AANA Journal course: update for nurse anesthetists--a comprehensive review of remifentanil: the next generation opioid.

Over the last two decades, profound changes have taken place in the way elective surgery is practiced with the majority of surgical patients now admitted and discharged through ambulatory surgical facilities. After initial hesitation on the part of the surgeons, anesthesia care providers, and patients and their families, this practice is now clearly accepted. A variety of surgical advances (e.g., new endoscopic procedures, laser technology, and extracorporeal shock wave procedures) have allowed surgeons to simplify and abbreviate surgical procedures. Anesthesia care providers now, more than ever, need rapid acting agents to keep apace with these surgical technological advances; the pressure to produce rapid room turnover and rapid recovery from anesthesia is unprecedented. Ideally, the anesthetic care plan and drug selection should precisely match the need of the individual patient and the surgical procedure. Remifentanil, a new member of the fentanyl family, is the first ultra-short-acting opioid that can be rapidly titrated and individualized for various levels of surgical stimuli. Relatively large doses can be administered, permitting rapid extubation and awakening at the end of the procedure. Remifentanil differs from all other opioids, possessing an ester linkage that allows predictable pharmacokinetics. Remifentanil may have potential for clinical exploitation where rapid onset and offset of opioid effects are desirable.