Remifentanil Induced Bradycardia In A Β-Blocked Patient With Grave'S Disease.

Proposal Number:


Proposal Type:

Medically Challenging Case Report Poster 


Mitchell Kerfeld  
Mayo Clinic


Yvette Martin McGrew  
Mayo Clinic


chronic Beta Blocker use, Intraoperative Bradycardia

Learning Objectives:
1. Review the pharmacology of remifentanil and beta blockers
2. Identify and treat hemodynamic instability caused by remifentanil and beta blockers
3. Review management of anticipated difficult airways in emergent situations

Case Description:
35-year-old female with Grave's disease on methimazole and propranolol, underwent thyroidectomy. 12-hours later she returned to the operating room for evacuation of an anterior cervical hematoma. Her first anesthetic with remifentanil + propofol maintenance was remarkable for hypotension and bradycardia (MAP 42, HR 30). For the surgical evacuation of the cervical hematoma, remifentanil and propofol was also used for maintenance. Twenty minutes after induction, patient became hypotensive and bradycardic (HR 50's). This was refractory to ephedrine administration and exacerbated by phenylephrine administration. The bradycardia and hypotension responded to atropine and fluid administration. Patient was monitored in the ICU overnight due to airway edema. This response was similar to what was seen with Elliott et al. during bolus administration of remifentanil during induction of CV surgery patients, which was terminated after inclusion of only 8 patients due to safety concerns(1).

Graves's disease is managed with methimazole and high dose propranolol. Remifentanil use in the setting of chronic beta blocker use has the potential to exacerbate the bradycardic effects of remifentanil and can be refractory to standard treatment. Care should be taken when utilizing remifentanil in the setting of chronic beta blockers.

Professional Category:



OR Management/Administration

Enter up to two references.

1. 1. Elliott, Peter, Ronan O’Hare, K. Moyna Bill, Anne S. Phillips, Fiona M. Gibson, and Rajinder K. Mirakhur. "Severe cardiovascular depression with remifentanil." Anesthesia & Analgesia 91, no. 1 (2000): 58-61.