Alternatives to remifentanil for the analgesic component of total intravenous anaesthesia: a narrative review

Abstract

Propfol-remifentanil-based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in remifentanil supply has presented an opportunity to diversify or even avoid the use of opioids and consider adjuncts to propofol-based total intravenous anaesthesia. Propofol, while a potent hypnotic, is not an effective analgesic. The administration of opioids, along with other adjuncts such as α-2 adrenoceptor agonists, magnesium, lidocaine, ketamine and nitrous oxide provide surgical anaesthesia and avoids large doses of propofol being required. We provide an overview of both target-control and manual infusion regimes for the alternative opioids: alfentanil, sufentanil and fentanyl. The optimal combination of hypnotic-opioid dose, titration sequence and anticipated additional postoperative analgesia required depend on the chosen combination. In addition, we include a brief discussion on the role of non-opioid adjuncts in total intravenous anaesthesia, suggested doses and expected reduction in propofol dose.

Sedatives and Postoperative Delirium: Reply

“…We appreciate Hughes et al . 3 for their interest and thoughtful comments on our recent study. The main objective of our work was to investigate the effect of sedatives on the occurrence of postoperative delirium, particularly in healthy older adults, rather than frail individuals.…”

“…We thank Nelson et al , 1 Goodwin et al ., 2 and Hughes et al . 3 for their responses to our article. 4…”