Version June 2024
| Drug | Induction of general anesthesia | Maintenance of general anesthesia | Monitored anesthesia care (MAC) | Comments | Management of acute postoperative pain |
| Fentanyl | Bolus dose(s): 25 to 100 mcg or 0.5 to 1 mcg/kg; may be administered in divided doses. High-dose opioid induction (ie, "cardiac induction"): 10 to 25 mcg/kg. | Bolus dose(s): 25 to 50 mcg as needed. Maintenance infusion to supplement TIVA: 1 to 2 mcg/kg per hour.¶ | Bolus doses: 25 to 50 mcg. | High-dose fentanyl is not commonly used for anesthetic induction, but may be selected for patients with severe myocardial dysfunction. Continuous infusions are not commonly used if extubation is planned at the end of the procedure because emergence may be delayed due to a long context-sensitive half time. | Bolus doses: 25 to 50 mcg every five minutes until patient is comfortable. |
| Remifentanil | Remifentanil intubation technique without an NMBA: 3 to 5 mcg/kg administered with an induction dose of propofol and ephedrine 10 mg. | Maintenance infusion to supplement inhalation anesthesia or TIVA: 0.05 to 0.3 mcg/kg per minute. (Some clinicians administer a loading dose, typically 0.5 to 1 mcg/kg over 60 to 90 seconds.) | Before placement of regional block:
Maintenance dose: Infusion at 0.05 to 0.3 mcg/kg per minute. | A different opioid or another analgesic agent or technique should be initiated before the remifentanil infusion is discontinued to ensure adequate postoperative analgesia. | |
| Sufentanil | Bolus dose(s): 0.05 to 0.1 mcg/kg in divided doses. High-dose opioid induction (ie, "cardiac induction"): 1 to 3 mcg/kg. | Bolus dose(s): 5 to 10 mcg as needed. Maintenance infusion to supplement TIVA: 0.05 to 0.15 mcg/kg per hour (or 0.0008 to 0.0025 mcg/kg per minute). | Infusion is typically discontinued 30 to 45 minutes prior to end of surgery for a predictable decline in concentration. | ||
| Alfentanil | Bolus dose(s): 500 mcg (which may be repeated), or 50 to 100 mcg/kg administered in divided doses. Maintenance: 0.5 to 1.5 mcg/kg per minute. | Bolus dose(s): 500 mcg as needed. Maintenance infusion to supplement TIVA: 0.5 to 1.5 mcg/kg per minute. | Infusion is typically discontinued 30 to 45 minutes prior to end of surgery for a predictable decline in concentration. | ||
| Hydromorphone | Bolus doses: 0.2 to 0.5 mg as needed. | It is ideal to use hydromorphone towards the end of surgery (rather than during surgery) in order to provide pain relief in the PACU and beyond. | Initial bolus doses of 0.2 to 0.5 mg every five minutes until pain is relieved or unwanted side effects become evident. After initial pain control, typical doses are 0.2 to 0.5 mg every three to four hours. | ||
| Morphine | Bolus doses: 1 to 2 mg as needed. | It is ideal to use morphine towards the end of surgery (rather than during surgery) in order to provide pain relief in the PACU and beyond. Typically, 1 to 2 mg increments to a total of approximately 0.05 to 0.2 mg/kg IBW are administered about 20 minutes prior to the expected time of extubation. | Initial bolus doses of 1 to 3 mg every five minutes until pain is relieved or unwanted side effects become evident. After initial pain control, typical doses are 2 to 4 mg IV every three hours. | ||
| Methadone | 0.1 to 0.2 mg/kg (ideal body weight) IV up to 20 mg, given post-induction. | A single post-induction dose has been shown to have overall opioid-sparing effects throughout the perioperative period in various surgical populations. Evidence is equivocal regarding whether a single post-induction dose results in clinically significant respiratory depression. Data is lacking on the effect of a single dose of methadone on QTc. Consider other options for patients with underlying prolonged QTc. | Repeat dosing is not recommended as redistribution half-life is relatively short (approximately 1 minute), but once exceeded the elimination half-life is much longer (approximately 30 hours). |
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