Clinical effects of remimazolam alone or in combination with dexmedetomidine in patients receiving bronchoscopy and influences on postoperative cognitive function: a randomized-controlled trial

Comparison of the efficacy and safety of remimazolam and propofol for fiberoptic bronchoscopy in older patients: a prospective, randomized controlled study

OBJECTIVE

The aim of this study was to compare the efficacy and safety of remimazolam with those of propofol in older patients undergoing fiberoptic bronchoscopy with preserved spontaneous breathing.

METHODS

Sixty older patients were randomly and equally divided into a remimazolam group (group R) and a propofol group (group P). Both groups received 0.15 µg/kg of sufentanil for analgesia. Group R received an initial dose of 0.2 mg/kg remimazolam and was injected with a maintenance dose of 1 mg/kg/h. Group P received an initial dose of 2 mg/kg propofol and was injected with a maintenance dose of 4 mg/kg/h. The primary evaluation indicators were the success rate of sedation and the incidence of hypotension. The secondary evaluation indicators were respiratory depression, hypertension, tachycardia, bradycardia, awakening time, quality of recovery-15 (QOR-15) score, patient satisfaction, physician satisfaction, and adverse events.

RESULTS

Success rates of sedation were similar between group R (96.7%) and group P (100%). The incidence of hypotension in group R was lower than that in group P (2/30 vs. 10/30, p = 0.01). Respiratory depression was lower in group R than in group P (3/30 vs. 10/30, p = 0.03). Fewer patients reported injection pain in group R (0/30 vs. 7/30, p = 0.01). There were no significant differences in hypertension, tachycardia, bradycardia, awakening time, QoR-15 score, patient satisfaction, physician satisfaction, or adverse events between the two groups.

CONCLUSIONS

Remimazolam has a high sedation success rate for painless fiberoptic bronchoscopy in older patients, and the incidence of hypotension and respiratory depression is lower than that of propofol. Remimazolam may be a better choice for sedation during painless fiberoptic bronchoscopy in older patients with preserved spontaneous breathing.

TRIAL REGISTRATION

ChiCTR2300069041; 6/3/2023.

The safety and efficacy of remimazolam, ciprofol, and propofol anesthesia in endoscopy: a systematic review and network meta-analysis

BACKGROUND

While propofol remains widely used for endoscopic sedation, its cardiovascular depression and injection pain limitations have prompted exploration of novel agents (remimazolam, ciprofol). This study aimed to compare their safety and efficacy profiles systematically.

METHODS

We conducted a network meta-analysis to evaluate remimazolam, ciprofol, and propofol for gastrointestinal endoscopy. Bayesian random-effects models were used to estimate relative risks (RR) and mean differences (MD) with 95% credible intervals(CrI).

RESULTS

Forty-two randomized controlled trials (N = 10,540 patients) were included. Remimazolam demonstrated superior cardiovascular safety (RR = 0.44, 95%CrI 0.35-0.54 vs propofol) and lowest respiratory depression risk (RR = 0.36, 0.28-0.46). Propofol showed faster recovery (MD -14.22 min, -2.35 to -30.83 vs remimazolam). Both remimazolam (RR = 0.045) and ciprofol (RR = 0.054) significantly reduced injection pain versus propofol.

CONCLUSION

Remimazolam should be prioritized for high-risk patients (cardiovascular/respiratory comorbidities) despite slightly longer recovery times. Propofol remains suitable for low-risk procedures requiring rapid turnover, while ciprofol offers balanced efficacy for endoscopy.

TRIAL REGISTRATION

The study was registered with the UK National Institute for Health Research's PROSPERO platform (CRD42024569405; https://www.crd.york.ac.uk/prospero/ ).

Effect of remimazolam on postoperative delirium and cognitive function in adults undergoing general anesthesia or procedural sedation: a meta-analysis of randomized controlled trials

BACKGROUND

Remimazolam is a novel short-acting benzodiazepine. This study compared the effects of remimazolam and propofol on cognitive function in adult patients after surgery or other procedures.

METHODS

We searched electronic databases, including PubMed, Embase, CENTRAL, Web of Science, and Scopus, for relevant studies. The primary outcome was the proportion of participants who experienced delirium or impaired cognitive function postoperatively. Secondary outcomes included the incidence of hypotension, bradycardia, and postoperative nausea and vomiting. We estimated the odds ratios (OR) and mean differences (MD) with 95% CIs using a random-effects model.

RESULTS

In total, 1295 patients from 11 randomized controlled trials were included. The incidence of postoperative delirium was 8.0% in the remimazolam group and 10.4% in the propofol group that was not significantly different (OR: 0.74, 95% CI [0.39-1.42], P = 0.369, I2 = 32%). More favorable cognitive function, as assessed using the Mini-Mental State Examination, was observed in the remimazolam group compared to the propofol group (MD: 1.06, 95% CI [0.32-1.80], P = 0.005, I2 = 89%). Remimazolam lowered the incidence of hypotension (OR: 0.28, 95% CI [0.21-0.37], P = 0.000, I2 = 0%) compared to propofol.

CONCLUSIONS

Remimazolam did not increase the risk of postoperative delirium and maintained cognitive function well, providing hemodynamic stability during surgery compared to propofol.

Remimazolam for procedural sedation: A systematic review with meta-analyses and trial sequential analyses

BACKGROUND

Midazolam and propofol are frequently used for procedural sedation. Remimazolam may provide a more controllable sedation with fewer adverse effects.

OBJECTIVE

To assess the sedation success rate and respiratory and cardiovascular complications of remimazolam versus placebo and other sedatives in adults undergoing procedural sedation.

DESIGN

A systematic review of randomised controlled trials (RCTs) with meta-analyses, trial sequential analyses (TSA), and GRADE evaluations of the certainty of evidence.

DATA SOURCES

We searched Medline, Embase, CENTRAL, BIOSIS, CINAHL, and Web of Science Core Collection from their inception to 22 June 2024.

ELIGIBILITY CRITERIA

RCTs allocating participants undergoing procedural sedation to remimazolam versus placebo or any active comparator.

RESULTS

We included 63 trials randomising 13 953 participants. All included trial results were judged to be at high risk of bias. The sedation success rate was similar with remimazolam versus active comparators, relative risk (RR) 1.04, [97.5% confidence interval (CI), 0.96 to 1.14; TSA-adjusted CI, 0.95 to 1.18], P   =  0.26, GRADE: very low. Subgroup analyses indicated that remimazolam versus midazolam increased sedation success rate, while the risks were similar with remimazolam versus comparators. Remimazolam versus active comparators decreased the risk of respiratory complications, RR 0.47, (97.5% CI, 0.36 to 0.61; TSA-adjusted CI, 0.35 to 0.61), P  < 0.01; and cardiovascular complications, RR 0.46, (97.5% CI, 0.37 to 0.56; TSA-adjusted CI, 0.38 to 0.57), P  < 0.01. Subgroup analyses indicated that remimazolam versus propofol reduced respiratory and cardiovascular complications, while the risks were similar versus midazolam.

CONCLUSION

Remimazolam seems to provide a similar sedation success rate as other active comparators (propofol, ciprofol, midazolam, dexmedetomidine, etomidate), although subgroup analyses indicated that remimazolam increased sedation success rate compared to midazolam. Remimazolam compared to propofol may decrease the risk of respiratory and cardiovascular complications. The certainty of the evidence was very low to low, and firm conclusions could not be drawn.

Association of remimazolam with delirium and cognitive function: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND AND STUDY OBJECTIVE

Delirium is an organic mental syndrome significantly associated with long-term cognitive decline, increased hospital stays and higher mortality. This systematic review of randomised controlled trials (RCTs) with meta-analysis assesses the association of remimazolam with postoperative cognitive function and delirium compared with non-benzodiazepine hypnotics.

DESIGN

Systematic review of RCTs with meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library and Web of Science databases up to 27 April 2024.

ELIGIBILITY CRITERIA

Adult patients undergoing general anaesthesia or sedation procedures; use of remimazolam as the primary hypnotic or as an adjunct, administered via intermittent bolus or continuous infusion; comparison with other hypnotics or sedatives; evaluation of cognitive function or delirium.

MAIN RESULTS

Twenty-three RCTs with 3598 patients were included. The incidence of delirium was not significantly different between remimazolam and other sedatives in general anaesthesia and sedation procedures [ n  = 3261; odds ratio (OR) = 1.2, 95% confidence interval (CI), 0.76 to 1.91; P  = 0.378843; I2  = 17%]. Regarding cognitive function evaluation, remimazolam showed no difference compared with the control group in Mini-Mental State Examination (MMSE) scores on the first postoperative day ( n  = 263; mean difference = 0.60, 95% CI, -1.46 to 2.66; P  = 0.5684; I2  = 90%) or on the third postoperative day ( n  = 163; mean difference  = 1.33, 95% CI, -0.72 to 3.38; P  = 0.2028; I2  = 93%). Remimazolam exhibited superiority over the control group in MMSE scores on the seventh postoperative day ( n  = 247; mean difference = 0.53, 95% CI, 0.30 to 0.75; P  < 0.0001; I2  = 28%).

CONCLUSION

Remimazolam does not increase the incidence of delirium or cognitive impairments compared with non-benzodiazepine hypnotics. However, the analysis showed that the type of surgery significantly influenced the incidence of delirium. Additionally, remimazolam was associated with better short-term postoperative cognitive function.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42024532751.

Effect of intraoperative intravenous remimazolam on the postoperative quality of recovery after noncardiac surgery: A meta-analysis of randomized controlled trials

OBJECTIVES

The postoperative quality of recovery holds significant economic and prognostic implications. Numerous studies have investigated the postoperative quality of recovery following surgery. However, the impact of intraoperative intravenous remimazolam on postoperative recovery has yielded conflicting results.

METHODS

In this qualitative review of randomized controlled clinical trials assessing the use of intraoperative remimazolam, we present the effects of intravenous remimazolam on postoperative recovery quality in noncardiac surgery patients. We conducted a comprehensive search of PubMed, MEDLINE, Web of Science and Cochrane Library for randomized controlled trials published up to September 23, 2024, without any language restrictions, to investigate the impact of intraoperative intravenous remimazolam on the quality of postoperative recovery following noncardiac surgery. The primary outcome measure was the quality of postoperative recovery assessed using global QoR-40 scores or QoR-15 scores. Secondary outcomes included five dimensions of quality of postoperative recovery: physical comfort, emotional state, physical independence, psychological support, and pain. As well as time to extubation, VAS score, PACU stay, and days in hospital. We analyzed the pooled data using a random-effects model.

RESULTS

This meta-analysis included 18 studies published between 2022 and 2024 involving 1720 patients. The quality of postoperative recovery was assessed using the QoR-15 or QoR-40 questionnaires. The pooled results showed no significant difference in QoR scores between the two groups on the first postoperative day (SMD =  0.12; 95% CI -0.13-0.36; I2 = 78%; p =  0.35). Furthermore, differences in QoR dimensions, PACU duration, extubation time, and length of hospital stay were not observed.

CONCLUSION

Our analysis showed that the quality of recovery after general anaesthesia in the remimazolam group was similar to that of conventional sedation. Therefore, remimazolam may be used as a potential anaesthetic agent as an alternative to conventional sedation for non-cardiac surgical anaesthesia.

Remimazolam Combined with Andrographolide Improve Postoperative Cognitive Dysfunction in Rats after Cardiopulmonary Bypass through the AMPK/SIRT1 Signaling Pathway

INTRODUCTION

The effects of remimazolam (Re) in combination with andrographolide (AP) on learning, memory, and motor abilities in rats following cardiopulmonary bypass (CPB) surgery were studied.

METHODS

We hypothesized that the combination of Re and AP could improve postoperative cognitive dysfunction (POCD) in rats after CPB by modulating nervous system inflammation. Cognitive function was assessed using the Morris Water Maze test, and the concentrations of tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6) in serum were measured by enzyme-linked immunosorbent assay (ELISA). Apoptosis was evaluated using western blotting and the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end labeling (TUNEL) staining assay.

RESULTS

The results indicated that both Re and AP independently improved cognitive function in rats after CPB and inhibited the secretion of inflammatory factors and apoptosis in hippocampal tissues. Combined administration of Re and AP enhanced the alleviation of POCD compared with monotherapy. The adenosine monophosphate-activated protein kinase/silent information regulator of transcription 1 (AMPK/SIRT1) signaling pathway was activated by the combination of Re and AP.

CONCLUSIONS

Collectively, the combination of Re and AP treatment significantly improves POCD in rats after CPB through activation of the AMPK/SIRT1 signaling pathway.

Effectiveness and safety of remimazolam tosilate versus propofol for sedation in patients undergoing gastrointestinal endoscopy: a randomized controlled trial

BACKGROUND

Remimazolam tosilate is a new type of benzodiazepine currently used for gastrointestinal endoscopy and can be combined with alfentanil.

AIM

This trial compared the effectiveness and safety of remimazolam with alfentanil to propofol with alfentanil in patients undergoing gastrointestinal endoscopy.

METHOD

One hundred and sixty-six patients were randomly divided into propofol-alfentanil anaesthesia (Group P) and remimazolam-alfentanil anaesthesia (Group R). The primary outcomes were perioperative haemodynamic variables, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and oxygen saturation (SpO2) preoperatively (T0); after anaesthesia induction (T1); when the gastroscope passed through the oropharynx (T2); 3 min (T3), 5 min (T4) and 7 min (T5) after T2; at the end of surgery (T6); and when patients successfully awakened (T7). The secondary outcomes included induction and awakening time, patient satisfaction, operator satisfaction, and adverse event occurrences.

RESULTS

Compared with those in Group P, the SBP in Group R was significantly higher at T1, T2, T3, and T6 (P < 0.05); the DBP and MAP were significantly higher at T1, T2, T3, T5, and T6 (P < 0.05); the HR was significantly faster at T1 to T6 (P < 0.05); the SpO2 was significantly higher at T1 to T4 (P < 0.05); the incidences of hypoxemia, hypotension, and drug injection pain were significantly lower in Group R (P < 0.05); the incidence of hiccups was higher (P < 0.05); the awakening time was shorter in Group R (P < 0.05); and the operator satisfaction score was high (P < 0.05).

CONCLUSION

Compared to propofol with alfentanil, remimazolam with alfentanil can be used safely and effectively for sedation in patients undergoing gastrointestinal endoscopy, with less impact on the patient's circulatory and respiratory systems and a lower incidence of adverse events.

TRIAL REGISTRATION

This trial protocol was registered in the Chinese Clinical Trial Registry (ChiCR2300077252, date: 2023-11-02).

Comparing Remimazolam and Propofol for Postoperative Anesthesia Satisfaction in Outpatient Gynecological Surgery: A Randomized Clinical Trial

Purpose

This study aimed to compare the efficacy of remimazolam and propofol regarding postoperative anesthesia satisfaction in patients undergoing outpatient gynecological surgery.

Patients and Methods

This was a single-center, open-label, non-inferiority, randomized clinical trial. Patients aged ≥ 18 years who underwent outpatient gynecological surgery with sedation were enrolled. Participants were randomly assigned to be sedated with remimazolam or propofol. The primary endpoint was the immediate postoperative anesthesia satisfaction score, evaluated through the Iowa Satisfaction with Anesthesia Scale (ISAS).

Results

168 patients were randomly allocated to either the remimazolam group (n = 84) or the propofol group (n = 84). The mean (standard deviation) ISAS scores immediately after surgery were 1.7 (0.6) for the remimazolam group and 2.0 (0.7) for the propofol group (difference, -0.2; 97.5% confidence interval [CI]: -0.5 to -0.0; p = 0.02), indicating non-inferiority. The length of post-anesthesia care unit (PACU) stay was longer in the remimazolam group than in the propofol group (27.6 [9.1] min vs 22.4 [7.0] min; difference, 5.2 [95% CI: 2.7 to 7.6] min; p < 0.001). High-intensity injection pain was less frequently observed in the remimazolam group than in the propofol group (3.6% vs 45.2%; difference, -41.7% [95% CI: -54.2% to -29.1%]; p < 0.001). The nausea score was higher in the remimazolam group immediately after surgery than in the propofol group. Pain, nausea, sleep quality, anxiety, and depression scores were higher in the remimazolam group than in the propofol group on postoperative day 1. The incidence of adverse events and other secondary endpoints was comparable between the two groups.

Conclusion

Remimazolam was non-inferior to propofol regarding postoperative anesthesia satisfaction in patients undergoing outpatient gynecological surgery. Therefore, it should be considered as a new sedation alternative in such procedures.

Opioid-free anesthesia attenuates perioperative immunosuppression by regulating macrophages polarization in gastric cancer patients treated with neoadjuvant PD-1 inhibitor

Background

Opioid anesthesia can modulate the impaired immune response and opioid-sparing anesthesia may preserve immune functions. This study was performed to assess the effects of opioid-free anesthesia (OFA) and opioid-based anesthesia (OA) on perioperative macrophages differentiation, cytokine changes, and perioperative complications in locally advanced GC (LAGC) patients.

Methods

We used quality of recovery-15 (QoR-15) questionnaire scores and visual analog scale (VAS) scores to compare postoperative quality of recovery and pain level. In addition, the adverse reactions of patients in the two groups were compared. The perioperative serum level of inflammatory cytokines and the ratio of macrophage subtypes were detected.

Results

The OFA group had significantly longer extubation time and PACU stay, whereas the OA group had significantly higher rate of hypotension, higher doses of norepinephrine, higher PONV and dizziness rate, and delayed flatus passage time. The QoR-15 score on postoperative 24 h was significantly higher in OFA group than in OA group. At the end of or after the surgery, the OFA group had higher levels of interleukin (IL)-12, IL-1β, tumor necrosis factor (TNF)-α, CD68+CD163- macrophage rate, but lower levels of IL-10, transforming growth factor (TGF)-β, and CD68+CD163+ macrophage rate, indicating OFA attenuated perioperative immunosuppression by diminishing M2 and promoting M1 macrophage polarization. And the reversal tendency is more obvious in LAGC patients with neoadjuvant PD-1 inhibitor.

Conclusions

The OFA may attenuate perioperative immunosuppression by diminishing M2 and promoting M1 macrophage polarization in LAGC patients with neoadjuvant PD-1 inhibitor.

Clinical trial registration

http://gcpgl.sysucc.org.cn, identifier 2022-FXY-001.

Knowledge, attitudes, and practices regarding Post-anesthesia cognitive dysfunction in patients undergoing gastrointestinal endoscopy

BACKGROUND

The administration of anesthesia during gastrointestinal endoscopy potentially contributes to post-anesthesia cognitive dysfunction (PACD), with detrimental impacts for cognitive function. This study aimed to assess the knowledge, attitudes, and practices (KAP) towards PACD among patients undergoing gastrointestinal endoscopy in Wenzhou region.

METHODS

This cross-sectional study was conducted between June and August 2023, and recruited individuals undergoing gastrointestinal endoscopy. Demographic data and KAP scores were collected through questionnaires. Pearson correlation analysis was applied to evaluate correlations between KAP scores, and logistic regression was utilized to identify influential factors.

RESULTS

We collected 405 valid questionnaires, with 54.57% being male and 29.88% aged 31-40 years. Mean KAP scores were 13.99 ± 4.80, 16.19 ± 2.35, and 15.61 ± 2.86, respectively (possible range: 0-16, 0-25, and 0-25). Pearson correlation analysis demonstrated significant positive correlations between knowledge and practice (r = 0.209, P < 0.001), attitude and practice (r = 0.233, P < 0.001), and knowledge and attitude (r = 0.328, P < 0.001). Multivariate logistic regression revealed negative associations of opting for standard gastrointestinal endoscopy (without anesthesia) with knowledge (OR = 0.227, 95%CI: 0.088-0.582, P = 0.002) and practice scores (OR = 0.336, 95%CI: 0.154-0.731, P = 0.006). Additionally, the presence of cognitive-related diseases or symptoms before undergoing gastrointestinal endoscopy was negatively associated with knowledge scores (OR = 0.429, 95%CI: 0.225-0.818, P = 0.010).

CONCLUSION

Patients undergoing gastrointestinal endoscopy demonstrated good knowledge, neutral attitudes, and moderate practices regarding PACD. Educational interventions and behavior modification are recommended, particularly for individuals with lower monthly income, undergoing standard gastrointestinal endoscopy, or experiencing cognitive-related conditions.

Benefits of remimazolam as an anesthetic sedative for older patients: A review

Owing to the decreased levels of receptors in the peripheral and central nervous systems, the functions of various organ systems decline in older patients. When administering anesthesia to older patients, it is necessary to consider the effects of medication on the homeostatic balance. Remimazolam, a new benzodiazepine, was recently developed as an anesthetic drug that has shown promise in clinical anesthesia application owing to its molecular structure, targets, pharmacodynamics, and pharmacokinetic characteristics. Remimazolam exhibits a rapid onset and metabolism, with minor effects on liver and kidney functions. Moreover, the drug has a specific antagonist, flumazenil. It is safer to use in older patients than other anesthetic sedatives and has been widely used since its introduction. Comparisons of the pharmacokinetics, metabolic pathways, effects on target organs, and hemodynamics of different drugs with those of commonly used anesthetic sedative drugs are useful to inform clinical practice. This article elaborates on the benefits of remimazolam compared with those of other anesthetic sedatives for sedation in older patients to demonstrate how it offers a new option for anesthetics in older patients. In cases involving older patients with increased clinical complexities or very old patients requiring anesthesia, remimazolam can be selected as the preferred anesthetic sedative, as outlined in this review.

Efficacy and safety of remimazolam in bronchoscopic sedation: A meta-analysis

BACKGROUND

Remimazolam is a new benzodiazepine used for procedural sedation and general anesthesia. Several studies have used remimazolam for bendable bronchoscopy.

AIM

To assess the safety and efficacy of remimazolam for sedation in patients undergoing bendable bronchoscopy by performing a meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched the EMBASE, PubMed, Cochrane Library, and Web of Science databases for RCTs on bendable bronchoscopic procedural sedation with remimazolam vs conventional sedatives (CS).

RESULTS

Five studies with 1080 cases were included. Remimazolam had the same sedation success rate compared with CS [relative risk (RR): 1.35, 95%CI: 0.60-3.05, P = 0.474, I2 = 99.6%]. However, remimazolam was associated with a lower incidence of hypotension (RR: 0.61; 95%CI: 0.40-0.95, P = 0.027; I2 = 65.1%) and a lower incidence of respiratory depression (RR: 0.50, 95%CI: 0.33-0.77, P = 0.002, I2 = 42.3%). A subgroup analysis showed a higher success rate of sedation with remimazolam than midazolam (RR: 2.45, 95%CI: 1.76-3.42, P < 0.001). Compared with propofol, the incidence of hypotension (RR: 0.45, 95%CI: 0.32-0.64, P < 0.001, I2 = 0.0%), respiratory depression (RR: 0.48, 95%CI: 0.30-0.76, P = 0.002, I2 = 78.4%), hypoxemia (RR: 0.36, 95%CI: 0.15-0.87, P = 0.023), and injection pain (RR: 0.04, 95%CI: 0.01-0.28, P = 0.001) were lower.

CONCLUSION

Remimazolam is safe and effective during bronchoscopy. The sedation success rate was similar to that in the CS group. However, remimazolam has a higher safety profile, with fewer inhibitory effects on respiration and circulation.

Effect of pre-use of Dexmedetomidine on the effective inhibitory dose of remimazolam tosilate on positive cardiovascular response in double-lumen endobronchial intubation: a clinical study

BACKGROUND

Herein, the effect of pre-use of Dexmedetomidine(Dex) on the half-effective dose (ED50) and 95%-effective dose (ED95) of Remimazolam tosilate(RT) in inhibiting the positive cardiovascular response(CR) which means blood pressure or heart rate rises above a critical threshold induced by double-lumen bronchial intubation was evaluated.

METHODS

Patients who underwent video-assisted thoracic surgery were divided into groups A (0), B (0.5 µg/kg), and C (1 µg/kg) based on different Dex doses. Group A included subgroups comprising young (A-Y) and elderly (A-O) patients. Neither groups B nor C included elderly patients due of the sedative effect of Dex. Based on the previous subject's CR, the dose of RT was increased or decreased in the next patient using the sequential method. This trial would be terminated when the seventh crossover occurred, at which point the sample size met the stable estimate of the target dose. Heart rate (HR) and mean arterial pressure (MAP) were monitored throughout the trial, and sedation was assessed using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. HR and MAP were recorded at baseline (T1), the end of Dex (T2), and the end of RT (T3), the maximum HR and MAP were recorded within 3 min of intubation from beginning to end (T4). There was a positive CR when the T4 levels rose above 15% of the baseline. The ED50/ED95 and corresponding confidence interval were calculated using probability regression.

RESULTS

In total, 114 patients completed the trial. Without the use of Dex, the ED50/ED95 of TR inhibiting the positive CR caused by double-lumen bronchial intubation was 0.198/0.227 and 0.155/0.181 mg/kg in groups A-Y and A-O, respectively. The changes in vital signs from T1 to T3 were similar in the subgroups, indicating that the elderly patients were more sensitive to the dose of RT. The ED50/ED95 of RT inhibiting the positive CR caused by double-lumen endobronchial intubation was 0.122/0.150 and 0.068/0.084 mg/kg in groups B and C, respectively. And, the fluctuation of blood pressure from T3 to T4 was reduced by using Dex. RT was 100% effective in sedation with no significant inhibition of circulation. Apart from one case of hypotension occurred in group A-Y, two cases of low HR in group B, and one case of low HR in group C, no other adverse events were noted.

CONCLUSIONS

The optimal dose of RT to inhibit positive CR induced by double-lumen bronchial intubation in elderly patients was 0.18 mg/kg and 0.23 mg/kg in younger patients. When the pre-use dose of Dex was 0.5 µg/kg, the optimal dose to inhibit positive CR of RT was 0.15 mg/kg. And, when the pre-use dose of Dex was 1 µg/kg, the optimal dose of RT was 0.9 mg/kg.

CLINICAL TRIAL REGISTRATION

NCT05631028.

Remimazolam and serious adverse events: A scoping review

Remimazolam is anticipated to be an interesting anaesthetic and sedative. It combines the pharmacodynamic properties of midazolam with pharmacokinetic properties similar to remifentanil. However, worrisome case reports of anaphylaxis, delayed emergence and re-sedation have emerged recently and necessitate further investigation.PubMed (including MEDLINE) and EMBASE were searched for all studies reporting serious adverse events where remimazolam was administered for sedation or anaesthesia.Thirty-six case reports and 73 trials were identified, involving a total of 6740 patients who received remimazolam. Hypotension was reported in 911 cases, delayed emergence in 68 cases, anaphylaxis in 10 cases and re-sedation in 8 cases. The incidence of hypotension seems to be lower compared with other anaesthetics, even in high-risk patients.Delayed emergence might be related to the metabolism of remimazolam through carboxylesterase 1 (CES1), a tissue esterase predominant in the liver. There is significant interindividual variation, and it is inhibited by flavonoids, fatty acids and alcohol. Individual benzodiazepine sensitivity has also been reported. A higher BMI, older age and low plasma albumin concentration are risk factors for delayed emergence. Anaphylaxis might be related to a non-IgE-mediated effect of the excipient dextran-40 or a partially IgE-mediated reaction to remimazolam itself. Resedation has been reported after flumazenil reversal and is explained by the specific pharmacokinetic properties of flumazenil and remimazolam. Reversal by flumazenil should be reserved for and used carefully in patients with delayed emergence.

VISUAL ABSTRACT

http://links.lww.com/EJA/A864 .

Monitored Anesthesia Care Under a Combination of Low-Dose Remimazolam Infusion and Flumazenil Antagonism: A Case Report

Remimazolam is a novel benzodiazepine known for its short-acting properties. The safe use of flumazenil antagonism following remimazolam infusion remains a subject of debate. We present a case of monitored anesthesia care managed to be safe through low-dose remimazolam infusion and flumazenil antagonism. Pharmacokinetic simulations revealed that low-dose remimazolam was practically useful as one of the components of multimodal sedation/analgesia. Subsequent sedation with the readministration of remimazolam after a dose of flumazenil could also be attained.

Effect of Dexmedetomidine and Two Different Doses of Esketamine Combined Infusion on the Quality of Recovery in Patients Undergoing Modified Radical Mastectomy for Breast Cancer - A Randomised Controlled Study

Purpose

This study evaluated the effect of a combined infusion of dexmedetomidine and esketamine on the quality of recovery in patients undergoing modified radical mastectomy.

Methods

A total of 135 patients were randomly divided into three groups: dexmedetomidine group (group D) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion), dexmedetomidine plus low-dose esketamine group (group DE1) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion) and esketamine (0.5 mg/kg loading, 2 µg/kg/min infusion), dexmedetomidine plus high-dose esketamine group (group DE2) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion) and esketamine (0.5 mg/kg loading, 4 µg/kg/min infusion). The primary outcome was the overall quality of recovery-15 (QoR-15) scores at 1 day after surgery. The secondary endpoints were total QoR-15 scores at 3 days after surgery, propofol and remifentanil requirement, awaking and extubation time, postoperative visual analogue scale (VAS) pain scores, rescue analgesic, nausea and vomiting, bradycardia, excessive sedation, nightmares, and agitation.

Results

The overall QoR-15 scores were much higher in groups DE1 and DE2 than in groups D 1 and D 3 days after surgery (P < 0.05). VAS pain scores at 6, 12, 24 h postoperatively, propofol and remifentanil requirements were significantly lower in groups DE1 and DE2 than in group D (P < 0.05). Compared with group D, awaking time, extubation time, and post-anesthesia care unit (PACU) stay were significantly prolonged in groups DE1 and DE2 (P < 0.05) and were much longer in group DE2 than in group DE1 (P < 0.05). The proportion of postoperative rescue analgesics and bradycardia was higher and the incidence of excessive sedation was lower in group D than in groups DE1 and DE2 (P < 0.05).

Conclusion

Dexmedetomidine plus esketamine partly improved postoperative recovery quality and decreased the incidence of bradycardia but prolonged awaking time, extubation time, and PACU stay, especially dexmedetomidine plus 4 µg/kg/min esketamine.