Remifentanil

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napman

napman

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Hi Everybody
what clinical scenarios are you using Remifntanil in your clinical practice?
and how are you using it?
My pharmacy has restriction on this drug only to be used for awake cranie's
 
Awake cranies, TIVA with monitoring. Carotids with 0.5 MAC volatile.
 
Most recently I've used it for rigid bronchs, suspension microlaryngoscopy (peds), spines (+/- ketamine), cranies (asleep), in combination with propofol gtt of course. I think it's helpful in short cases when you don't necessarily want to paralyze or give a ton of narcotic. I have almost always have given some kind of opioid at the start of the case, and haven't seen the post-op 'hyperalgesia' yet.
 
Bronchoscopies with EBUS, most ENT cases, TIVA for SSEP/MEP.
 
I like using it for aneurysm coilings, thyroidectomies, cranies, and for bronchs. I have used it for an RSI in a patient with pseudocholinesterase deficiency on a super short case as well. It's a great drug that is perfect in our world.
Red
 
i'll add to the list

Awake fibre optic intubation
With RSI for Pre Eclamptics undergoing GA
 
I use it in anything but short airway cases in kiddos. I also like to use it in neonates that are predisposed to postop. apnea...myelomeningocele and pyloric stenosis kiddos come to mind.
 
I like alfentanil better than remifentanil for many of these uses.

Way cheaper, too.
 
Thanks for the responses
what dose do you use for RSI ? do you use any muscle relaxants also?
What dose do you start for Awake fiberoptic?
 
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napman said:
Thanks for the responses
what dose do you use for RSI ? do you use any muscle relaxants also?
What dose do you start for Awake fiberoptic?
Click to expand...

1 mcg/kg, and yes sux. remi is to blunt response to laryngoscopy (though i'm sure you can intubate on remi, I wouldn't in an emergent c section)
awake fibre optic - start low and increase slowly - probably start at about 0.05 mcg/kg/min

agree alfentanil is good for rsi -- probably better even - i don't always have it available though
 
Remifentanil should only be used in residency so you know how it works.

Otherwise I add this to the list of things (like the BiS monitor) that are both costly and heavily marketed by the people who want you to buy and it but really serve no discrete unique or appreciable purpose.
 
BuzzPhreed said:
Remifentanil should only be used in residency so you know how it works.

Otherwise I add this to the list of things (like the BiS monitor) that are both costly and heavily marketed by the people who want you to buy and it but really serve no discrete unique or appreciable purpose.
Click to expand...

disagree - i used remi a lot in training, and still use it about 10x/year for the above listed discretely unique and appreciable purposes. imho it really isn't useful as a long term infusion (which negates your cost argument).

the bis is trash, agreed.
 
napman said:
Thanks for the responses
what dose do you use for RSI ? do you use any muscle relaxants also?
What dose do you start for Awake fiberoptic?
Click to expand...

4ug/kg - no relaxant (that's usually the indication/point). i don't use it for awake fob. lidocaine is good for those, and if i absolutely have to give sedation i'm starting to like dexmed...
 
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nap$ter said:
disagree - i used remi a lot in training, and still use it about 10x/year for the above listed discretely unique and appreciable purposes.
Click to expand...

I can do just as much with careful and judicious administration of fentayl at a fraction of the cost. Our hospital doesn't even stock remi. I did an emergency crani yesterday. The patient lived without remi. To the shock and disbelief I'm sure of many-a-cookie-cutter anesthetists out there.
 
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JobsFan said:
awake fibre optic - start low and increase slowly - probably start at about 0.05 mcg/kg/min
Click to expand...

I honestly don't comprehend how complicated people make sedation/analgesia for AFOI. Dex gtts, remi gtts...how much time and money do you have to waste on this procedure?

How about, small doses of midazolam and/or fentanyl...which you already have laying around...titrated to effect? Or...gasp...nothing?!
 
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fakin' the funk said:
Do you also put pacer pads on in anticipation of the bradyasystole that ensues?
Click to expand...

out of hundreds of inductions c that dose (including peds), i have never once had bradycardia that needed treatment, or asystole.

the slowing of the HR signals time to perform laryngoscopy.

is your fear born of dogma or personal experience (ie anecdote)?
 
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BuzzPhreed said:
I can do just as much with careful and judicious administration of fentayl at a fraction of the cost. Our hospital doesn't even stock remi. I did an emergency crani yesterday. The patient lived without remi. To the shock and disbelief I'm sure of many-a-cookie-cutter anesthetists out there.
Click to expand...

fentanyl is a great choice for an emergent crani. shock and disbelief is quite easy to generate in cookie cutter anesthetists. we're talking about those few cases (approx 10/year for me) where careful and judicious use of fentanyl is not an option.

a general example (in addition to all the above examples) - induction/maintenance when a great depth of anesthesia is desired for a very short period of time and postop narcosis and intraop paralysis is suboptimal/unacceptable.

what do you think the cost difference is and how do you arrive at that difference?

the best reason you have presented thus far is that your hospital doesn't stock it...
 
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nap$ter said:
4ug/kg - no relaxant (that's usually the indication/point). i don't use it for awake fob. lidocaine is good for those, and if i absolutely have to give sedation i'm starting to like dexmed...
Click to expand...

When you use remi for intubations without relaxant, do you ever see closed vocal cords when you DL?

Ie, laryngospasm aka "chest wall rigidity" as it is sometimes labeled?
 
pgg said:
When you use remi for intubations without relaxant, do you ever see closed vocal cords when you DL?

Ie, laryngospasm aka "chest wall rigidity" as it is sometimes labeled?
Click to expand...

nope - cords are always open in my experience. i never try to mask in a RSI situation.
 
BuzzPhreed said:
I can do just as much with careful and judicious administration of fentayl at a fraction of the cost. Our hospital doesn't even stock remi. I did an emergency crani yesterday. The patient lived without remi. To the shock and disbelief I'm sure of many-a-cookie-cutter anesthetists out there.
Click to expand...

Different strokes for different folks...there are a thousand different ways to deliver a safe anesthetic with the same result at the end. I'm sure there are plenty anesthetists out there who could accomplish the exact same thing you accomplish with halothane rather than your sevoflurane, atracurium instead of your cisatracurium, low-flow anesthesia versus your high-flow anesthesia. Everyone has their way of doing things...you choose to cut costs without using remi, so more power to you. In anyway event, in training I learned how to use both remi and fentanyl for cranis. No appreciable difference in the outcomes for either, wakeup times are pretty much identical as long as you know when to turn off the fentanyl infusion.

I remi for airway cases (including rigid bronchs) and certain cranis (esp if they're huge and predisposed to obstruction)...really the only two things that are coming to mind. Out of curiosity -- what types of spines are we talking about for those that use it for spine? When it comes to larger multilevel spines with instrumentation I can't imagine using something like remi for those folks since they're in boatloads of pain even after several hours of a fentanyl infusion...
 
nap$ter said:
what do you think the cost difference is and how do you arrive at that difference?
Click to expand...

A vial of remi is about $52. A 250mcg vial of fentanyl - about $2. Run it as an infusion? Hey, it's easy to spend other people's money. (That's the biggest problem with our government too. Doesn't mean it's prudent or right.)

Urzuz said:
Different strokes for different folks...there are a thousand different ways to deliver a safe anesthetic with the same result at the end.
Click to expand...

Yes (and the rest of your post). The problem is the thoughtless "cookie-cutter" dogmatic approach to anesthesia that infiltrates certain practices and people stop thinking about what they're doing, what could be better/cheaper/more efficient, and what makes the most sense perioperatively. Me? I'm generally a "less is more" kind of guy. And my patients seem to have fewer "issues" post-operatively. I spend less money overall. I rarely need to leave people intubated going to the PACU. I don't believe every latest B.S. study that says everything I've done for the past 11 years is wrong. It's really hard to quantify a thinking-man's approach. And most people don't care. I happen to care.

In fact even yesterday that neurosurgeon told me - and I quote - "thank God it's you doing this case and not Dr. 'Pink'" (who I turned a neuromonitoring case over to with the same surgeon last week only to have it completely f*cked-up by "Dr. Pink" I find out the next day). I know how to use all the drugs in the drawer. Doesn't mean I have to. An elegant anesthetic is often one that has as few variables as possible and makes complete sense in the broader peri-operative context.

In my mind remi is a **** drug with little clinical value. Just like the BiS monitor. Beware the sales/marketing people and their agendas. That's all. You don't need to use remi. For anything.
 
nap$ter said:
ya don't need any opiates for pyloric stenosis cases...
Click to expand...

somedumbDO said:
No narcs esp w lap pylos... Local all u need
Click to expand...

I agree but the author asked for cases in which we will use remifentanil in our practices. I have used it as a sole anesthetic in pylorics and don't have any reservations in doing so. I probably use it once a month (all-comers) and when I do, it's usually to simplify the anesthetic in a complicated clinical situation. No, I don't think of pyloric cases as complicated and as such tend to use atropine, succinylcholine, and desflurane for most of these.

I remain skeptical of the absolute cost difference of my anesthetics with remi and those without, purely because of selective use. I've seen too many complicated anesthetics with iatrogenic side-effects being countered with more interventions/medications (i.e. cost) to know better.
 
hudsontc said:
I've seen too many complicated anesthetics with iatrogenic side-effects being countered with more interventions/medications (i.e. cost) to know better.
Click to expand...

I think we're talking about the same thing here.
 
it certainly works very well in the tiny world of out-patient dental anesthesia.
we mix it with the prop, go through about 100mcg per 1hr case...comes out to between $4-5/hr...it pays for itself with the 10 minute discharge

i agree with buzz...the way it is used in the hospitals I trained at was financially insane...25 minute op time, then waste the rest of the 2g (if i remember correctly) vial

and last time i looked I thought alfenta was actually very comparable in cost to remi...but maybe it works out differently in the hospital with bulk purchasing and having to waste the whole bottle
 
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fakin' the funk said:
I honestly don't comprehend how complicated people make sedation/analgesia for AFOI. Dex gtts, remi gtts...how much time and money do you have to waste on this procedure?

How about, small doses of midazolam and/or fentanyl...which you already have laying around...titrated to effect? Or...gasp...nothing?!
Click to expand...

what i use depends on the indication for awake fibre optic.
a reassuring manner instead of sedation is certainly an option.

fent/midaz is ok - but if you're doing fibre optic because you're concerned about a CICO situation - why not use something that is ultrashort acting?

Remi is only good for the indications above and very short, highly stimulating procedures that aren't particularly painful post operatively.
we tend to avoid it here due to concerns of inducing acute opioid tolerance / hyperalgesia in any procedure that is going to be painful post operatively.
 
BuzzPhreed said:
A vial of remi is about $52. A 250mcg vial of fentanyl - about $2. Run it as an infusion? Hey, it's easy to spend other people's money. (That's the biggest problem with our government too. Doesn't mean it's prudent or right.)



Yes (and the rest of your post). The problem is the thoughtless "cookie-cutter" dogmatic approach to anesthesia that infiltrates certain practices and people stop thinking about what they're doing, what could be better/cheaper/more efficient, and what makes the most sense perioperatively. Me? I'm generally a "less is more" kind of guy. And my patients seem to have fewer "issues" post-operatively. I spend less money overall. I rarely need to leave people intubated going to the PACU. I don't believe every latest B.S. study that says everything I've done for the past 11 years is wrong. It's really hard to quantify a thinking-man's approach. And most people don't care. I happen to care.

In fact even yesterday that neurosurgeon told me - and I quote - "thank God it's you doing this case and not Dr. 'Pink'" (who I turned a neuromonitoring case over to with the same surgeon last week only to have it completely f*cked-up by "Dr. Pink" I find out the next day). I know how to use all the drugs in the drawer. Doesn't mean I have to. An elegant anesthetic is often one that has as few variables as possible and makes complete sense in the broader peri-operative context.

In my mind remi is a **** drug with little clinical value. Just like the BiS monitor. Beware the sales/marketing people and their agendas. That's all. You don't need to use remi. For anything.
Click to expand...

in red - which vial of remi costs that much (1,2 or 5mg)? regardless, comparing ug/dollar of remi vs fentanyl is a pinhole view - equianalgesic doses have very different uses and durations of actions. i've previously agreed that long infusions of remi are a bad idea. if you are going to make a cost comparison you need to look at the "broader perioperative context". ie specific patient/case uses, pacu time, oxygen needs, OR time, complication rates etc. not just your anecdotes but statistics.

you don't have remi in your drawer - you said your hospital doesn't carry it.

i have never in 10 years seen a remifentanil ad/marketing ploy/or rep in any of my workplaces that i can remember. (as opposed to the many BIS pushers i have met over the years (although they have thankfully faded away...))

your statement in blue is awesome. the stuff between the red and blue seems to be a bit of a ramble.

however, comparing remifentanil to the BIS is silly.

we'll just have to disagree there. it's the perfect drug for a very few situations. i agree completely with urzuz - different strokes, man. if fentanyl works for you, more power to you. 99% of the time fentanyl or the old fashioned works great, but 1% of the time there's a better drug, a better way. try it, you'll like it.
 
hudsontc said:
I agree but the author asked for cases in which we will use remifentanil in our practices. I have used it as a sole anesthetic in pylorics and don't have any reservations in doing so. I probably use it once a month (all-comers) and when I do, it's usually to simplify the anesthetic in a complicated clinical situation. No, I don't think of pyloric cases as complicated and as such tend to use atropine, succinylcholine, and desflurane for most of these.

I remain skeptical of the absolute cost difference of my anesthetics with remi and those without, purely because of selective use. I've seen too many complicated anesthetics with iatrogenic side-effects being countered with more interventions/medications (i.e. cost) to know better.
Click to expand...

:wow: why????
 
nap$ter said:
:wow: why????
Click to expand...
I'm curious about his technique. How much bolus and how much infusion. When does it get turned off? Any atropine?

It might be a technique to consider if the neuroapoptosis research keeps growing.
 
urge said:
I'm curious about his technique. How much bolus and how much infusion. When does it get turned off? Any atropine?

It might be a technique to consider if the neuroapoptosis research keeps growing.
Click to expand...
I would also be curious to hear this technique described. We do them all the time. Almost everyone uses Prop, Sux, tube, Sevo/air/O2, local and rectal Tylenol. A few use 0.5-1 MCG/kg of fentanyl. They are very fast and efficient and they really are 20min cases. I think the fent offers little other than delaying the wakeup.
 
Atropine 20mcg/kg, Remi 2mcg/kg for intubation followed by .4mcg/kg/m infusion. Turn off with ~7-8 minutes or as soon as they are out of the abdomen. That's about it. It's just a train track anesthetic with fast extubation. There is good evidence that relaxation isn't as great for intubation as with sux but that probably goes without saying.

What you have described is what I typically do, too, Ildestriero...don't think I've ever given fentanyl though.
 
Interesting, nothing for amnesia? I guess you don't have to worry about them suing you for awareness....
 
I find it to be useful for MEP cases with a particular surgeon who is famous for booking 4 hour cases then giving you five min closing notice 1 hour into the case. Or making his 2 hour lami a 6 hour case.

It is more forgiving of his unpredictability.

Same reason I like Des.

In the MRI suite, I can use whatever drugs I want because I know exactly when the case is going to end.

Cost? It's peanuts in the grand scheme. I could do all of my spine cases this year with Remi for the cost of one implant.

Cost? Give me a F'ing break.

-pod
 
periopdoc said:
Cost? Give me a F'ing break.
Click to expand...

This is the same attitude our federal government has. Every drop that goes in the bucket eventually will drown us. Easy to spend money when it's not coming out of your wallet.

Remi is just a tool. Personally, and as I said already, I think it's a **** drug that doesn't offer much. I think when it was discovered and developed by pharma it was nothing more than a solution looking for a problem. And I think the sales/marketing folks have done a wonderful job of selling a lot of people.

So, cost? F*** yeah, cost. If it's expensive and worth it, that's one thing. If it's not, that's something else entirely.
 
I love remi. We use it for just about all cases we can't use NMBs (under 4 hrs, sufenta if longer) and cases we want patients we absolutely don't want bucking on emergence, like neck cases. The wake-ups are amazing.

Remi/prop is our go to TIVA for people with PONV history. And our surgicenter uses remi/prop for most cases due to fast wake-ups and rapid turnover.
 
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Alfentanil is better. And cheaper. Especially in that situation.
 
I find Remifentanil especially useful in 2 scenarios: any case in which a fast awakening is necessary, and any TIVA case, especially with neuro-monitoring. In an especially long TIVA case, I may opt to use Sufentanil instead of Remi, particularly if I know I won't be extubating the patient at the end.
 
pgg said:
Are you going to keep using neostigmine when Sugammadex eventually gets approved and is off patent, too?
Click to expand...

No, I have no inherant problem with new drugs, or ones that can do things that no other drug can do (like Sugammadex). I'm generally a Sevo guy not an Iso guy for instance (Des requires I ask a tech to change out the vaporizer for every case so it's more trouble than it's worth). I just don't think remi falls into this category. Remi gives you nothing that you can't do equally well or better with other drugs though they may require a bit more artful approach. To quote one of my favorite former attendings, using Remi is a "decerebrate" way to practice anesthesia. Turn it on, turn it off . . . no thought, skill, or art involved. It's a crutch. You can achieve equally as fast and smooth wake-ups using conventional narcotics as you can with remi without the risk of hyperalgesia or inducing acute withdrawal symptoms later on (I know someone who received a remi infusion at gradually escalating doses as part of the phase 3 clinical trials at U of Utah. They said it felt amazing during the infusion, but later that day after going home suffered bad withdrawal symptoms - N/V, chills, etc.)
 
Everybody has a favorite tool. If it's remi, so be it, as long as the job gets done and the costs are comparable.

People who love to whine about the lack of des, or dex, or remi, should either learn to prove that the costs are comparable, or that the drug is irreplaceable, or learn to have alternatives, just like when taking the oral boards. For example, in a crani or spine case, remi can be easily replaced with fenta or alfenta.
 
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