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Year : 2012  |  Volume : 6  |  Issue : 4  |  Page : 322

Short acting opioids for the elderly: What's the point?

Anesthesia and Intensive Care Unit, Hôtel Dieu de France Hospital, Beyrouth, Liban, France

Correspondence Address:
Christine Dagher
Anesthesia and Intensive Care Unit, Hôtel Dieu de France Hospital, Beyrouth, Liban
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-354X.105850

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Date of Web Publication10-Jan-2013

How to cite this article:
Dagher C. Short acting opioids for the elderly: What's the point?. Saudi J Anaesth 2012;6:322

How to cite this URL:
Dagher C. Short acting opioids for the elderly: What's the point?. Saudi J Anaesth [serial online] 2012 [cited 2023 Jan 30];6:322. Available from:

Alfentanil and Remifentanil are two short acting opioids that have been known for several years and used for short procedures. [1],[2] Remifentanil is a synthetic opioid with direct action on mu-opioid receptors. It has a rapid onset and short latency to peak effect. It is rapidly inactivated by esterases in both blood and tissues, resulting in a very short duration of action. The context-sensitive half-life remains very short (three to four minutes), independent of the duration of infusion. The rapid effect-site equilibration characteristic of alfentanil is a result of the low pK of this opioid, so that nearly 90% of the drug exists in the non-ionized form at physiologic pH. The non-ionized fraction readily crosses the blood-brain barrier. Alfentanil, depends on its small volume of distribution for rapid termination of its effect, but still possesses the potential to accumulate because of its relatively long terminal elimination half-life.

When comparing pharmacokinetics and pharmacodynamics of both drugs, Egan et al. concluded that with the exception of remifentanil's nearly 20-times greater potency, the drugs are pharmacodynamically similar. [3] Pharmacological characteristics of both drugs seem interesting for old people having short procedures.

Alfentanil and remifentanil have been compared in both children and adults. The speed of recovery is controversial. [4],[5],[6],[7] No data was found concerning old people. In this current issue, Entezariasl et al., [8] in a prospective, randomized and blinded study compared recovery time after alfentanil or remifentanil administration for cataract surgery in elderly patients. Although time to respiration, eyes opening, verbal response and stay in the post anesthesia care unit were not statistically different between the two groups, incidence of postoperative nausea and vomiting (PONV) was higher after remifentanil infusion. Although, the authors did not evaluate the incidence of nausea and its severity, the frequency of antiemetics use and the incidence of retching and vomiting alone, it remains a very important issue, particularly vomiting after eye surgeries in elderly patients. We think it deserves a more detailed and structured study. Postoperative nausea and vomiting is one of the major concerns of patients. They are willing to pay more money to avoid PONV than postoperative pain. [9]

Remifentanil is known to induce postoperative hyperalgesia and this particular criterion was not evaluated, although it is part of postoperative recovery. [5] The authors did not mention if local or regional anesthesia were used.

After all, what really matters is the economic impact of these results. How long will the patient stay in the post anesthesia care unit? Will he/she need an antiemetic drug? Will vomiting have a negative impact on cataract surgery? Which opioid is more expensive: remifentanil or alfentanil?

  References Top

1.Rosow C. Remifentanil: A unique opioid analgesic. Anesthesiology 1993;79:875-6.  Back to cited text no. 1
2.Kay B, Pleuvry B. Human volunteer studies on Alfentanil (R39209), a new short-acting narcotic analgesic. Anaesthesia 1980;35:952-6.  Back to cited text no. 2
3.Egan TD, Minto CF, Hermann DJ, Barr J, Muir KT, Shafer SL. Remifentanil versus alfentanil: Comparative pharmacokinetics and pharmacodynamics in healthy adult male volunteers.Anesthesiol 1996;84:821-33.  Back to cited text no. 3
4.Cicek M, Koroglu A, Demirbilek S, Teksan H, Ersoy MO. Comparison of propofol-alfentanil and propofol-remifentanil anaesthesia in percutaneous nephrolithotripsy. Eur J Anaesthesiol 2005;22:683-8.  Back to cited text no. 4
5.Komatsu R, Turan AM, Orhan-Sungur M, McGuire J, Radke OC, Apfel CC. Remifentanil for general anaesthesia: A systematic review. Anaesthesia 2007;62:1266-80.  Back to cited text no. 5
6.Mortensen CR, Larsen B, Petersen JA, Rotbøll P, Riist J, Thorshauget H. Remifentanil vs. alfentanil infusion in non-paralyzed patients: A randomized, double-blind study. Eur J Anaesthesiol 2004;21:787-92.  Back to cited text no. 6
7.Dilger JA, Sprung J, Maurer W, Tetzlaff J. Remifentanil provides better analgesia than alfentanil during breast biopsy surgery under monitored anesthesia care. Can J Anaesth 2004;51:20-4.  Back to cited text no. 7
8.Entezariasl M, Akhavanakbari G, Isazadehfar K. The comparison of Alfentanil and Remifentanil infusion during anesthesia on post-anesthesia recovery. Saudi J Anaesth 2012;6:323-6.  Back to cited text no. 8
  Medknow Journal  
9. Gan TJ, Sloan F, Dear Gde L, El-Moalem HE, Lubarsky DA. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg 2001;92:393-400.  Back to cited text no. 9


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