Correlation of Vital Signs and Depth of Sedation by Modified Observer's Assessment of Alertness and Sedation (MOAA/S) Scale in Bronchoscopy

Efficacy of adjuvant dexmedetomidine on penile block for pediatric hypospadias repair

INTRODUCTION

The management of postoperative pain, particularly in younger children, presents a challenge due to their limited ability to articulate the intensity of pain, lower pain threshold, and restricted availability of approved analgesics for pediatric use. Peripheral nerve blocks may be favored over neuraxial blocks because they allow quicker mobilization after surgery.

OBJECTIVE

The present study aims to investigate the potential impact of adding dexmedetomidine to a local anesthetic (bupivacaine) on the analgesic efficacy in dorsal penile nerve block in hypospadias repair surgery.

METHOD

In this prospective double-blinded clinical trial, 50 children aged between 6 months and 6 years old undergoing hypospadias repair surgery participated. Analgesia was administered through a dorsal penile nerve block (DPNB) at the end of surgery. Participants were divided into two groups; one received bupivacaine alone, and the other received dexmedetomidine and bupivacaine in DPNB. Pain and sedation levels were assessed with FLACC score and MOAA/S score, respectively, at 0,1,2 and 4 h after surgery. Vital signs and adverse effects were also recorded, including hemodynamic changes, nausea, and vomiting.

RESULT

There was no statistically significant difference in demographic variables. As illustrated in Figure, the median of FLACC score in group BD was significantly lower compared to group B at every measured time point. MOAA/S score was significantly lower in group BD than in group B (p < 0.001), indicating a higher sedation level. None of the participants in either group experienced any adverse effect except for vomiting, which was not statistically significant (8 % in group B vs. 4 % in group BD, p > 0.999).

DISCUSSION

Several studies have documented the supplementary analgesic properties of dexmedetomidine when used in conjunction with local anesthetic during various surgical procedures and nerve blocks. The present study provides evidence for the additional analgesic efficacy of dexmedetomidine and bupivacaine in the context of dorsal penile nerve block during hypospadias repair surgery while not yielding any significant adverse outcomes. Although the patients in our study were monitored for 4 h in the postanesthesia care unit (PACU), conducting a more comprehensive assessment of patients is advisable.

CONCLUSION

The findings of our study indicate that incorporating dexmedetomidine alongside bupivacaine in dorsal penile nerve block during hypospadias repair surgery may lead to enhanced management of postoperative pain. The lack of adverse effects implies it may be a potentially safe supplementary pain reliever for surgical procedures.

The Safety and Efficacy of Remimazolam Compared to Dexmedetomidine for Awake Tracheal Intubation by Flexible Bronchoscopy: A Randomized, Double-Blind, Controlled Trial

Background

Remimazolam is a novel ultra-short-acting benzodiazepine sedative that has the potential to be an alternative for procedural sedation due to its rapid sedation and recovery, no accumulation effect, stable hemodynamics, minimal respiratory depression, anterograde amnesia effect, and specific antagonist. Here, we aimed to compare the safety and efficacy of remimazolam with dexmedetomidine for awake tracheal intubation by flexible bronchoscopy (ATI-FB).

Methods

Ninety patients scheduled for ATI-FB were randomly divided into three groups, each consisting of 30 cases: dexmedetomidine 0.6 µg/kg + sufentanil (group DS), remimazolam 0.073 mg/kg + sufentanil (group R1S), or remimazolam 0.093 mg/kg + sufentanil (group R2S). The primary outcome was the success rate of sedation. Secondary outcomes were MOAA/S scores, hemodynamic and respiratory parameters, intubation conditions, intubation time, tracheal intubation amnesia, and adverse events.

Results

The success rates of sedation in groups R2S and DS were higher than that in group R1S (93.3%, 86.7%, respectively, vs 58.6%; P = 0.002), and intubation conditions were better than those in group R1S (P < 0.05). Group R2S had shorter intubation times than groups R1S and DS (P = 0.003), and a higher incidence of tracheal intubation amnesia than group DS (P = 0.006). No patient in the three groups developed hypoxemia or hypotension, and there were no significant differences in oligopnea, PetCO2, or bradycardia (P > 0.05).

Conclusion

In conclusion, both DS and R2S had higher success rates of sedation, better intubation conditions, and minor respiratory depression, but R2S, with its shorter intubation time, higher incidence of anterograde amnesia, and ability to be antagonized by specific antagonists, may be a good alternative sedation regimen for patients undergoing ATI-FB.

Comparison of the bispectral indices of patients receiving remimazolam and propofol for general anesthesia: a randomized crossover trial

BACKGROUND

Remimazolam is a safe and effective new benzodiazepine sedative that has unique advantages in anesthesia induction and maintenance. The differences in the electroencephalogram bispectral index (BIS) during general anesthesia between propofol and remimazolam deserve further exploration.

METHODS

Single-center randomized crossover study. Patients who required multiple hysteroscopic surgery were randomly assigned to use remimazolam (0.27 mg/kg for induction and 1 mg/kg/h for maintenance) first and then propofol (2.0 mg/kg for induction and 6 mg/kg/h for maintenance) during hysteroscopic surgery again 3 months later, or in the opposite order. Both drugs were used at the latest ED95 for unconsciousness. The BIS values (primary endpoint), intraoperative conditions, and incidence of adverse reactions (secondary endpoints) were compared at each time point. BIS values were analyzed with a mixed model of repeated measurements (MMRM).

RESULTS

Seventeen patients completed the study. The lowest BIS value in the remimazolam regimen was significantly higher than that in the propofol regimen (p = 0.001). The MMRM analysis of the BIS values revealed significant differences between the regimens at each time point (p < 0.001). The intraoperative diastolic blood pressure and heart rate changes were smaller, the recovery was faster, and there were fewer adverse reactions and less injection pain, but a greater incidence of intraoperative body movement and hiccups, in the remimazolam regimen.

CONCLUSION

The trial indicated that remimazolam maintained a higher BIS level than propofol. The correlation between the BIS and the depth of anesthesia induced by remimazolam needs to be further studied.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov: ChiCTR2200064551.

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.

The 50% and 95% effective dose of remimazolam tosilate for anaesthesia induction in sleep disorders patients undergoing laparoscopic cholecystectomy: an up-and-down sequential allocation trial

PURPOSE

Previous reports argue that preoperative sleep conditions of patients can influence the dosage of general anaesthesia drugs. Therefore, we aimed to investigate the dose-effect relationship of preoperative sleep disorders on the induction of general anaesthesia with remimazolam tosilate and calculate the Median effective (ED50) and 95% effective (ED95) dosages.

METHODS

Included in our study were 56 patients who underwent laparoscopic cholecystectomy at our hospital. A separate group of 27 patients with sleep disorders (SD group) and 29 patients without sleep disorders (NSD group) using the Pittsburgh Sleep Quality Index (PSQI) were also included. According to the Dixon 'up-and-down' design, patients received remimazolam at preselected concentrations starting at 0.2 mg/kg. After the administration of remimazolam, loss of consciousness was observed. By observing whether consciousness disappeared within a minute, we adjusted the dose of remimazolam by 0.1 mg/kg (up and down) in the following patient. The Median effective dose (ED50), 95% effective dose (ED95), and 95% confidence interval (CI) of remimazolam for effective sedation were calculated.

RESULTS

The ED50 of remimazolam was 0.226 mg/kg (95%CI 0.221-0.232 mg/kg) in the SD group and 0.191 mg/kg (95%CI, 0.183-0.199 mg/kg) in the NSD group. The ED95 of remimazolam was 0.237 mg/kg (95%CI 0.231-0.262 mg/kg) in the SD group and 0.209 mg/kg (95%CI 0.200-0.254 mg/kg) in the NSD group.

CONCLUSIONS

In the SD group, the ED50 and ED95 of remimazolam during anaesthesia induction were 0.226 and 0.237 mg/kg, respectively. The induction dose of remimazolam in the SD group was significantly higher than that in the NSD group.

The safety of remimazolam versus propofol in gastroscopic sedation: a meta-analysis

BACKGROUND

This meta-analysis was designed to compare the safety and efficiency of remimazolam with those of propofol in patients undergoing gastroscope sedation.

METHODS

We searched PubMed, Cochrane Library, Embase, Ovid, Wanfang Database, China National Knowledge Infrastructure, SINOMED, and ClinicalTrials.gov for studies that reported on remimazolam versus propofol for gastroscope sedation from establishment to February 25, 2023. The sedative efficiency and the incidence of adverse events were assessed as outcomes. Version 2 of the Cochrane risk-of-bias assessment tool was used to assess the risk of bias. Review Manager 5.4 and STATA 17 were used to perform all statistical analyses.

RESULTS

A total of 26 randomized controlled trials involving 3,641 patients were included in this meta-analysis. The results showed that remimazolam had a significantly lower incidence of respiratory depression (risk ratio [RR] = 0.40, 95% confidence interval [CI]: 0.28-0.57; p < 0.01, GRADE high), hypoxemia (RR = 0.34, 95% CI: 0.23-0.49; p < 0.01, GRADE high), bradycardia (RR = 0.34, 95% CI: 0.23-0.51; p < 0.01, GRADE high), dizziness (RR = 0.45, 95% CI: 0.31-0.65; p < 0.01, GRADE high), injection site pain (RR = 0.06, 95% CI: 0.03-0.13; p < 0.01, GRADE high), nausea or vomiting (RR = 0.79, 95% CI: 0.62-1.00; p = 0.05, GRADE moderate), and hypotension (RR = 0.36, 95% CI: 0.26-0.48; p < 0.01, GRADE low).

CONCLUSIONS

Remimazolam can be used safely in gastroscopic sedation and reduces the incidence of respiratory depression, hypoxemia, bradycardia, injection site pain, and dizziness compared with propofol, and doesn't increase the incidence of nausea and vomiting.

The effective dose of remimazolam in adult gastroscopy

OBJECTIVES

The objectives of this study were to explore the median effective dose (ED50) and the dose required for successful anesthesia in 95% of the patients (ED95) of remimazolam for intravenous anesthesia in adult outpatients undergoing gastroscopy.

METHODS

This pilot study was conducted in patients scheduled to undergo painless gastroscopy at the authors' hospital between March 15, 2022 and March 25, 2022. The ED of remimazolam was determined using the modified Dixon sequential method, using an initial induction dose of 0.2 mg/kg. With successful or failed anesthesia, the remimazolam dose was decreased or increased by 0.05 mg/kg for the next patient, respectively.

RESULTS

Twenty-two patients (43.6 ± 10.5 years of age) were enrolled. During gastroscopy, the remimazolam induction dose was 19.93 ± 2.96 mg (0.2-0.45 mg/kg). Eighteen patients could complete anesthesia with remimazolam alone, and four patients needed propofol to complete anesthesia. The induction time after the injection of remimazolam was 20.8 ± 8.4 s, the gastroscopy time was 5.1 ± 1.3 min, and the anesthesia recovery time was 17.5 ± 5.6 min. The ED50 and the ED95 of remimazolam were 0.362 mg/kg (95% confidence interval [CI]: 0.313-0.455 mg/kg) and 0.464 mg/kg (95% CI: 0.403-2.242 mg/kg), respectively. The vital signs of all patients remained within the predefined acceptable limits. No patients required antagonist rescue.

CONCLUSION

The ED50 and ED95 of remimazolam for adult gastroscopy were 0.362 mg/kg and 0.464 mg/kg, respectively. Additional anesthetics might be required during gastroscopy in some patients.

TRIAL REGISTRATION

The trial was registered. The number is ChiCTR2200057446.

Efficacy and safety of remimazolam besilate for sedation in outpatients undergoing impacted third molar extraction: a prospective exploratory study

BACKGROUND

Dental treatments often cause anxiety, fear, and stress in patients. Intravenous sedation is widely used to alleviate these concerns, and various agents are employed for sedation. However, it is important to find safer and more effective sedation agents, considering the adverse effects associated with current agents. This study aimed to investigate the efficacy and safety of remimazolam besilate (hereinafter called "remimazolam") and to determine the optimal dosages for sedation in outpatients undergoing dental procedures.

METHODS

Thirty-one outpatients aged 18-65 years scheduled for impacted third molar extraction were included in the study. Remimazolam was administered as a single dose of 0.05 mg/kg followed by a continuous infusion at a rate of 0.35 mg/kg/h, with the infusion rate adjusted to maintain a sedation level at a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 2-4. The primary endpoint was the sedation success rate with remimazolam monotherapy, and the secondary endpoints included induction time, recovery time, time until discharge, remimazolam dose, respiratory and circulatory dynamics, and frequency of adverse events.

RESULTS

The sedation success rate with remimazolam monotherapy was 100%. The remimazolam induction dose was 0.08 (0.07-0.09) mg/kg, and the anesthesia induction time was 3.2 (2.6-3.9) min. The mean infusion rate of remimazolam during the procedure was 0.40 (0.38-0.42) mg/kg/h. The time from the end of remimazolam administration to awakening was 8.0 (6.7-9.3) min, and the time from the end of remimazolam administration to discharge was 14.0 (12.5-15.5) min. There were no significant respiratory or circulatory effects requiring intervention during sedation.

CONCLUSIONS

Continuous intravenous administration of remimazolam can achieve optimal sedation levels without significantly affecting respiratory or circulatory dynamics. The study also provided guidance on the appropriate dosage of remimazolam for achieving moderate sedation during dental procedures. Additionally, the study findings suggest that electroencephalogram monitoring can be a reliable indicator of the level of sedation during dental procedural sedation with remimazolam.

TRIAL REGISTRATION

The study was registered in the Japan Registry of Clinical Trials (No. jRCTs061220052) on 30/08/2022.

Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage

BACKGROUND

Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH.

METHODS

The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms.

RESULTS

Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality.

CONCLUSIONS

Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.

ED50 and ED95 of Propofol Combined with Different Doses of Intravenous Lidocaine for First-Trimester Uterine Aspiration: A Prospective Dose-Finding Study Using Up-and-Down Sequential Allocation Method

Purpose

This study aimed to test the effect of different doses of intravenous lidocaine on the median effective dose (ED50) and 95% effective dose (ED95) of propofol-induction dose and identify the optimal dose.

Patients and Methods

Patients undergoing first-trimester uterine aspiration were screened and randomly enrolled into the following groups: saline (L₀), 0.5 mg/kg lidocaine (L_0.5), 1.0 mg/kg lidocaine (L_1.0), and 1.5 mg/kg lidocaine (L_1.5). Anesthesia was induced with 1.0 µg/kg fentanyl. Prepared lidocaine or saline solution was injected later according to allocation, followed by propofol. The dose of propofol for each patient was determined using the up-and-down sequential study design. The primary end point was the ED50 and ED95 of the propofol-induction dose. The total propofol doses, awakening time, and adverse events were recorded.

Results

The ED50 (95% confidence interval) of propofol was significantly lower in groups L_1.0 and L_1.5 than group L₀ (1.6 [1.5–1.7] mg/kg and 1.8 [1.6–1.9] mg/kg, versus 2.4 [2.3–2.5] mg/kg, respectively; p<0.001). There was no significant difference in ED50 between groups L_1.0 and L_1.5 (p>0.05). However, surprisingly, the ED50 was significantly higher in group L_0.5 than L₀ (2.8 [2.6–3.0] mg/kg vs 2.4 [2.3–2.5] mg/kg; p<0.05). The total doses of propofol in groups L_1.0 and L_1.5 were lower than those in groups L₀ and L_0.5 (p<0.05). The systolic blood pressure (SBP) decline after anesthesia induction in group L_0.5 was greater than that in group L₀ (p<0.01). The incidence of respiratory depression in group L_0.5 was greater than that in groups L₀ and L_1.0 (p<0.05).

Conclusion

In patients who underwent first-trimester uterine aspiration, intravenous lidocaine 1.0 mg/kg prior to propofol injection significantly reduced the ED50 of propofol induction dose without severe side effects, equivalent to the effect of 1.5 mg/kg dose. We recommend 1.0 mg/kg as the optimal dose.

Intranasal sufentanil combined with intranasal dexmedetomidine: A promising method for non-anesthesiologist sedation during endoscopic ultrasonography

Intranasal sufentanil combined with intranasal dexmedetomidine exhibited an estimated sedation success probability as high as 94.9%, higher satisfaction scores, and only minor adverse events during endoscopic ultrasonography (EUS). This is a promising method for EUS sedation that does not require the presence of an anesthesiologist.

Moderate sedation with single-dose remimazolam tosilate in elderly male patients undergoing transurethral resection of the prostate with spinal anesthesia: a prospective, single-arm, single-centre clinical trial

Background

Remimazolam tosilate (RT) is a newly listed benzodiazepine for sedation and anesthesia featuring quick onset of effects, short maintenance and recovery times, which is currently under research. This trial was conducted to determine the median effective dose (ED₅₀) and the 95% effective dose (ED₉₅) of single-dose remimazolam for moderate sedation in elderly patients undergoing transurethral resection of the prostate (TURP) under spinal anesthesia, and to evaluate its efficacy and safety.

Methods

Thirty male patients aged 65–80 years old were recruited for selective TURP. Remimazolam was administered intravenously to pain-free patients (VAS score < 1) within 1 min of successful spinal anesthesia by the same anesthesiologist. We used modified Dixon’s up-and-down sequential allocation method to determine the ED₅₀ and ED₉₅ of the agent with an initial dosage of 0.1 mg/kg. Successful sedation was defined as an MOAA/S score ≤ 3 and above 1. A score of > 3 was deemed as failed sedation. Recruitment continued until ten independent pairs (from successful sedation to failed sedation) would give a reliable estimation of the ED₅₀ and ED₉₅ of RT and their 95% confidence intervals.

Results

The ED₅₀ of remimazolam was 0.063 (95% C.I. 0.045–0.073) mg/kg. Its ED₉₅ was 0.079 (95% C.I. 0.07–0.137) mg/kg. Remimazolam was safe in its application.

Conclusions

A single-dose of RT proves to be safe for assisted sedation during TURP in elderly male patients under spinal anesthesia with a lower incidence of adverse events. Its ED₅₀ and ED₉₅ were 0.063 mg/kg and 0.079 mg/kg, respectively.

Trial registration

http://www.chictr.org.cn (ChiCTR2100051912).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01788-1.

The Efficacy and Safety of Remimazolam Tosilate Versus Dexmedetomidine in Outpatients Undergoing Flexible Bronchoscopy: A Prospective, Randomized, Blind, Non-Inferiority Trial

Purpose: This study aimed to compare the efficacy and safety of remimazolam tosilate-remifentanil (RT-RF) vs dexmedetomidine-remifentanil (Dex-RF) for outpatients undergoing fiberoptic bronchoscopy (FB).

Patients and methods: We conducted a double-blind, randomized, prospective study involving a total of 146 outpatients undergoing FB divided into two groups. The RT-RF (RR) group (n = 73) received an initial dose of 12 mg/kg/h of RT for 10 min followed by a maintenance dose of 1–2 mg/kg/h, while the Dex-RF (DR) group (n = 73) received an initial dose of 0.5 μg/kg of Dex for 10 min followed by a maintenance dose of 0.2–0.7 μg/kg/h. All outpatients also received 0.05–0.2 μg/kg/min RF to maintain the Modified Observer’s Assessment of Alertness and Sedation (MOAA/S) scale <3. The primary outcome was rate of successful FB completed. Secondary outcomes were time metrics, hemodynamics, intubating conditions, oxygen saturation, coughing severity, number of remedies, total dose of fentanyl, RF, RT, and Dex, incidence of dreaming, patient and bronchoscopist satisfaction, willingness to repeat bronchoscopy, and adverse events.

Results: The FB successful completion rate was 94.52% (95% CI: 89.20–99.90) in the RR group and 91.78% (95% CI: 85.30–98.20) in the DR group. Compared with patients in the DR group, the onset time, time to fully alert, and hospital discharge were all significantly shorter in the RR group (p < 0.01), and hemodynamics were more stable in the RR group. Intubating conditions, clinically acceptable intubating conditions, lowest oxygen saturation, coughing severity, consumption of fentanyl and RF, number of remedies, and patient and bronchoscopist satisfaction were similar between the groups (p > 0.05), as were demographic characteristics, incidence of dreaming, willingness to repeat bronchoscopy, and adverse events (p > 0.05).

Conclusion: RT-RF has non-inferior efficacy, better time metrics and hemodynamic stability for outpatients undergoing FB than Dex-RF.

Systematic Review Registration: [http://www.chictr.org.cn/showproj.aspx?proj=66673], identifier [ChiCTR2000041524].