperative:

A continuous IV infusion at 0.1 mcg/kg/min should be used. Adjust as necessary the infusion rate every five minutes in 0.025 mcg/kg/min increments to balance respiratory rate and level of analgesia. A maximum rate of 0.2 mcg/kg/min should be maintained.

  • Dosing needs to be tailored to individual response
  • Patients should be closely monitored for respiratory depression, especially with initiation and following all dose increases. The dose should be adjusted as necessary.
  • Continuous IV infusions should be given via a calibrated infusion device.
  • Due to the rapid offset of action, no residual analgesic activity will be present five to ten minutes after discontinuation. If some degree of pain is expected then alternative analgesics should be given prior to the discontinuation.

Interactions

Interactions between drugs can cause severe side effects and reduce the effectiveness of each of the medications. To avoid side effects, it's important that you give your doctor or a healthcare professional a full list of all the medication you are currently taking and have taken in the past. This list should include all prescription and non-prescription drugs, all herbal products, remedies and vitamins. You should also let your doctor know if you are currently suffering from any other medical conditions and if any serious medical conditions run in your family history.

The use of this medication is not recommended with the following medications. Your doctor may avoid treating you with this medicine altogether or change the other medications you are taking.

  • Naltrexone

The use of this medication with any of the following medications is not usually recommended. In some cases, however, it may be the best treatment choice for you. If you are prescribed both medications together, your doctor may alter the dosage or frequency in which you use one or both medications

  • Alfentanil
  • Acepromazine
  • Alprazolam
  • Anileridine
  • Amisulpride
  • Amobarbital
  • Aripiprazole
  • Baclofen
  • Asenapine
  • Bromazepam
  • Benperidol
  • Bromopride
  • Butabarbital
  • Buprenorphine
  • Buspirone
  • Butalbital
  • Carbinoxamine
  • Butorphanol
  • Carisoprodol
  • Cariprazine
  • Carphenazine
  • Chlordiazepoxide
  • Chloral Hydrate
  • Chlorpromazine
  • Clobazam
  • Chlorzoxazone
  • Clonazepam
  • Clozapine
  • Clorazepate
  • Codeine
  • Dantrolene
  • Cyclobenzaprine
  • Dexmedetomidine
  • Diazepam
  • Diacetylmorphine
  • Dichloralphenazone
  • Dihydrocodeine
  • Difenoxin
  • Diphenhydramine
  • Donepezil
  • Diphenoxylate
  • Doxylamine
  • Estazolam
  • Droperidol
  • Enflurane
  • Eszopiclone
  • Ethopropazine
  • Ethchlorvynol
  • Ethylmorphine
  • Flunitrazepam
  • Fentanyl
  • Flibanserin
  • Fluphenazine
  • Fluspirilene
  • Flurazepam
  • Fospropofol
  • Haloperidol
  • Halazepam
  • Halothane
  • Hydrocodone
  • Hexobarbital
  • Hydromorphone
  • Iloperidone
  • Hydroxyzine
  • Isoflurane
  • Ketazolam
  • Ketamine
  • Ketobemidone
  • Lormetazepam
  • Levorphanol
  • Lorazepam
  • Lurasidone
  • Melperone
  • Meclizine
  • Medazepam
  • Meperidine
  • Mephobarbital
  • Mephenesin
  • Meprobamate
  • Meptazinol
  • Metaxalone
  • Mesoridazine
  • Methadone
  • Methocarbamol
  • Methdilazine
  • Methohexital
  • Methylene Blue
  • Methotrimeprazine
  • Midazolam
  • Morphine
  • Molindone
  • Moricizine
  • Morphine Sulfate Liposome
  • Nicomorphine
  • Nalbuphine
  • Nitrazepam
  • Olanzapine
  • Orphenadrine
  • Nitrous Oxide
  • Opium
  • Opium Alkaloids
  • Oxazepam
  • Oxymorphone
  • Oxycodone
  • Paliperidone
  • Pentazocine
  • Papaveretum
  • Paregoric
  • Pentobarbital
  • Perphenazine
  • Phenobarbital
  • Perampanel
  • Perazine
  • Periciazine
  • Pimozide
  • Pimavanserin
  • Piperacetazine
  • Piritramide
  • Pipotiazine
  • Prazepam
  • Prochlorperazine
  • Primidone
  • Promazine
  • Propofol
  • Promethazine
  • Propoxyphene
  • Quetiapine
  • Quazepam
  • Ramelteon
  • Remoxipride
  • Remifentanil
  • Risperidone
  • Sertindole
  • Secobarbital
  • Sodium Oxybate
  • Sulpiride
  • Sufentanil
  • Suvorexant
  • Temazepam
  • Tapentadol
  • Thiethylperazine
  • Thiopropazate
  • Thiopental
  • Thioridazine
  • Thiothixene
  • Tizanidine
  • Tilidine
  • Tolonium Chloride
  • Triazolam
  • Topiramate
  • Tramadol
  • Trifluoperazine
  • Triflupromazine
  • Trifluperidol
  • Trimeprazine
  • Ziprasidone
  • Zaleplon
  • Zolpidem
  • Zotepine
  • Zopiclone

Other Medical Problems

If you suffer from other medical conditions, this could affect the effectiveness of this medication. Ensure you tell your doctor or a healthcare professional if you have any other medical conditions, especially:

  • Lunch or breathing problems (e.g. respiratory depression or apnea)
  • Heart rhythm problems
  • Bradycardia (slow heartbeat)
  • Fentanyl allergy (e.g. Duragesic®, Actiq®, Sublimaze®). This drug should not be used in those patients who suffer from this condition.
  • Hypotension (low blood pressure) - Caution should be exercised as this drug can make these conditions worse.

Warnings

Use in pediatric population

Studies conducted to date have not indicated pediatric-specific issues that would limit the effectiveness of remifentanil in children when given with an anesthetic before or during an operation. Therefore, efficacy and safety have not been established in the pediatric population for the relief of pain after surgery.

Use in geriatric population

Studies conducted to date have not indicated a geriatric-specific problem that could limit the effectiveness of remifentanil in the older population. However, older patients are more sensitive to the effects of remifentanil, which may require a dose adjustment for those receiving remifentanil.

Use in pregnancy and breastfeeding

This drug is under FDA pregnancy category C. If you take remifentanil while pregnant, there is a risk that your baby could be dependant on the medication. This can cause life-threatening withdrawal symptoms in the baby once it is born. Babies who are born dependent on habit-forming medication may need medical treatment for several weeks. Let your doctor know if you are pregnant.

With regards to breastfeeding, it's not known whether this drug passes into breast milk or if it could cause potential harm to a nursing infant. Many other similar opioid medications can pass into breast milk and cause breathing problems or drowsiness in a nursing infant. It's important to let your doctor know if you are breastfeeding.

This mediation can add to the effects of alcohol and other CNS depressants. Some examples of CNS depressants are medication for hay fever, colds, tranquilizers, sedatives or sleeping medicine. Check with your doctor or a healthcare professional before you take any of these drugs before receiving this medication.

Seek help from your doctor immediately if you have bluish skin or lips, chest pain, a fast, pounding, or irregular heartbeat or pulse, difficulty with breathing, shortness of breath, or muscle stiffness after receiving this medication.

Lightheadedness, dizziness or fainting may occur with this medication, especially when you get up from a sitting or lying position suddenly. Getting up slowly can help, but if the problem persists, speak with your doctor.

Storage

This drug should be stored in vials at 36°F - 77°F (2°C - 25°C). This drug is stable at room temperature for 24 hours after reconstitution and further dilution.

Summary

When used correctly, remifentanil is successful in relieving pain during and after surgical and medical procedures. This drug will be administered in a hospital setting under medical supervision. Due to the high number of interactions with other drugs, it is important that you let your doctor know of all drugs you are currently taking. This drug should be avoided during pregnancy due to the potential of an addiction in the infant once born. It should be avoided during breastfeeding. Safety and efficacy have not been established in the use of this medication on children.

 

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Last Reviewed:
January 30, 2018
Last Updated:
January 27, 2018
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