Anesth Analg 2006;103:1627-1628
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000247177.35297.77
LETTER TO THE EDITOR
Editor-in-Chief Steven L. Shafer
Respiratory Depression Caused by Remifentanil Infusion for Postoperative Pain Control
Bon N. Koo, MD, PhD,
Seung H. Choi, MD,
Duk H. Chun, MD,
Hae K. Kil, MD,
Ki J. Kim, MD, PhD,
Kyeong T. Min, MD, PhD, and
Sung J. Lee, MD
Department of Anesthesia & Pain Medicine; Anesthesia and Pain Research Institute; koobn{at}yumc.yonsei.ac.kr (Koo, Choi)
Department of Anesthesia & Pain Medicine (Chun)
Department of Anesthesia & Pain Medicine; Anesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul, Korea (Kil, Kim, Min, Lee)
To the Editor:
We experienced three cases of serious respiratory depression in patients who received continuous, constant-dose infusions of IV remifentanil for postoperative analgesia, without infusion rate changes or intentional bolus delivery. All three cases involved inadvertent remifentanil boluses.
The first patient was a 27-year-old, 48 kg woman, who had been receiving remifentanil at 0.05 µg · kg–1 · min–1 since the end of surgery. On the first postoperative day, she received a 4 mL antibiotic dose via the same IV catheter. Five minutes later she was found cyanotic and unconscious. We ventilated the patient’s lungs with a bag and mask, and spontaneous ventilation began within several minutes. There was no abnormality found on her electrocardiogram, chest radiograph, cardiac enzyme and other tests, and she recovered without incident.
The second patient was a 43-year-old, 61 kg woman also receiving a continuous remifentanil infusion since the end of surgery. On the second postoperative day, we changed the infused fluid bag, and in the process a small amount of remifentanil solution flowed freely into the patient. She became apneic. Her lungs were ventilated with a bag and mask, and she was subsequently tracheally intubated. Soon after she began breathing spontaneously, and was tracheally extubated. Subsequent neurologic examination and brain magnetic resonance imaging found no organic cause, and she recovered without incident.
The third patient was a 46-year-old, 52 kg woman, who was receiving a remifentanil infusion since the conclusion of surgery. She received an IV dose of cimetidine in the same IV line, followed by 2 cc of flush solution. She immediately became cyanotic and apneic. We initiated cardiopulmonary resuscitation, and she awoke shortly afterwards. Her subsequent examination was normal, and she recovered without incident.
Calculations based on the infusate concentrations and plumbing suggest that these three patients received somewhere between 2 and 5 µg of remifentanil by bolus injection. This modest dose clearly can be poorly tolerated, possibly because the onset of remifentanil’s effect is so rapid (1,2). Even though there have been reports of successful remifentanil injection via a bolus (3) or IV patient-controlled analgesia (4,5–9), one must remember that extremely small doses of remifentanil can cause serious respiratory depression.
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