Remifentanil Use in ICU and PICU

Introduction to Remifentanil

The American College of Cardiology recommends remifentanil as an ultra-short-acting opioid for analgesia and sedation in adult and pediatric patients on mechanical ventilation in ICU and PICU, with advantages including organ-independent metabolism, rapid onset, and predictable recovery 1

The European Society of Cardiology recommends remifentanil as a first-line agent for analgesia and sedation in adult patients with mechanical ventilation, particularly in an analgesia-first sedation strategy 2, 1
The initial dose of remifentanil is 0.1-0.4 mcg/kg/min, with titration based on clinical response, using validated pain and sedation scales 1
Remifentanil is recommended for post-cardiac arrest patients with targeted temperature management (TTM) as a first-line agent for analgesia, sedation, and shivering control 2, 3

In pediatric patients, remifentanil can be used with careful hemodynamic monitoring, starting from a low dose 4
The European Society of Pediatric and Neonatal Intensive Care recommends remifentanil as an alternative to fentanyl for analgesia and sedation in pediatric patients 5

Low-dose opioids, such as remifentanil, are recommended for procedural pain management, with high-dose remifentanil showing significant reduction in chest tube removal pain compared to low-dose 6

Remifentanil has a unique pharmacological profile, with metabolism by non-specific plasma esterases, resulting in a rapid and predictable offset of action 1
The context-sensitive half-time of remifentanil is short and does not change with infusion duration, unlike fentanyl or morphine 1

The Society of Critical Care Medicine recommends remifentanil as one of the opioid choices for pain management in adult critically ill patients, with a strength of evidence based on multiple citations 7, 8, 9, 10

For procedural pain management, the Society of Critical Care Medicine guideline suggests using opioids with the lowest effective dose, which can include remifentanil, with a recommendation based on evidence from Critical Care Medicine 7, 8, 9