Bedside Snapshot

Use It For
Analgesia during general anesthesia; continued post-op analgesia in PACU/ICU; analgesic part of MAC; ventilated ICU analgesia-sedation (UK-labeled, off-label in US)
Adult Dose
  • Anesthesia, intubated: 0.05–2 mcg/kg/min IV
  • Ventilated ICU: start 0.1–0.15 mcg/kg/min, titrate every ≥5 min (max 0.74 mcg/kg/min)
  • MAC: 0.1 mcg/kg/min, then 0.05 (max 0.2 mcg/kg/min)
Pediatric Dose
  • 1–12 yr, anesthesia: 0.25 mcg/kg/min IV (US range 0.05–1.3)
  • Birth–2 mo: 0.4 mcg/kg/min (0.4–1) with nitrous oxide
  • Not established for post-op analgesia or MAC; no ICU use under 18
Onset / Duration
IV: about 1 min / effect gone 5–10 min after stopping, whatever the infusion length; respiratory depression can last up to 30 min with other anesthetics
Do Not Give / Hold If
Epidural or intrathecal use (glycine); remifentanil hypersensitivity; no airway-trained clinician. Halve or pause for RR <8, apnea, rising EtCO₂ or rigidity
Watch For
Apnea (capnography, RR <8); chest wall rigidity (cannot bag); bradycardia and hypotension (ECG, BP); rebound pain, hypertension and agitation when it stops
Reversal / Rescue
Stop or halve the infusion and ventilate: effect fades in 5–10 min. Rigidity: neuromuscular blocker. Naloxone 0.1–0.2 mg IV every 2–3 min (or nalmefene) if still needed
Must Remember
Give the next analgesic before it stops, and clear the line: analgesia ends 5–10 min after stopping, and drug left in the tubing can cause apnea and rigidity when the line is flushed

Indications

ED / ICU / Transport

  • Analgesia continued after surgery: The drip rides from the OR into the PACU or ICU under direct anesthesia supervision while longer-acting analgesia is set up (FDA-labeled, adults).
  • Analgesia-sedation in ventilated ICU adults: Analgesia comes first. Add a sedative such as propofol as needed, for up to 3 days (UK-labeled; off-label in the US beyond immediate postoperative care, and the US label has no data on ICU use longer than 16 hours)
  • ICU patients who need rapid offset: Frequent neurologic exams, recovery after cardiac surgery, or hepatic or renal failure, where other opioids build up.
  • Painful procedures in ventilated patients: A short rate increase covers suctioning, wound care or physiotherapy (UK-labeled; see Continuous Infusion).
  • Interfacility transfer: Intubated patients may arrive on a running infusion. It must not stop unplanned.

Other Uses

  • General anesthesia: Adults get it for induction and maintenance with a hypnotic or volatile agent. Children from birth to 12 years get it for maintenance only (FDA-labeled). The UK label does not recommend it under 1 year or for induction in children. Never the sole induction agent.
  • Monitored anesthesia care (MAC): The analgesic part of MAC, for spontaneously breathing adults (FDA-labeled, US only). The UK label advises against it in patients who stay conscious or have no airway support. For spontaneously breathing anesthetized patients with a secured airway (e.g., LMA), it gives a 0.04 mcg/kg/min start (studied 0.025–0.1) and no boluses
  • Tracheal intubation without a neuromuscular blocker: An anesthesia-clinician technique in adults, used when blockers are best avoided (off-label). Trials used 1.5–4 mcg/kg, which is above the US label's 1 mcg/kg maximum initial dose. Doses above 1 mcg/kg caused rigidity in 37% and bradycardia in 12% in label trials. Hemodynamic safety evidence is very low certainty. Not for ED, ICU or transport intubation. It is not a substitute for paralysis in emergency RSI
  • Labor analgesia by patient-controlled analgesia (PCA): An option when neuraxial analgesia is not possible. Use it under a unit protocol, with trained staff and continuous monitoring. Off-label, and mainly seen in UK and European practice.

Dosing & Administration

Doses vary by protocol; follow local protocols and medical direction.

Available Forms

  • Lyophilized powder for injection: 1 mg, 2 mg and 5 mg remifentanil base per single-dose vial (3, 5 and 10 mL vials); preservative-free; contains glycine
  • Reconstitution: 1 mL diluent per mg gives 1 mg/mL stock; never infuse undiluted. Dilute to 20, 25, 50 or 250 mcg/mL (e.g., 1 mg in 40 mL total gives 25 mcg/mL)
High-Alert Medication: The pump runs in mcg/kg/min, but the drug came reconstituted and diluted from the pharmacy or clinician. Concentration, dosing-weight and decimal errors are the usual traps. At every start, change and handoff, check the bag concentration, the dosing weight and the pump rate on your own.

Adult Dosing

IndicationDose & RouteRepeat / MaxNotes
General anesthesia: induction (with a hypnotic or volatile agent)
0.5–1 mcg/kg/min IV infusion; if intubating <8 min after the start, 1 mcg/kg IV over 30–60 sec
Initial dose 1 mcg/kg; never the sole induction agent
High-alert Reduce co-induction hypnotic doses (up to 75% less).
General anesthesia (GA): maintenance (intubated)
0.05–2 mcg/kg/min IV (0.1–2 with nitrous oxide); start 0.25 mcg/kg/min with propofol or isoflurane, 0.4 mcg/kg/min with nitrous oxide
1 mcg/kg IV bolus every 2–5 min if needed; above 1 mcg/kg/min deepen the other anesthetics
High-alert Supplemental boluses only during GA maintenance (besides the labeled induction and MAC single doses); never on top of an infusion in a spontaneously breathing patient.
Analgesia continued into PACU / ICU after surgery
0.1 mcg/kg/min IV; adjust by 0.025 mcg/kg/min every 5 min
Range 0.025–0.2 mcg/kg/min; no boluses
High-alert Above 0.2 mcg/kg/min: RR <8 if breathing spontaneously.
MAC, spontaneously breathing (with supplemental O₂)
Single dose 0.5–1 mcg/kg IV over 30–60 sec, 90 sec before the block (1 mcg/kg if used alone); or 0.1 mcg/kg/min from 5 min before, then 0.05 mcg/kg/min after the block
Max 0.2 mcg/kg/min; never bolus on top of a running infusion
High-alert With midazolam 2 mg: halve each dose (0.5 mcg/kg; 0.05 then 0.025 mcg/kg/min).
Ventilated ICU analgesia-sedation (UK label; off-label in US)
Start 0.1–0.15 mcg/kg/min IV; titrate by 0.025 mcg/kg/min, at least 5 min apart
Range 0.006–0.74 mcg/kg/min; not beyond 3 days (UK); no boluses in ICU
High-alert At 0.2 mcg/kg/min with inadequate sedation, add a sedative; keep titrating remifentanil only for analgesia (0.025 mcg/kg/min steps, max 0.74). US label: no data beyond 16 hr of ICU use.
Cardiac surgery (CABG)
1 mcg/kg/min IV through induction and maintenance; 1 mcg/kg/min continued into ICU
Maintenance 0.125–4 mcg/kg/min with 0.5–1 mcg/kg boluses; ICU 0.05–1 mcg/kg/min
High-alert Watch for induction hypotension. No bolus at induction; high-risk patients (poor ventricular function, valve surgery) max bolus 0.5 mcg/kg (UK SmPC).

Total body weight is the dosing weight, unless the patient is more than 30% above ideal. Then use ideal body weight. Adults over 65 years get half the starting dose and a slow titration. For ASA III/IV patients, cut the initial dose and titrate to effect (UK SmPC, which gives no initial reduction for cardiac anesthesia). Debilitated and hypovolemic patients react more strongly to its cardiovascular effects.

Pediatric Dosing

Anesthesia use only in children: The US label is for maintenance of general anesthesia only, from birth to 12 years. In neonates, clearance runs about twice the adult value and varies widely. See weight-based dosing.
IndicationDose (per kg) & RouteMax Single / Max TotalNotes
Anesthesia maintenance, 1–12 years (with halothane, sevoflurane or isoflurane)
0.25 mcg/kg/min IV (range 0.05–1.3 mcg/kg/min); optional initial 1 mcg/kg IV over 30–60 sec
Usual range 0.05–1.3 mcg/kg/min (US label; UK 0.05–0.9 with sevoflurane, 0.06–0.9 with isoflurane); supplemental 1 mcg/kg
High-alert Titrate up to 50% up or 25–50% down every 2–5 min; atropine blunts bradycardia.
Anesthesia maintenance, birth to 2 months (with 70% nitrous oxide)
0.4 mcg/kg/min IV (range 0.4–1 mcg/kg/min); 1 mcg/kg IV boluses
Studied range 0.4–1 mcg/kg/min; rates above the 0.4 start and extra boluses often needed (71% in the label study)
High-alert Bolus studied only in atropine-pretreated term infants ≥2.5 kg; otherwise give smaller boluses (hypotension, bradycardia).
Postoperative analgesia or MAC
Not established in children
—
Not studied; use a longer-acting opioid regimen.
ICU analgesia-sedation, under 18 years
Not recommended: no data (UK label)
—
Neonatal and pediatric ICU use is specialist only.

Continuous Infusion

SettingExample ConcentrationStartTitrateUsual Range / Max
General anesthesia
50 mcg/mL (example, institution-specific)
0.25–0.4 mcg/kg/min after intubation
25–100% up or 25–50% down every 2–5 min
0.05–2 mcg/kg/min
MAC
25 mcg/mL (label-recommended)
0.1 mcg/kg/min, then 0.05 mcg/kg/min after the block
0.025 mcg/kg/min every 5 min
0.025–0.2 mcg/kg/min
Ventilated ICU adult
Institution-specific (20–250 mcg/mL)
0.1–0.15 mcg/kg/min
0.025 mcg/kg/min, at least 5 min apart
0.006–0.74 mcg/kg/min; up to 3 days
Ventilated ICU: painful procedure (UK label; off-label in US)
Running infusion
At least 0.1 mcg/kg/min for at least 5 min before the procedure
25–50% every 2–5 min as needed
Mean 0.25, max 0.75 mcg/kg/min
Ventilated ICU: weaning and extubation (UK label; off-label in US)
Running infusion
Step down to 0.1 mcg/kg/min over up to 1 hr before extubation
After extubation, cut by 25% at least 10 min apart until off
Never increase during ventilator weaning; longer-acting analgesia first
Children 1 year and older
20 or 25 mcg/mL (label-recommended)
0.25 mcg/kg/min
Up to 50% up or 25–50% down every 2–5 min
0.05–1.3 mcg/kg/min

Preparation & Administration

  • Dilution: reconstitute, then dilute to 20–250 mcg/mL in NS, D5W, D5NS, 0.45% NaCl, D5LR or sterile water (stable 24 hr at room temperature); in LR alone, use within 4 hr (US label). UK label: do not reconstitute or dilute in LR or D5LR; compatible only via a running IV line.
  • Push rate: single doses go over 30–60 sec in nonintubated patients. Faster or larger doses cause rigidity.
  • Pump requirement: continuous infusions run only on an infusion pump. Use the drug library.
  • Line: inject at or close to the cannula; never in the same tubing as blood; clear or remove the line after stopping.
  • Ready at the bedside: O₂, suction, BVM, airway kit, naloxone, neuromuscular blocker.

Renal and hepatic dosing: see Special Populations.

Contraindications & Precautions

Contraindications

  • Epidural or intrathecal use: the formulation contains glycine
  • Hypersensitivity to remifentanil (e.g., anaphylaxis)
  • UK label adds: hypersensitivity to other fentanyl analogues; use as the sole induction agent (US label warns against it)

Precautions

  • Setting: only clinicians trained in anesthetic drugs and airway rescue should give it, with intubation equipment, O₂ and naloxone at hand.
  • Limited respiratory reserve (COPD, cor pulmonale, hypoxia, hypercapnia, frailty): apnea can come even at recommended doses.
  • Raised ICP or head injury: Spontaneous breathing with CO₂ retention raises ICP.
  • Hypovolemia: Bradycardia and hypotension track the dose.
  • Intraoperative awareness: Reported in patients under 55 years when combined with propofol at ≤75 mcg/kg/min.
  • Other: seizure disorders, biliary disease or pancreatitis, MAOIs within 14 days.

Hold / Reassess If

  • Spontaneous breathing with RR <8, apnea, rising EtCO₂ or falling SpO₂: halve the rate or pause, stimulate, ventilate
  • Rigidity or inability to ventilate: stop the infusion; neuromuscular blocker and ventilate
  • Bradycardia or hypotension: lower the rate; atropine or glycopyrrolate, fluids or vasopressor
FDA Boxed Warning: Three things are in the box. Addiction, abuse and misuse. Serious, life-threatening or fatal respiratory depression, especially at the start or after a dose increase. Profound sedation, respiratory depression, coma and death when combined with benzodiazepines or other CNS depressants, including alcohol.
The line flush that stops breathing: Remifentanil left in the tubing has caused apnea and rigidity when the line was flushed later. Inject it close to the cannula. After you stop, clear or remove the line.

Adverse Effects & Toxicity

Common

  • Hypotension (19% during general anesthesia)
  • Muscle rigidity (11%, chest wall 5%; under 1% when given with or after a hypnotic)
  • Bradycardia (7%)
  • Nausea (22% during postoperative infusion; 36% after discontinuation) and vomiting (8%; 16%)
  • MAC use: nausea (44%), vomiting (22%), pruritus (18%)
  • Shivering and fever (5% each) after discontinuation

Serious / Life-Threatening

EffectRecognitionManagement
Respiratory depression / apnea
RR <8, rising EtCO₂, flat capnogram; blood levels above 5 ng/mL (typically about 0.2 mcg/kg/min), boluses of 0.5–1 mcg/kg or rate steps above 0.05 mcg/kg/min are associated with respiratory depression, apnea and rigidity; can persist up to 30 min after stopping with other anesthetics
Halve the rate or stop; stimulate, O₂, BVM; naloxone if still inadequate
Chest wall rigidity
Cannot bag, high airway pressure; risk after single doses >1 mcg/kg over 30–60 sec or infusions >0.1 mcg/kg/min, or any bolus on a running infusion
Stop or slow the infusion; neuromuscular blocker (succinylcholine or rocuronium) and ventilate; naloxone if life-threatening
Bradycardia and hypotension
Peak 3–5 min after a dose or rate increase; can progress to asystole (usually preceded by bradycardia)
Lower the rate; atropine or glycopyrrolate; fluids; ephedrine or norepinephrine
Rebound pain and opioid-induced hyperalgesia
Severe pain, hypertension, tachycardia and agitation within 5–10 min of stopping, especially after rates ≥0.3 mcg/kg/min
Longer-acting analgesia before stopping; taper (UK ICU: 25% steps at least 10 min apart); multimodal analgesia (e.g., ketamine)
Withdrawal after prolonged use
Tachycardia, hypertension, agitation after abrupt stop, mainly after more than 3 days
Restart and taper the infusion

Overdose & Toxicity Management

  • Signs: apnea, stupor or coma, pinpoint pupils (dilated if hypoxic), bradycardia, hypotension, rigidity or flaccidity.
  • Management: stop the infusion, open and protect the airway, ventilate; effect usually fades within 5–10 min. ACLS for arrest.
  • Antidote: naloxone (the label also names nalmefene), only for significant respiratory or circulatory depression: adult 0.1–0.2 mg IV every 2–3 min to effect; child, small IV increments every 2–3 min (label: 0.005–0.01 mg); neonate 0.01 mg/kg IV, IM or subcut. Titrate to avoid acute pain and withdrawal.
  • Delayed toxicity: Toxic leukoencephalopathy has shown up days to weeks after an opioid overdose.

Monitoring
ParameterWhen / How OftenTarget / Act If
Clinical: capnography and RR
Continuous in every patient; watched by someone not doing the procedure during MAC
RR <8, apnea or rising EtCO₂ in a spontaneously breathing patient: halve the rate or stop, stimulate, ventilate
Clinical: SpO₂
Continuous; supplemental O₂ during MAC
Falling SpO₂ or hard to bag: suspect apnea or rigidity; ventilate, neuromuscular blocker if rigid
Clinical: HR, BP, ECG
Continuous ECG; BP frequently, especially 3–5 min after a start or rate increase (hemodynamic peak)
Bradycardia or hypotension: lower the rate; atropine or glycopyrrolate, fluids, vasopressor
Clinical: pain and sedation (ICU)
Validated pain and sedation scores at each titration and per unit protocol
Titrate to the pain goal first; add a sedative at 0.2 mcg/kg/min if sedation is still inadequate
Clinical: after stopping
Pain at 5–10 min; breathing for at least 30 min
Rebound pain: longer-acting analgesia; delayed hypoventilation from co-anesthetics: support ventilation
Infusion safety
At start, each change, bag change and handoff
Confirm mcg/mL on the bag, mcg/kg/min, dosing weight, line close to cannula and bag volume left

Interactions & Compatibility

Clinically Significant Interactions

Drug / ClassEffectWhat To Do
Benzodiazepines, propofol, volatile agents, other opioids, gabapentinoids, alcohol
Synergy: hypotension, apnea, coma, death (boxed warning)
Hypnotic doses may need to be up to 75% lower; capnography; fluids ready
Beta-blockers, calcium channel blockers
Additive bradycardia and hypotension (UK label)
Lower starting rate; atropine or glycopyrrolate, fluids or vasopressor ready
Serotonergic drugs (SSRIs, SNRIs, TCAs, triptans, 5-HT3 antagonists such as ondansetron, linezolid, methylene blue)
Serotonin syndrome
Monitor; stop remifentanil if suspected
MAOIs, current or within 14 days
Serotonin syndrome or opioid toxicity
Not recommended; if urgent, small test doses and close BP monitoring
Buprenorphine, butorphanol, nalbuphine, pentazocine
Reduced analgesia; withdrawal
Consider another analgesic; monitor closely
Blood products in the same line
Blood esterases inactivate remifentanil
Separate line
CYP450 inhibitors and inducers
None expected: not metabolized by the liver
No adjustment (unlike fentanyl and alfentanil)

IV Compatibility

  • Diluents: NS, D5W, D5NS, 0.45% NaCl, D5LR, sterile water (24 hr); LR (4 hr). UK label: not LR or D5LR for dilution; only into a running line.
  • Y-site: Compatible with propofol in a running IV set. The manufacturer has not evaluated other drugs.
  • Incompatible: blood and blood products in the same tubing.
  • Verify with an institutional compatibility resource.

Special Populations
  • Pediatrics: The US label covers anesthesia maintenance (not induction) from birth to 12 years. The UK label does not recommend it under 1 year, or for induction at 1–12 years. It has not been studied for postoperative analgesia or MAC. ICU use under 18 years is not recommended (UK label). See the Pediatric Dosing table.
  • Neonates: Clearance runs about twice the adult value and varies widely. Rates above the 0.4 mcg/kg/min start may be needed. Chest wall rigidity is common with neonatal use. Slow infusion and the lowest effective dose reduce it. Atropine pretreatment blunts bradycardia.
  • Pregnancy: Human data are not enough to judge birth-defect or miscarriage risk. Animal studies showed no malformations. It crosses the placenta, with fetal levels about half of maternal, so neonatal respiratory depression is possible. The US label does not recommend it during or just before labor. Prolonged opioid use can cause neonatal withdrawal.
  • Lactation: There are no human milk data. The very short half-life makes infant effects unlikely after use for surgery or labor. LactMed says that is not a reason to stop breastfeeding. Watch the infant for sleepiness, poor feeding or breathing problems. The UK label differs. It advises stopping breastfeeding for 24 hours.
  • Older Adults: Over 65 years, patients are twice as sensitive and clearance runs about 25% lower. Halve the starting dose (US label, all indications), then titrate slowly. UK label: halve for general anesthesia. No initial reduction for cardiac anesthesia or ICU.
  • Renal Impairment: No adjustment, including for dialysis and CRRT. The inactive acid metabolite accumulates. Its half-life is 90 min, or up to 30 hr when anephric, and its dialysis extraction ratio is about 30%. Over 3 days, that buildup has no clinically relevant opioid effect.
  • Hepatic Impairment: No adjustment. Pharmacokinetics are unchanged (US and UK labels). The US label reports an unchanged ventilatory response to CO₂ in severe hepatic dysfunction. The UK label says severe impairment may slightly increase sensitivity to respiratory depression. So monitor closely and titrate.
  • Obesity / Dosing Weight: Base starting doses on ideal body weight when the patient is more than 30% above ideal.
  • Pseudocholinesterase Deficiency: Duration stays normal. Remifentanil is not a plasma cholinesterase substrate.
  • Opioid-Dependent Patients: Requirements are higher and variable. Titrate naloxone in small increments to avoid acute withdrawal.

Field & Transport Considerations
  • Scope: EMS does not carry it. Critical-care transport crews (CCRN, CFRN, FP-C, CCP-C) may continue a running infusion in intubated patients, but only under an agency protocol and medical direction. Transport continuation is outside US labeling, which requires direct anesthesia-practitioner supervision in a PACU or ICU. It varies by state and agency protocol. Differs from FDA label: The label allows continuation as an analgesic "under the direct supervision of an anesthesia practitioner in a postoperative anesthesia care unit or intensive care setting". Transport continuation falls outside that. It is not in the National EMS Scope of Practice Model for any EMS level. An agency that allows continuation does so under specialty-care credentialing by the state and medical director.
  • Storage & Stability: Powder keeps at 2–25 °C (36–77 °F). Diluted solutions stay stable 24 hr at room temperature, or 4 hr in LR. No preservative. C-II security and witnessed waste apply.
  • Carried Concentration: There is no standard concentration. 20, 25, 50 or 250 mcg/mL are all labeled. Read the bag label and match the pump library entry before you leave.
  • Infusions in Transport: Never let it stop by accident. An empty bag, a kinked line or a pump fault ends analgesia within 5–10 min. Pain, agitation, hypertension and tachycardia follow. Bring enough volume for the trip plus delays. Use a dedicated line close to the cannula, and do not flush it.
  • If It Must Stop: Longer-acting analgesic and sedative first. Agree it with the sending team or medical control.
  • Handoff Essentials: concentration, rate in mcg/kg/min and dosing weight, last titration, co-sedatives and rates, longer-acting analgesia given (drug, time), line contents.

Clinical Pearls
Plan the landing before you stop: Analgesia is gone 5–10 minutes after you stop, whatever the infusion length. Get the longer-acting drug in early enough to work before the drip ends. Otherwise the patient wakes up in severe pain.
Context-insensitive offset (CCRN, CFRN, FP-C): Blood esterases clear it. Its half-time stays 3–6 minutes after any infusion length.
  • Remifentanil: Esterases clear it. No accumulation. Liver, kidney or pseudocholinesterase do not change it.
  • Fentanyl and alfentanil: Hepatic CYP3A4 clears them. Duration lengthens with a prolonged infusion.
Do not bolus a breathing patient on a drip: Even a small bolus on a running drip can cause chest wall rigidity. Breathing on their own? Titrate the rate instead.
Analgesia, not amnesia: Remifentanil alone does not reliably cause unconsciousness. Pair it with a hypnotic. Low propofol rates in younger patients are when you watch for awareness.
High rates, harder landing: Hyperalgesia is most likely after high-rate infusions stop abruptly. Taper. Start multimodal analgesia early. Expect higher opioid needs afterward.

Pharmacology

Mechanism of Action

  • μ-opioid receptor agonist → turns down pain transmission → analgesia, with a blunted response to surgical stress.
  • Brainstem respiratory centers → less drive to respond to CO₂ → dose-related hypoventilation and apnea.
  • Vagal and vascular effects → bradycardia and vasodilation → hypotension, peaking 3–5 min after a dose.
  • Ester linkage → blood and tissue esterases break it down → offset in minutes, with no accumulation.

Pharmacokinetics

RouteOnsetPeakDuration
IV
About 1 min (blood-brain equilibration half-time 1 min)
Rapid; new steady state 5–10 min after a rate change (3–5 min with a bolus, intubated only)
Effect gone 5–10 min after stopping, independent of infusion length
  • Half-life: effective 3–10 min; context-sensitive half-time 3–6 min after any infusion length; terminal 10–20 min.
  • Metabolism: over 95% by nonspecific blood and tissue esterases (not plasma cholinesterase, not liver) to a carboxylic acid metabolite about 1/4,600 as potent.
  • Elimination: metabolite excreted by the kidneys (half-life about 90 min). Clearance about 40 mL/kg/min; about 20% lower during hypothermic bypass.
  • Protein binding / Vd: about 70% bound; Vd about 350 mL/kg at steady state.

Names & Classification
Generic Name
Remifentanil hydrochloride (strength expressed as remifentanil base)
Brand Names
Ultiva (US and international); generic remifentanil for injection
Pharmacologic Class
μ-opioid receptor agonist; esterase-metabolized fentanyl derivative
Therapeutic Class
Ultra-short-acting opioid analgesic; anesthetic adjunct
Controlled Substance
C-II (DEA Schedule II)
ISMP High-Alert
Yes: ISMP high-alert medication (opioids, IV)
Look-Alike / Sound-Alike
None commonly reported; store and label apart from fentanyl, alfentanil and sufentanil, which differ widely in potency
Error-Prone Abbreviations to Avoid
Write mcg, never µg or ug; write mcg/kg/min in full

Related

References
  1. Mylan Institutional (Viatris). (2025). Ultiva (remifentanil hydrochloride) for injection, for intravenous use, CII: Prescribing information (revised 12/2025). DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4dbcb8f9-1987-4b66-bd2f-d251fda0be10
  2. Aspen Pharma Trading. (2024). Remifentanil 1 mg powder for concentrate for solution for injection/infusion: Summary of product characteristics (text revised July 2024). electronic medicines compendium (UK). https://www.medicines.org.uk/emc/product/794/smpc
  3. Santos, L., Zheng, H., Singhal, S., & Wong, M. (2024). Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: A systematic review and meta-analysis. Anaesthesia, 79(7), 759–769. https://doi.org/10.1111/anae.16255
  4. Vitin, A. A., & Egan, T. D. (2024). Remifentanil-induced hyperalgesia: The current state of affairs. Current Opinion in Anaesthesiology, 37(4), 371–378. https://doi.org/10.1097/ACO.0000000000001400
  5. Maroni, A., Aubelle, M. S., & Chollat, C. (2023). Fetal, preterm, and term neonate exposure to remifentanil: A systematic review of efficacy and safety. Pediatric Drugs, 25(5), 537–555. https://doi.org/10.1007/s40272-023-00583-w
  6. Hughes, D. A., Broom, M. A., Eley, V. A., Melber, A., Metodiev, Y., Maclennan, K., Sundaram, S., Van de Velde, M., Anderson, P., & Lucas, N. (2026). Remifentanil patient-controlled analgesia for labour analgesia: Guidance from the Obstetric Anaesthetists’ Association. European Journal of Anaesthesiology, 43(6), 486–498. https://doi.org/10.1097/EJA.0000000000002373
  7. Fresenius Kabi USA. (2025). Naloxone hydrochloride injection: Prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=201fdedf-1736-4e52-9d7d-de14292547fd
  8. National Institute of Child Health and Human Development. (2025). Remifentanil. In Drugs and Lactation Database (LactMed) (revised December 15, 2025). National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501253/
  9. Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., and 35 co-authors. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825–e873. https://doi.org/10.1097/CCM.0000000000003299
  10. National Highway Traffic Safety Administration. (2021). National EMS Scope of Practice Model: Including Change Notices 1.0 and 2.0 (DOT HS 813 151, August 2021), Specialty Care Delivered by Licensed EMS Personnel, pp. 15–16. https://mn.gov/oems/assets/National_EMS_Scope_of_Practice_Model_2021_%20%28002%29_tcm1221-744908.pdf

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