FENTANYL AND REMIFENTANIL IN ANESTHETIC PRACTICE: AN INTEGRATIVE REVIEW OF DIRECT AND INDIRECT EVIDENCE FROM RANDOMIZED CLINICAL TRIALS
DOI:
https://doi.org/10.66104/f7w0py51Keywords:
Fentanyl, Remifentanil, Anesthesia, Perioperative analgesiaAbstract
The rational choice between fentanyl and remifentanil in anesthetic practice remains controversial, given the pharmacokinetic differences impacting analgesic efficacy and perioperative safety. The study aimed to comparatively analyze the efficacy and safety of these opioids through an integrative literature review. The search was conducted in PubMed and EBSCO Host (with MEDLINE accessed through PubMed), on November 25, 2025, applying the Population, Intervention, Comparison, Outcome (PICO) strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart, including randomized clinical trials published between 2015 and 2025, in Portuguese or English. Selection was conducted by three reviewers in independent stages. A total of 407 records were identified, of which 15 studies met the eligibility criteria — four with direct comparison between fentanyl and remifentanil (Group A) and eleven with indirect evidence (Group B) — all with level 2 evidence according to the Agency for Healthcare Research and Quality (AHRQ). A semi-structured risk-of-bias assessment was performed covering six methodological domains. At titrated sedative doses under balanced general anesthesia, fentanyl and remifentanil presented equivalent analgesic efficacy and hemodynamic stability in healthy adult patients. Remifentanil was associated with greater cardiovascular instability during pharmacological transitions and a high incidence of respiratory depression (25%) in geriatric patients under conscious sedation, evidence derived from comparison with dexmedetomidine. Remifentanil presented contextual advantage in short-duration outpatient procedures, conditioned upon multimodal transition analgesia. Indirect evidence favors fentanyl in major surgeries, neurosurgery, and as an obstetric neuraxial adjuvant, although the absence of direct comparisons limits definitive inferences. Limitations included the scarcity of direct comparisons, heterogeneity of comparators, and follow-up restricted to immediate recovery. It is concluded that fentanyl and remifentanil constitute complementary pharmacological tools, whose selection requires individualization contextualized to the patient and the procedure.
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Copyright (c) 2026 Lucas Stêvão Oliveira Crêspo, José Ferreira de Sousa Netto, Wenno de Melo Cadete, Antonio Fernando de Souza Leão Neto, Wagner Breitner de Araujo Pinheiro Filho, João Gabriel Lucena Silva
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