Intravenous and inhalational agents: stopping a remifentanil infusion: practice question

A Anaesthesia question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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Anaesthesia · Intravenous and inhalational agents: stopping a remifentanil infusion

Sample item

After a four-hour high-dose remifentanil infusion for spine surgery, the infusion is stopped at skin closure with no other analgesic. Within minutes the patient wakes in severe pain. What should have been done?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

B. Start a longer-acting analgesic before stopping the infusion, since remifentanil offset is very rapid

Remifentanil is broken down by non-specific esterases, so its effect disappears within minutes of stopping regardless of the duration of infusion. Analgesia must be provided in advance with a longer-acting opioid or other measures, and acute tolerance and hyperalgesia after high doses add to the problem.

Option by option

  • A. Double the infusion rate at the end to prevent acute tolerance

    Increasing the dose at the end would not prevent the rapid offset and would add to hyperalgesia.

  • B. Start a longer-acting analgesic before stopping the infusion, since remifentanil offset is very rapid (correct)

    Correct. Because offset is within minutes, the next analgesic must be on board first.

  • C. Give naloxone before the end of surgery to avoid accumulation of a metabolite

    Remifentanil does not accumulate; naloxone would worsen pain.

  • D. Give neostigmine to overcome plasma cholinesterase deficiency

    Plasma cholinesterase is not the main enzyme, and neostigmine would inhibit rather than help.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this Anaesthesia question

What is the answer to this Anaesthesia question?

The best answer is B, Start a longer-acting analgesic before stopping the infusion, since remifentanil offset is very rapid. Remifentanil is broken down by non-specific esterases, so its effect disappears within minutes of stopping regardless of the duration of infusion.

Why is "Double the infusion rate at the end to prevent acute tolerance" not the answer?

Increasing the dose at the end would not prevent the rapid offset and would add to hyperalgesia.

Why is "Give naloxone before the end of surgery to avoid accumulation of a me…" not the answer?

Remifentanil does not accumulate; naloxone would worsen pain.

Why is "Give neostigmine to overcome plasma cholinesterase deficiency" not the answer?

Plasma cholinesterase is not the main enzyme, and neostigmine would inhibit rather than help.

What concept does this question test?

It tests Intravenous and inhalational agents: stopping a remifentanil infusion in Anaesthesia. Analgesia must be provided in advance with a longer-acting opioid or other measures, and acute tolerance and hyperalgesia after high doses add to the problem.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Intravenous and inhalational agents: stopping a remifentanil infusion?

Make a table of each agent, its key advantage and its main side effect. Then use the flashcards and the other Anaesthesia questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.