Remi shortage: use alfentanil?

[iron]

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The license for remi has been sold to another manufacturer. The new manufacturer is not going to make/distribute any until the "old" stock is used up. There prob. won't be any remi until mid-Sept or October. Currently there are some 5mg in 10ml premixed syringes (costs almost $100) out there.

We use remi boluses 30 - 50mcg for peribulbar blocks, local injection for carpal tunnels and ocular plastics. I'd like to replace remi with Alfentail however, I haven't used Alfentanil in years --
I recall 750mcg bolus for peribulbar blocks but the minimal literature I found states 250 - 500mcg. Alfentanil 1000mcg ampule costs $2.20.

What doses are you using for Alfentanil boluses?

Yes, we could use just Midaz and tell people to hold still, or Propofol or Thiopental.... But I think the Alfentanil will give us the conditions we and our surgeons are used to.

 

[Noyac]

I seem to recall using 750 mcg boluses as well. It's been 8 yrs though.

 

[coprolalia]

I've used this drug a lot. It's excellent for cut-downs in the angio suite and for, as you guys note, peri- and retrobulbar blocks. Good one-time bolus dose range is 5-8 mcg/kg. Give it about 45 seconds before the maximal stimulation, and often the patient will briefly go apneic.

For cut-downs in neuroradiology for cererbral angios, I will usually give the patient 0.5 mg/kg bolus of propofol then about 250-500mcg of alfentanil (1/2 mL to 1 mL). They will "blank out" for about a minute, and then be completely awake a few minutes later for the breath holding portions of the case. It's very smooth, they don't move during the cut-down like they do with just propofol alone, and they don't have that "disinhibited" phase emerging from the propofol bolus alone. I've done tons of these many different ways, and I find that this consistently yielded the best results.

Have never used remifentanil for this application. Have used remi (and precedex and propofol gtt) a lot for TIVA's in the neurorad when they are doing IONM.

-copro

 

[huktonfonix]

we used to use it similarly to copro. mix 60mg of propofol (6 ml), 20mg (2 ml) lidocaine, 1000 mcg alfentanil (2ml) in a 10 cc syringe and administer to effect, typically 3-7 mcg/kg of alfentanil.

 

[OB1🤙]

we used to use it similarly to copro. mix 60mg of propofol (6 ml), 20mg (2 ml) lidocaine, 1000 mcg alfentanil (2ml) in a 10 cc syringe and administer to effect, typically 3-7 mcg/kg of alfentanil.

Quoted to vouch for the awesomeness of this concoction.

The guy who came up with it recently got cute and changed a cc of the alfenta to a cc of straight fent, so it's 60 prop, 20 lido, 500 alfenta, 50 fent in a 10 cc syringe to be titrated to effect. I like the original better, especially for the older folks.

 

[jwk]

We don't use alfentanil or remifentanil. It's not even available on formulary at our hospitals. We just couldn't seem to find a reasonable use for either one that couldn't be met with something else.

 

[anesthesiadoc]

I've been using Sufentanil this week on C-spine fusions requiring neuro monitoring. So far, so good.

 

[seattledoc]

Like JWK,
Remi and Alfenta aren't on our formulary.
We use Propofol and Midaz 1-2mg for our retrobulbars

 

[Confusant]

Is there any situation where alfentanil is preferred over remifentanil?

My understanding is that remifentanil has a shorter time of onset and offset, which is the only distinctive advantage over the former.

 

[huktonfonix]

Is there any situation where alfentanil is preferred over remifentanil?

My understanding is that remifentanil has a shorter time of onset and offset, which is the only distinctive advantage over the former.

alfentanil is cheaper

 

[Confusant]

Ah, I see. Any other reasons? 🙂

 

[Idiopathic]

yes, you can currently get alfentanil from the manufacturer. so, its cheaper and available.

 

[coprolalia]

Ah, I see. Any other reasons? 🙂

Yes. For alfentanil, unlike remifentanil, one doesn't have to set-up an infusion, which also decreases time (and therefore cost... pump use, IV tubing, checking/verifiying set-up, programming pump, etc.) of its adminstration.

Remi, in my opinion, has very few, very limited - but clearly important - clinical uses. It's a great drug. It's just a pain in the ass. And, it's expensive.

-copro