Fospropofol and remimazolam

Efficacy and safety of remimazolam compared with propofol in hypertensive patients undergoing breast cancer surgery: a single-center, randomized, controlled study

BACKGROUND

Remimazolam, as a novel anesthetic, has recently been shown to improve hemodynamic stability during anesthesia induction and maintenance; however, it has not been reported in the hypertensive population. This study aimed to compare the effects of remimazolam and propofol on hemodynamic stability in hypertensive patients undergoing breast cancer surgery.

METHODS

We enrolled 120 hypertensive patients undergoing breast cancer surgery in this prospective study and randomly allocated them to remimazolam (n = 60) or propofol (n = 60) groups. Anesthesia regimens were consistent between groups, except for the administration of remimazolam and propofol. Our primary outcome was the incidence of post-induction hypotension, which was either an absolute mean arterial pressure (MAP) < 60 mmHg or a > 30% relative drop in MAP compared to baseline within 20 min of induction or from induction to the start of surgery. Secondary outcomes included minimum MAP and MAP at different time points during anesthesia, the application of vasoactive drugs, adverse events, and the patient's self-reported Quality of Recovery-40 scale for the day after surgery.

RESULTS

The incidence of post-induction hypotension was lower and the minimum MAP during induction was higher in the remimazolam group than those in the propofol group. There were no significant differences between the two groups in the remaining outcomes.

CONCLUSION

Remimazolam is safe and effective in hypertensive patients undergoing breast cancer surgery. Induction with remimazolam in hypertensive patients may result in more stable hemodynamics than propofol.

TRIAL REGISTRATION

This study was registered at the Chinese Clinical Trials Registry ( http://www.chictr.org.cn ) on 03/12/2020, with registration number ChiCTR2000040579.

Nonoperating Room Anesthesia: Anesthesia in the Gastrointestinal Suite

Exponential growth in endoscopy suite procedures due to technological advances requires teamwork between anesthesiologists, endoscopists, nursing teams, and technical and support staff. The current standard of care for moderate sedation includes a combination of anxiolytic drugs and analgesic drugs and sometimes are not adequate to ensure patient safety, efficiency, and comfort. The use of anesthesia services can improve safety, recovery, turnovers, and efficiency. The article discusses comprehensive preoperative evaluation, optimization of comorbidities, and intraoperative airway management strategies to deliver safe and efficient anesthesia, given the need to share the airway and allow the use of carbon dioxide in the gastrointestinal suite.

Metabolic Profiles of Propofol and Fospropofol: Clinical and Forensic Interpretative Aspects

Propofol is an intravenous short-acting anesthetic widely used to induce and maintain general anesthesia and to provide procedural sedation. The potential for propofol dependency and abuse has been recognized, and several cases of accidental overdose and suicide have emerged, mostly among the health professionals. Different studies have demonstrated an unpredictable interindividual variability of propofol pharmacokinetics and pharmacodynamics with forensic and clinical adverse relevant outcomes (e.g., pronounced respiratory and cardiac depression), namely, due to polymorphisms in the UDP-glucuronosyltransferase and cytochrome P450 isoforms and drugs administered concurrently. In this work the pharmacokinetics of propofol and fospropofol with particular focus on metabolic pathways is fully reviewed. It is concluded that knowing the metabolism of propofol may lead to the development of new clues to help further toxicological and clinical interpretations and to reduce serious adverse reactions such as respiratory failure, metabolic acidosis, rhabdomyolysis, cardiac bradyarrhythmias, hypotension and myocardial failure, anaphylaxis, hypertriglyceridemia, renal failure, hepatomegaly, hepatic steatosis, acute pancreatitis, abuse, and death. Particularly, further studies aiming to characterize polymorphic enzymes involved in the metabolic pathway, the development of additional routine forensic toxicological analysis, and the relatively new field of ‘‘omics” technology, namely, metabolomics, can offer more in explaining the unpredictable interindividual variability.

Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers

Understanding the pharmacologic options for pediatric sedation outside the operating room will allow practitioners to formulate an ideal anesthetic plan, allaying anxiety and achieving optimal immobilization while ensuring rapid and efficient recovery. The authors identified relevant medical literature by searching PubMed, MEDLINE, Embase, Scopus, Web of Science, and Google Scholar databases for English language publications covering a period from 1984 to 2017. Search terms included pediatric anesthesia, pediatric sedation, non-operating room sedation, sedation safety, and pharmacology. As a narrative review of common sedation/anesthesia options, the authors elected to focus on studies, reviews, and case reports that show clinical relevance to modern day sedation/anesthesia practice. A variety of pharmacologic agents are available for sedation/anesthesia in pediatrics, including midazolam, fentanyl, ketamine, dexmedetomidine, etomidate, and propofol. Dosing ranges reported are a combination of what is discussed in the reviewed literature and text books along with personal recommendations based on our own practice. Several reports reveal that ketofol (a combination of ketamine and propofol) is quite popular for short, painful procedures. Fospropofol is a newer-generation propofol that may confer advantages over regular propofol. Remimazolam combines the pharmacologic effects of remifentanil and midazolam. A variety of etomidate derivatives such as methoxycarbonyl-etomidate, carboetomidate, methoxycarbonyl-carboetomidate, and cyclopropyl-methoxycarbonyl metomidate are in development stages. The use of nitrous oxide as a mild sedative, analgesic, and amnestic agent is gaining popularity, especially in the ambulatory setting. Utilizing a dedicated and experienced team to provide sedation enhances safety. Furthermore, limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans.