Remifentanil in children

Abstract

SummaryRemifentanil has gained the confidence of anesthesiologists and has given a real opportunity to change the way anesthesia is given. It can be considered the ideal opioid despite many obstacles to pediatric use: the condition of 'off-label', the lack of wide randomized clinical trials, and the fear of adverse events because of its high potency. Experiences in the field with this opioid over the years encouraged its use. Use has been associated with N 2 0 and volatile agents for general anesthesia and with propofol for total intravenous anesthesia (TIVA). It seems very useful for sedation inside and outside the operating room and in intensive care for both short painful procedures and synchronization with mechanical ventilation. However, its unique pharmacokinetic characteristics causing rapid onset and offset of effect appear unchanged in small children and even in premature neonates and need to be really confirmed by further pharmacokinetic studies. Moreover, the real risks of tolerance and hyperalgesia should be evaluated in the pediatric population. In this review, we go through the newer aspects of this versatile drug that has been proposed as 'the pediatric anesthetist's opiate'.Keywords: remifentanil; pharmacokinetics; pharmacodynamics; shortacting opioids; children; TCI Remifentanil can be considered the best answer to the search for the ideal opioid because of its unique pharmacokinetic characteristics, different from any other opioid (1-4). PharmacokineticsThe ester-linkage makes the compound susceptible to metabolism by nonspecific plasma and tissues esterases, independent from hepatic and renal function (5,6), and it can be safely used even in anhepatic period of liver transplantation or when facing with failure or immaturity of most parenchyma (7,8).Pharmacokinetics (PK) does not change in patients who are deficient in pseudocholinesterase activity, showing that it is not a good substrate for butyrylcholinesterase (9). Remifentanil has a rapid onset, small volume of distribution (Vd), rapid clearance (CL), and a brief half-time (1.0-1.5 min) for equilibration (t ½ Ke0) between plasma and the effect compartment (10). Its extremely short contextsensitive half-life (3-5 min) and the rapid recovery from drug effect are the hallmarks of remifentanil's unicity.

Stress indicators during general anesthesia with opioid analgesics in children

“…This can be explained by pharmacodynamic drug properties, rapid concentration decrease, and rapid termination of effect after the application (8). It is of great importance to have experience and knowledge of the remifentanil properties because a prompt analgesic treatment of postoperative pain is required, often to be started during the surgical intervention.…”

The Effect of Ketamine with Remifentanil for Improving the Quality of Anaesthesia and Recovery in Paediatric Patients Undergoing Middle-Ear Ventilation Tube Insertion

“…This may be explained by the fact that remifentanil decreases postoperative delirium. 16 Dizziness after ketamine use is common as a result of transient diplopia. 3 In contrast, patients who received ketamine with remifentanil in the present study showed reduced rates of dizziness, probably because of the use of remifentanil and smaller doses of ketamine.…”

“…13 -15 Remifentanil is an ultra-short-acting opioid, without an active metabolite, that provides effective sedation, rapid onset, rapid recovery, easy titration, reduced nausea and vomiting, and decreased postoperative delirium. 16 Thus, remifentanil can be administered as an adjuvant to ketamine, for brief procedures. Reports in the literature about the combined administration of ketamine and remifentanil are, however, rare.…”

Correction to: Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

“…Remifentanil is well suited for analgo-sedation during short painful procedures, but a less favorable option for postoperative pain control in non-ventilated or sedated children owing to its short duration of action [161], and has gained wide acceptance [162][163][164]. Studies elucidating the PK-pharmacodynamic relationship are particularly needed in children of all age groups because of its popularity [165].…”