While many believe (including myself) believe that remi is a relatively expensive drug, with limited applications, I do believe it has a role in certain cases.

As a student, one of the places where I trained was a new outpatient surgery center where the chief MDA only allowed TIVA. Our starting dose for GA was 80mcg/kg/min of prop with 0.2mcg/kg/min of remi. I never saw any major problems with remi at this dose - sometimes you would see minor bradycardia (HRs in 50s) but nothing too scary.

However, the other day at one of my sites where I now work as a CRNA, the chief CRNA was going on this tirade (in the break room) about how people start their remi gtt's way too high. He pointed out in some book that the starting dose was 0.05mcg/kg/min and he said he never ran any patient at a rate higher than 1mcg/kg.min. I failed to see the advantage of starting super low.

So, here's my questions for all your remi experts, for GA cases where the remi is being used to cover transient stimulation (i.e. pneumo with lap surgery) in lieu of other narcotics or beta blockers:

At what rate are you starting your remi and how do you titrate it during the case (witha PIA on board)?