Anaes Cases · Opioids & analgesics
Remifentanil-induced hyperalgesia
Hot case — remifentanil-induced hyperalgesia (acute opioid tolerance). Ketamine infusion (NMDA antagonist); transition to long-acting opioid before remifentanil offset; multimodal.
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Prompt
After remifentanil infusion for prolonged surgery, the patient has severe postoperative pain unresponsive to high-dose morphine. Diagnose and manage.
Presentation
After 4-hour spine surgery under TIVA with remifentanil (0.2 mcg/kg/min) and propofol, the patient wakes in severe pain (score 9 to 10 out of 10) despite morphine 25 mg in the first hour. The patient is agitated and distressed. Diagnose and manage.
[2]References1ShowHide
- [2]Hughes DA, et al. Remifentanil patient-controlled analgesia for labour analgesia: guidance from the obstetric anaesthetists' association: Recommendations for well tolerated provision of remifentanil PCA for labour analgesia. Eur J Anaesthesiol, 2026.PMID 42080744