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Kotani T, Ida M, Naito Y, Kawaguchi M. Comparison of remimazolam-based and propofol-based total intravenous anesthesia on hemodynamics during anesthesia induction in patients undergoing transcatheter aortic valve replacement: a randomized controlled trial. J Anesth 2024; 38:330-338. [PMID: 38347233 DOI: 10.1007/s00540-024-03311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/10/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE This study aimed to compare the hemodynamic effects of remimazolam- and propofol-based total intravenous anesthesia in patients who underwent transcatheter aortic valve replacement. METHODS This was a single-center, single-blind, randomized controlled trial set at Nara Medical University, Kashihara, Japan. We included 36 patients aged ≥ 20 years scheduled to undergo elective transfemoral transcatheter aortic valve replacement (TAVR) under general anesthesia. The participants were randomly assigned to the remimazolam and propofol groups (n = 18 each). Remimazolam- or propofol-based total intravenous anesthesia was initiated at 12 mg/kg/min or 2.5 mcg/mL via target-controlled infusion, respectively, along with remifentanil. After confirming the loss of consciousness, the administration rate was adjusted using electroencephalographic monitoring. The primary outcome was the rate of arterial hypotension, defined as a mean arterial pressure < 60 mmHg, from anesthesia induction until the beginning of the surgical incision. The total doses of ephedrine and phenylephrine were also assessed. RESULTS During anesthesia induction, the arterial hypotension rates were 11.9% and 21.6% in the remimazolam and propofol groups, respectively (P = 0.01). The total dose of ephedrine was higher in the propofol group (14.4 mg) than in the remimazolam group (1.6 mg) (P < 0.001); however, the total dose of phenylephrine was not significantly different between the two groups (propofol 0.31 mg vs. remimazolam: 0.17 mg, P = 0.10). CONCLUSION Remimazolam-based total intravenous anesthesia resulted in a lower hypotension rate than propofol-based total intravenous anesthesia during induction in patients undergoing TAVR. Remimazolam-based total intravenous anesthesia can be used safely during anesthetic induction in patients with severe aortic stenosis.
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Affiliation(s)
- Taichi Kotani
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan.
| | - Yusuke Naito
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan
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Tsukimoto S, Kitaura A, Yamamoto R, Hirase C, Nakao S, Nakajima Y, Sanuki T. Comparative Analysis of the Hemodynamic Effects of Remimazolam and Propofol During General Anesthesia: A Retrospective Study. Cureus 2024; 16:e58340. [PMID: 38752064 PMCID: PMC11095992 DOI: 10.7759/cureus.58340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/18/2024] Open
Abstract
PURPOSE Hypotension is common during anesthesia induction. However, minimal hemodynamic effects of remimazolam anesthesia have been reported. We hypothesized that remimazolam would have weaker hemodynamic effects than would propofol. To test this, we simultaneously evaluated the hemodynamics using the estimated continuous cardiac output (esCCO) system and heart rate variability (HRV) during anesthesia induction. METHODS This was a single-center, observational, retrospective study of patients undergoing dental surgery under general anesthesia between 2020 and 2022. Seventy patients were divided into two groups: remimazolam (R group; n=34) and propofol (P group; n=36). The information obtained from the anesthesia records, patient information, esCCO system parameters, and HRV were integrated and analyzed. The percentages of various parameters were set to 100% for the pre-induction phase as the baseline. RESULTS The %MAP (noninvasive mean arterial blood pressure) decreased over a narrower range in the R compared to the P group (-17.8% (-26.3%, -11.9%) vs. -22.6% (-32.9%, -17.0%); P=0.039). The %HR (heart rate) increased significantly in the R group and decreased in the P group (+10.7% (+6.5%, +18.6%) vs. -6.5% (-14.5%, +8.4%); P<0.01). The %SVesCCO (stroke volume calculated using the esCCO system) decreased significantly in both groups, but the R group showed a smaller difference compared to the P group (- 5.1% (-7.7%, -2.1%) vs. -10.0% (-13.8%, -5.6%); P<0.01). The rates of change in %LF nu (normalized unit of low frequency) and %HF nu (normalized unit of high frequency) were lower for the R than for the P group, although the difference was not significant (+6.8% (-14.5%, 32.4%) vs. +9.2% (-7.2%, +59.7%), P=0.30; +7.9% (-51.0%, +66.9%) vs. +22.8% (-26.1%, +61.6%), P=0.57). CONCLUSION Remimazolam demonstrated a lower MAP reduction rate than propofol. A compensatory increase in HR occurred with a decrease in stroke volume. However, the HR increase was not attributable to the autonomic nervous system.
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Affiliation(s)
- Shota Tsukimoto
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | | | - Rina Yamamoto
- Department of Anesthesiology, Kindai University, Osaka, JPN
| | | | - Shinichi Nakao
- Perioperative Management Center, Okanami General Hospital, Mie, JPN
| | | | - Takuro Sanuki
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
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Huang S, Liao Z, Chen A, Wang J, Xu X, Zhang L. Effect of carotid corrected flow time combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients: a prospective cohort study. Int J Surg 2024; 110:799-809. [PMID: 37983823 PMCID: PMC10871564 DOI: 10.1097/js9.0000000000000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/22/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Hypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients. MATERIALS AND METHODS The prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5 min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90 mmHg and MAP below 60 mmHg within 3 min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8 ml/kg of balanced crystalloids (lactated Ringer's solution) in 30 min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction. RESULTS The area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95 ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95 ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%). CONCLUSIONS Carotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.
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Affiliation(s)
- Shishi Huang
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Zhenqi Liao
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Andi Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, People’s Republic of China
| | - Jiali Wang
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Xiaodong Xu
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Liangcheng Zhang
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
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Jeon YG, Kim S, Park JH, Lee J, Song SA, Lim HK, Song SW. Incidence of intraoperative hypotension in older patients undergoing total intravenous anesthesia by remimazolam versus propofol: A randomized controlled trial. Medicine (Baltimore) 2023; 102:e36440. [PMID: 38065872 PMCID: PMC10713151 DOI: 10.1097/md.0000000000036440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/10/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND An increase in the frequency of surgeries among older individuals is observed in some countries. Hypotension is common and exaggerated in older patients and can lead to increased morbidity and mortality. Total intravenous anesthesia is commonly administered with propofol, while remimazolam has been suggested as an alternative to propofol because of advantages such as a more stable hemodynamic profile and less respiratory suppression. We conducted a single-blind, parallel-group randomized controlled trial to compare the incidence of intraoperative hypotension between patients administered with remimazolam and propofol. METHODS A total of 132 patients, aged between 65 to 80 years and undergoing laparoscopic cholecystectomy or transurethral resection of bladder tumors were randomly assigned to the propofol or remimazolam group with a permuted block system while being blinded to the hypnotic agent. Remifentanil was administered via target-controlled infusion in both groups, with an initial effect-site concentration of 3.0 ng/mL and titration range of 1.5 to 4.0 ng/mL intraoperatively. The primary outcome of this study was the overall incidence of hypotension during general anesthesia. RESULTS Patients in the propofol group experienced higher intraoperative hypotension than those in the remimazolam group (59.7% vs 33.3%, P = .006). Multivariate logistic regression analysis showed that remimazolam administration was associated with reduced hypotension (adjusted odds ratio, 0.34; 95% CI, 0.16-0.73). Secondary outcomes such as recovery time, delirium, and postoperative nausea and vomiting were comparable in both groups. CONCLUSION Total intravenous anesthesia with remimazolam was associated with less intraoperative hypotension than propofol in older patients, with a comparable recovery profile.
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Affiliation(s)
- Yeong-Gwan Jeon
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
| | - Sujin Kim
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
| | - Ji-Hyoung Park
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
| | - Jonghoon Lee
- Department of Anesthesiology and Pain Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Sang A Song
- Department of Anesthesiology and Pain Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Hyun Kyo Lim
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
| | - Seung Woo Song
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
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So KY, Park J, Kim SH. Safety and efficacy of remimazolam for general anesthesia in elderly patients undergoing laparoscopic cholecystectomy: a randomized controlled trial. Front Med (Lausanne) 2023; 10:1265860. [PMID: 38020112 PMCID: PMC10652398 DOI: 10.3389/fmed.2023.1265860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction There is insufficient evidence regarding the efficacy and safety of remimazolam in elderly patients. Therefore, this study evaluated the differences in the anesthesia characteristics and perioperative hemodynamic profiles of elderly patients receiving total intravenous anesthesia with remimazolam or propofol. Methods Eighty-four patients aged >65 years with an American Society of Anesthesiologists physical status of I-III were randomly assigned to Group R (receiving remimazolam, n = 42) or Group P (receiving propofol, n = 42). In Group R, remimazolam was initiated at a rate of 6 mg/kg/h until loss of consciousness (LOC) was achieved and maintained at 1 mg/kg/h subsequently. In Group P, 1.0-1.5 mg/kg of propofol was injected for 1 min and maintained at 100 μg/kg/min subsequently. The maintenance infusion rate was adjusted to maintain an appropriate depth of anesthesia until the end of the surgery. The primary outcome was the time to LOC. The depth of anesthesia scores and hemodynamic profiles were recorded perioperatively. Results The time to LOC was significantly longer in Group R (120 s) than in Group P (60 s) (p < 0.001). The time to eye-opening (Group R, 10 min; Group P, 10 min; p = 0.056), the incidence of maintenance of hemodynamic changes within 20% of the peri-anesthetic values, and treatments for hemodynamic instability did not differ significantly between the groups. The depth of anesthesia scores did not differ significantly between the groups; however, the scores were higher in Group R than those in Group P before endotracheal intubation. The hemodynamic parameters did not differ significantly at any time point. The time to extubation was longer in Group R (12 min) than that in Group P (10 min) (p = 0.007). Similarly, the time to discharge from the operating room was significantly longer in Group R (15 min) compared to Group P (12 min) (p = 0.018). Conclusion Remimazolam does not exhibit a comparable effect to propofol in terms of anesthesia induction and recovery. However, it demonstrates a similar effect to propofol regarding intraoperative anesthesia depth and hemodynamic profile in elderly patients undergoing remifentanil-based total intravenous anesthesia.
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Affiliation(s)
- Keum Young So
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Republic of Korea
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Jihwan Park
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Republic of Korea
| | - Sang Hun Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Republic of Korea
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, Gwangju, Republic of Korea
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Kempenaers S, Hansen TG, Van de Velde M. Remimazolam and serious adverse events: A scoping review. Eur J Anaesthesiol 2023; 40:841-853. [PMID: 37727906 DOI: 10.1097/eja.0000000000001902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
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 .
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Affiliation(s)
- Sander Kempenaers
- From the Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium (SK), Department of Anaesthesia and Intensive Care, Akershus University Hospital, Lorenskog (TGH), Faculty of Medicine, Institute of Clinical Medicine, Oslo University, Oslo, Norway (TGH), Department of Cardiovascular Sciences, KU Leuven (MVdV) and Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium (MVdV)
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Duan J, Ju X, Wang X, Liu N, Xu S, Wang S. Effects of Remimazolam and Propofol on Emergence Agitation in Elderly Patients Undergoing Hip Replacement: A Clinical, Randomized, Controlled Study. Drug Des Devel Ther 2023; 17:2669-2678. [PMID: 37680862 PMCID: PMC10480494 DOI: 10.2147/dddt.s419146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/07/2023] [Indexed: 09/09/2023] Open
Abstract
Purpose The aim of this study was to compare the effects of remimazolam and propofol on emergence agitation (EA) in elderly patients undergoing hip replacement. Methods A total of 60 elderly patients undergoing hip replacement were recruited for this prospective, single-center, clinical, randomized, controlled study from February to April 2023. They were randomly assigned to two groups: the remimazolam group (group R) and the propofol group (group P). In group R, remimazolam was administered intravenously during the induction and maintenance of anesthesia, In group P, propofol was used during the induction and maintenance of anesthesia. The incidence of EA was recorded as the primary indicator. Secondary indicators included heart rate (HR) and mean arterial pressure (MAP) values at the following moments: 5 min prior to anesthetic induction (T0), 1 min following induction (T1), 5 min after the laryngeal mask was inserted (T2), the beginning of surgery (T3), the moment the laryngeal mask was removed (T4), and the overall incidence of postoperative adverse events (bleeding or splitting of the surgical incision, removal of the intravenous infusion needle, falling off the bed, hypoxemia, and hypertension). Results The incidence of EA was significantly lower in group R than in group P (10% vs 33%, P < 0.05). At T1, T2, and T3, the HR and MAP values of group R were higher than those of group P (P < 0.05). The overall incidence of postoperative adverse events was significantly lower in group R than in group P (P < 0.05). Conclusion Remimazolam further reduced the incidence of emergence agitation when compared to propofol during geriatric hip replacement. Moreover, it has a minor hemodynamic effect and lower the incidence of postoperative adverse events.
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Affiliation(s)
- Jinjuan Duan
- Department of Anesthesiology, Affiliated Anqing Medical Centre of Anhui Medical University, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Xia Ju
- Department of Anesthesiology, Affiliated Anqing Medical Centre of Anhui Medical University, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Xing Wang
- Department of Anesthesiology, Affiliated Anqing Medical Centre of Anhui Medical University, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Ning Liu
- Department of Anesthesiology, Affiliated Anqing Medical Centre of Anhui Medical University, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Siqi Xu
- Department of Anesthesiology, Affiliated Anqing Medical Centre of Anhui Medical University, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Shengbin Wang
- Department of Anesthesiology, Affiliated Anqing Medical Centre of Anhui Medical University, Anqing Municipal Hospital, Anqing, People’s Republic of China
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Kim TK, Kwak HJ, Jung WS, Choi GB, Park SY, Kim JY. Effects of Remimazolam Anesthesia with Two Induction Doses on Hemodynamics and Recovery Profile in Older Patients: Comparison with Propofol Anesthesia. J Clin Med 2023; 12:5285. [PMID: 37629327 PMCID: PMC10455786 DOI: 10.3390/jcm12165285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Remimazolam has advantages such as hemodynamic stability and rapid onset. We investigated the effects of induction doses on hemodynamics and recovery profiles for remimazolam compared to propofol in older patients. Sixty-nine patients aged >65 years were randomly assigned to either the propofol anesthesia group (P group) or the remimazolam anesthesia group with an induction dose of 6 mg/kg/h (R6 group) or 12 mg/kg/h (R12 group), followed by 1 mg/kg/h. P group was anesthetized with 4 µg/mL of propofol effect-site concentration (Ce) with target-control infusion, followed by 2.5-3 µg/mL of Ce. The primary outcome was the difference between the baseline mean arterial pressure (MAP) and the lowest MAP during anesthesia (ΔMAP). ΔMAP was comparable between the P, R6, and R12 groups (43.8 ± 13.8 mmHg, 39.2 ± 14.3 mmHg, and 39.2 ± 13.5 mmHg, p = 0.443). However, the frequencies of vasoactive drug use were 54.5%, 17.4%, and 30.4% (p = 0.029), and the median doses of ephedrine 3 (0-6) mg, 0 (0-0) mg, and 0 (0-0) mg (p = 0.034), which were significantly different. This study showed remimazolam anesthesia with an induction dose of 6 mg/kg/h, rather than 12 mg/kg/h, could reduce the requirement for vasoactive drugs compared to propofol anesthesia.
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Affiliation(s)
- Tae Kwang Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea
| | - Hyun Jeong Kwak
- Department of Anaesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea
| | - Wol Seon Jung
- Department of Anaesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea
| | - Gyu Bin Choi
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea
| | - Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea
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