[Remifentanil in anesthesia and intensive care]. / Remifentanil: una realtà dall'anestesia alla terapia intensiva.

Remifentanil (R) is a novel short-acting mu-receptor opioid. R is in the same structural family as fentanyl and the other phenylpiperidines, but it differs from fentanyl because of its pharmacokinetic profile and its metabolism: R undergoes extrahepatic metabolism by blood and tissue nonspecific esterases. For these reasons the time required for decreases of any percentage plasmatic concentrations of R after termination of the infusion is independent of infusion duration. The pharmacokinetic profile of R is organ-independent and the dosing regimen must be regulated in elderly patients by reducing the bolus and infusion doses, and in obese subjects by calculating the intravenous dosages as a function of age and lean body mass. The placental transfer of R doesn't affect the newborn as recently described in literature but further and wider clinical experiences are needed for assessing the use of R in obstetric anesthesia. R causes either a reduction in the MAC of volatile anesthetics or a decrease in propofol requirements but it cannot be used as a sole anesthetic agent. R can be utilized to facilitate tracheal intubation without using muscle relaxants, to manage analgesia and sedation also in association with midazolam and/or propofol, furthermore as analgesic agent for monitored anesthesia care, for the critical patient in ICU and for the postoperative analgesia if a proper analgesic strategy had not been planned.

A double-blinded evaluation of propacetamol versus ketorolac in combination with patient-controlled analgesia morphine: analgesic efficacy and tolerability after gynecologic surgery.

UNLABELLED: We assessed the relative morphine consumption in a combined analgesic regimen (on-demand morphine plus the nonopioids propacetamol or ketorolac) after gynecologic surgery. Two hundred women randomly received two i.v. doses of propacetamol 2 g or ketorolac 30 mg in a double-blinded, double-dummy trial. Patients were monitored for 12 h, and the following efficacy variables were assessed: total dose of morphine, pain intensity, and global efficacy. Safety and tolerability were evaluated by the occurrence of adverse events, especially the presence and intensity of gastrointestinal symptoms. Hemostatic variables were measured 30 and 60 min after the first infusion; arterial blood pressure, heart and respiratory rates, sedation scores, and renal and hepatic function were also assessed. Total morphine requirements were not significantly different between the propacetamol (10.6 +/- 4.8 mg) and ketorolac (10.2 +/- 4.4 mg) groups. The evolution of pain intensity and the global efficacy also showed similar patterns in the two groups: 70.2% of patients in the propacetamol group rated the efficacy as "good/ excellent" compared with 68.2% in the ketorolac group. There were no clinically significant changes in vital signs or laboratory values and no observed differences between the two groups, although ketorolac slightly, but not significantly, prolonged the bleeding time. Epigastric pain was present in 9% and 15% of patients receiving propacetamol and ketorolac, respectively. There were two adverse events in the propacetamol group and four in the ketorolac group. Propacetamol demonstrates an efficacy similar to that of ketorolac and has an excellent tolerability after gynecologic surgery. IMPLICATIONS: Propacetamol and ketorolac, combined with patient-controlled analgesia morphine, show similar analgesic efficacy after gynecologic surgery. Morphine consumption and pain scores were comparable in the two studied groups. Propacetamol is as effective as ketorolac and has an excellent tolerability after gynecologic surgery.