Abstract Remifentanil is an ultra-short-acting μ-opioid agonist that has become integral to modern anesthetic practice due to its rapid onset, predictable offset, and metabolism by nonspecific plasma and tissue esterases independent of hepatic and renal function. These pharmacokinetic properties enable precise titration and rapid recovery even after prolonged infusions, making remifentanil particularly useful in high-risk populations, including pediatric, geriatric, and critically ill patients. This review summarizes current evidence on the pharmacokinetics, pharmacodynamics, and age-related considerations of remifentanil and explores its expanding clinical applications across anesthesia, intensive care, obstetrics, and procedural sedation. The role of remifentanil in total intravenous anesthesia, neuroanesthesia, labor analgesia, facilitation of tracheal intubation without neuromuscular blockade, and intensive care unit sedation is discussed, with comparison to conventional opioids. Emerging evidence regarding its organ-protective, neuroprotective, and immunomodulatory effects is reviewed. Recent advances in drug delivery, including target-controlled infusion systems, mixed intravenous anesthesia techniques, and newer pharmacokinetic–pharmacodynamic models such as the Eleveld and Kim models, highlight ongoing efforts to improve dosing accuracy across diverse patient populations. Despite its advantages, remifentanil use is associated with specific challenges, including remifentanil-induced hyperalgesia, respiratory depression in obstetric and neonatal settings, and dependence on advanced infusion and monitoring technology. Continued research into individualized dosing strategies, multimodal analgesia, and adaptive infusion systems is essential. Overall, remifentanil remains a cornerstone of precision-based anesthesia with evolving clinical applications.
Bhatia et al. (Thu,) studied this question.