Comparing Analgesic Effect of Intravenous Fentanyl, Femoral Nerve Block and Fascia Iliaca Block During Spinal Anesthesia Positioning in Elective Adult Patients Undergoing Femoral Fracture Surgery: a Randomized Controlled Trial

Comparative study of the efficacy and safety of remimazolam and midazolam for general anesthesia in elderly patients: a randomized controlled trial

BACKGROUND

Elderly patients are a vulnerable group with high perioperative risks. Thus, reducing the duration of anesthesia is important. Remimazolam is a benzodiazepine sedative commonly used for the induction and maintenance of general anesthesia given its rapid induction and rapid recovery. Most reports have focused on nonelderly patients.

AIM

To compare the time to loss of consciousness, length of PACU stay and incidence of adverse events in patients older than 65 years who received remimazolam for general anesthesia with those of patients who received midazolam.

METHODS

This study was conducted at a university hospital between February 2022 and March 2023. We included 100 patients aged 65 years or older who were scheduled for surgery under general anesthesia. Patients were divided into 2 groups, namely, the midazolam group and the remimazolam group, with 50 patients in each group. The primary outcome was the time to loss of consciousness. The secondary outcomes included the time to extubation and length of PACU stay. We also recorded the percentage of flumazenil used and incidence of adverse events.

RESULTS

Clinical data from 96 patients who were scheduled for surgery under general anesthesia were included in the final analysis, with 46 patients in the remimazolam group and 50 patients in the midazolam group. The time to loss of consciousness was 304 (222, 330) s in the remimazolam group and 95 (67, 25) s in the midazolam group, and the difference was significant (p = 0.000). The time to extubation was 24.93 ± 11.617 min in the remimazolam group and 34.88 ± 19.740 min in the midazolam group, revealing a significant difference (p = 0.003). The length of PACU stay was 55 (48, 64) min in the remimazolam group and 65 (55, 85) min in the midazolam group, and the difference was significant (p = 0.001). The percentage of flumazenil used was 6% in the remimazolam group and 20% in the midazolam group, and the difference was significant (p = 0.003).

CONCLUSION

General anesthesia with remimazolam has been shown to be effective and safe for surgery in elderly patients. The time to extubation was significantly shorter, length of PACU stay was shorter, and percentage of flumazenil used was lower in the remimazolam group than in the midazolam group.

Comparison of Ultrasound-Guided Femoral Nerve Block and Intravenous Fentanyl For Analgesia During Positioning of Patients With Femur Fracture for Combined Spinal-Epidural Anesthesia: A Randomized Controlled Study

Background Central neuraxial blockade is the preferred anesthesia technique for femur fracture surgeries. However, positioning patients for neuraxial anesthesia can be challenging due to severe pain. Analgesic strategies, including nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, non-opioid analgesics, and nerve blocks like lumbar plexus, fascia iliaca, three-in-one, and femoral nerve blocks (FNBs), are used to ease positioning. This study compared the analgesic efficacy of intravenous (IV) fentanyl and ultrasound-guided FNB using visual analogue scale (VAS) scores in patients with femur fractures undergoing combined spinal-epidural (CSE) anesthesia. Methodology Sixty-four American Society of Anesthesiologists (ASA) physical status I/II adult patients were randomized into two groups (n = 32). Group A received IV fentanyl (1 mcg/kg), while Group B received FNB with 20 mL of 0.25% bupivacaine under ultrasound guidance. Patients were positioned for CSE anesthesia. VAS scores and hemodynamic parameters were recorded at rest (V1), during movement (V2), and at 5 (V3), 10 (V4), and 15 (V5) minutes post-intervention. Results Demographics and hemodynamics were comparable between groups. Both groups showed significant VAS score reduction with no statistically significant difference at any time point (V1-V5, p > 0.05). The mean time to position patients was 4.25 ± 1.68 minutes in Group A and 3.63 ± 1.87 minutes in Group B (p = 0.166). The time for CSE administration was also similar (p = 0.861). Conclusion IV fentanyl is as effective as ultrasound-guided FNB for pain relief during patient positioning for CSE anesthesia in femur fracture surgeries. Ultimately, both methods are valuable analgesic strategies for facilitating patient positioning and improving the overall safety and comfort during the administration of central neuraxial anesthesia. The choice of intervention can be tailored based on individual patient characteristics, institutional protocols, and resource availability.

The Role of microRNAs in Lidocaine-Induced Spinal Cord Neurotoxicity: An Exploration Based on Bioinformatics Analysis

This study investigated the impact of lidocaine-induced neurotoxicity on microRNA (miRNA) expression in the spinal cord of rats. Sprague-Dawley rats underwent intrathecal catheterization and were randomly assigned to receive either 10% lidocaine or normal saline for three consecutive days. Post-treatment, the paw withdrawal threshold significantly increased, accompanied by notable histopathological changes. Additionally, 470 miRNAs exhibited altered expression following lidocaine treatment, with miR-155-5p, miR-3544, and miR-675-5p showing significant changes. Gene Ontology analysis identified cellular metabolic processes as the most significantly enriched functions. Kyoto encyclopedia of genes and genomes pathway analysis revealed that the enriched signaling pathways are associated with neural injury and neuroprotection, and are involved in regulating cellular metabolism. The Mitogen-Activated Protein Kinase (MAPK) signaling pathway was notably enriched, with Mitogen-activated protein kinase kinase kinase 10 (Map3k10) and Mitogen-activated protein kinase kinase kinase 14 (Map3k14) identified as target genes of miR-155-5p. Following lidocaine treatment, there was an observed increase in the expression of MAP3K10 and MAP3K14 at both the mRNA and protein levels. These results indicate that miR-155-5p, miR-3544, and miR-675-5p might be significantly involved in lidocaine-induced neurotoxicity by influencing cellular metabolism. Furthermore, miR-155-5p/MAPK shows potential therapeutic value for treating lidocaine-induced neurotoxicity.

Effect of remimazolam tosilate for injection (HR7056) versus sevoflurane on the incidence of postoperative delirium in older patients undergoing total hip arthroplasty: study protocol for a prospective, multicentre, two-arm, parallel-group, randomised controlled trial

INTRODUCTION

Postoperative delirium (POD) is a common postoperative complication and is associated with numerous adverse outcomes. Advanced age and hip surgery are high risk factors for POD. Both remimazolam tosilate for injection and sevoflurane can be used as sedatives for the maintenance of general anesthesia, but the comparison of their impacts on the incidence of POD has not been reported. This study aims to compare the effect of remimazolam tosilate vernus sevoflurane on the incidence of POD in older patients undergoing total hip arthroplasty.

METHODS AND ANALYSIS

This is a two-arm, parallel, prospective, multicenter, randomized controlled trial. A total of 456 older patients at six clinical trial centers in China will be randomly assigned in a 1:1 ratio to receive general anesthesia with remimazolam tosilate or sevoflurane as sedative. The primary outcome measure is the prevalence of POD during the first 4 postoperative days. Secondary outcomes include cognitive function [Mini-Mental State Examination (MMSE)], perioperative pain degree [Visual Analogue Scale (VAS)], postoperative nausea and vomiting (PONV) within 4 days after surgery, recovery time after drug withdrawal, the amount of vasoactive drugs used during operation, length of hospital stay, and in-hospital complications.

ETHICS AND DISSEMINATION

The Research Ethics Committee of Qilu Hospital of Shandong University has approved the study protocol (REF: KYLL-202206-25), which is applicable to all research centers. Participant recruitment begins in August 2022. Written informed consent will be obtained from each patient before randomization. The findings will be published in an international peer-reviewed medical journal.

TRIAL REGISTRATION

The trial has been registered at the Chinese Clinical Trial Registry: ChiCTR2200062455; date of registration: 2022-08-08.

The sedation efficacy of different doses of remimazolam in elderly patients with regional nerve block anaesthesia

BACKGROUND

Remimazolam is a benzodiazepine sedative that is indicated for induction and maintenance during general anaesthesia. Remimazolam is also used for sedation in outpatient surgery; however, most reports have focused on nonelderly patients, whereas only a few studies have reported the use of remimazolam for elderly patients when receiving regional nerve block anaesthesia.

AIM

The aim of this study was to evaluate the effects of different doses of remimazolam in elderly patients when specifically related to regional nerve block anaesthesia.

METHODS

This study was conducted at a university hospital between February 2022 and March 2023. We included 80 patients aged 65 years or older under regional nerve block anaesthesia. After the effects of anaesthesia were determined, patients were intravenously administered different doses of the test drug, i.e. 4, 4.5, 5, 5.5, or 6 mg, which were named the R1, R2, R3, R4, and R5 groups, respectively. The primary outcome was the loss of consciousness time. The secondary outcomes included the maintenance time and the number of assisted ventilators needed. The exceptional response of patients in terms of loss of consciousness maintenance time, the mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), SpO2, and modified observers assessment of alertness/sedation (MOAA/S) scores were recorded at baseline (T0), 3 min after the injection of the test drug (T1), 6 min after the injection of the test drug (T2), 9 min after the injection of the test drug (T3), 12 min after the injection of the test drug (T4), 15 min after the injection of the test drug (T5), 18 min after the injection of the test drug (T6), 21 min after the injection of the test drug (T7), and 24 min after the injection of the test drug (T8).

RESULTS

We included 80 patients according to the inclusion and exclusion criteria, with 16 patients in each group. There were no significant differences in sex, age, and BMI amongst the 5 groups. The loss of consciousness time was significantly greater in the R2 group than in the R3, R4, and R5 groups (p < 0.001), and the loss of consciousness maintenance time was significantly greater in the R5 group than in the R3 group (p < 0.05). The MAP was significantly lower in the R2 and R5 groups than in the R1 group at T4 (p = 0.004) and significantly lower in the R5 group than in the R1 group at T5 (p = 0.007). The HR was significantly lower in the R5 group than in the R3 group at T3 (p = 0.004) and T4 (p = 0.007). The RR was significantly lower in the R5 group than in the R4 group at T4 (p = 0.049) and significantly greater in the R4 group than in the R2 group at T5 (p = 0.024) and T6 (p = 0.020). The RR was significantly lower in the R5 group than in the R1, R3 and R4 groups at T7 (p = 0.001). The RR was significantly greater in the R1 group than in the R2 and R5 groups at T8 (p = 0.001). The RR was significantly greater in the R4 group than in the R2 group at T8 (p = 0.001). SpO2 was significantly lower in the R3 group than in the R1 group at T3 (p = 0.003) and significantly lower in the R3 group than in the R1 and R5 groups at T4 (p = 0.002), T5 (p = 0.001), T6 (p = 0.000), and T7 (p = 0.000). The MOAA/S scores were significantly lower in the R4 and R5 groups than in the R1 and R2 groups at T1 (p = 0.000), significantly lower in the R5 group than in the R1 and R3 groups at T2 (p = 0.004), and significantly lower in the R5 group than in the R1 group at T3 (p = 0.036).

CONCLUSION

The results indicated that doses of 5-5.5 mg remimazolam are more suitable for sedation in elderly patients, and the loss of consciousness time and depth of sedation differed according to the remimazolam dosage. Doses of 5-5.5 mg remimazolam were associated with adequate levels of sedation in elderly patients and with a decreased risk of complications, whilst haemodynamic fluctuations occurred approximately 12-15 min after the administration of remimazolam.

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.

Comparison of pericapsular nerve group block and femoral nerve block in spinal anesthesia position analgesia for proximal femoral fractures in geriatric patients: a randomized clinical trial

BACKGROUND

This study aimed to compare the analgesic efficacy of the femoral nerve block (FNB) with that of the pericapsular nerve group (PENG) block in the lateral decubitus position for spinal anesthesia in geriatric hip fracture surgery.

METHODS

Patients aged ≥65 years scheduled to undergo hip fracture surgery for proximal femur fractures with an American Society of Anesthesiologists physical status of class I-IV and body mass index of 18-40 kg/m2 were included in the study. The PENG block or FNB was performed 20 min before positioning for spinal anesthesia. Lateral position, hip flexion, and lumbar spine flexion pain were evaluated during spinal anesthesia.

RESULTS

Sixty patients completed the study. The median pain scores for lateral positioning were 2 (0-4) and 2.5 in the PENG and FNB groups, respectively (P=0.001). The median pain scores during hip flexion were 1 (0-4) and 2.5 in the PENG and FNB groups, respectively (P<0.001). The median pain score during lumbar flexion was 1 (0-4) and 2.0 in the PENG and FNB groups, respectively (P=0.001). The two groups did not show a significant difference in the quality of the spinal anesthesia position (P>0.05).

CONCLUSION

Pre-operative PENG block is more effective in reducing the pain associated with spinal anesthesia position than FNB in geriatric hip fractures. Both blocks had a similar effect on posture quality and the number of spinal interventions.

The relationship between the orientation of the lateral decubitus position for spinal anesthesia and positioning pain in patients with a femoral neck fracture: randomized non-inferiority trial

BACKGROUND

To date, no clinical studies have investigated the relationship between positioning pain and orientation of the lateral decubitus position for hip fracture surgery. The aim of the present study was to test the hypothesis that performing spinal anesthesia in the lateral decubitus position with the fracture side up or down does not affect positioning pain in patients with a femoral neck fracture.

METHODS

This single-center, prospective, randomized non-inferiority trial examined 78 patients who received surgery for a femoral neck fracture under spinal anesthesia. By performing spinal anesthesia in the left lateral decubitus position in all patients, the positioning of the fracture up or down was randomized. Pain score during spinal anesthesia was evaluated objectively (0, calm; 1, facial grimacing; 2, moaning; 3, screaming; or 4, unable to proceed because of restlessness or agitation).

RESULTS

The data from 66 patients (fracture side down [n = 35] and up [n = 31]) were analyzed. There were no significant differences between the fracture side down and fracture side up groups regarding the percentage of patients who were assessed to have intense pain (score ≥ 3) when changing position from the supine to lateral position (13/35 [37%] vs 12/31 [39%]; 95% confidence interval [95% CI] for the difference of the percentage of patients of intense pain between the groups - 25.0 to 2.2; p = 1.000).

CONCLUSIONS

There were no significant differences in the percentage of patients experiencing severe pain between the two groups. The 95% CI exceeded the preliminarily set a margin of inferiority of 20%; thus, the present study could not demonstrate the non-inferiority of the fractured side down group in terms of pain score.

Comparison of Femoral Nerve Block and Fascia Iliaca Block for Proximal Femoral Fracture in the Elderly Patient: A Meta-analysis

Introduction

Pain management modalities after proximal femoral fracture are variable and have been studied extensively. Regional anesthesia, specifically femoral nerve (FNB) and fascia iliaca compartment blocks (FICB), can be used to provide analgesia preoperatively.

Methods

Systematic searches of all related literature were conducted in the Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Randomized controlled trials (RCTs) of proximal femoral fractures were included. The pain scores at different time points, opioid requirement in 24 h, mean arterial pressure, time for spinal anesthesia, patient satisfaction, and incidence of side effects between the 2 groups were extracted throughout the study.

Results

Fifteen RCTs including 1240 patients met the inclusion criteria. The present meta-analysis indicated that compared with FNB, FICB could decrease the visual analog scale (VAS) scores at 4 h after surgery (P < .05). The incidence of side effects (nausea, vomiting, and sedation) was lower in the FNB group (P < .05). Compared to the FICB, no significant difference was found at any other observed time point. Additionally, no difference was found in opioid requirement at 24 h, mean arterial pressure, time for spinal anesthesia, or patient satisfaction (P > .05).

Conclusions

FICB demonstrates a reduction in VAS score at 4 while FNB decreases the risk of several adverse events. More high-quality RCTs are necessary for proper comparison of the efficacy and safety of FNB and FICB.

Is Femoral Nerve Block Superior to Fascia Iliac Block in Hip Surgery? Meta-Analysis of Randomized Controlled Trials

Background. Femoral nerve block (FNB) and fascia iliac compartment block (FICB) are alternative methods of pain relief during hip surgery. Nevertheless, the effectiveness and safety of FNB compared with FICB are yet to be fully determined. Methods. Electronic databases were systematically searched. Only randomized controlled trials (RCTs) on hip surgery were included. Postoperatively, the pain scores at different time points, narcotic requirements in 24 h, mean arterial pressure, spinal anesthesia (SA) time, patient satisfaction, and adverse effect rates between the two groups were extracted throughout the study. Results. Fourteen RCTs including 1179 patients were included. Compared to the FICB, FNB decreased the VAS scores postoperatively at 24 h at rest ( $P<0.05$ ) and the incidence rate of some side effects (nausea, vomiting, and sedation) ( $P<0.05$ ). However, compared to the FICB, no significant difference was found in the FNB regarding the VAS scores postoperatively at any of the other time points (2 min, 20 min, 2 h, 24 h at movement, 48 h at rest, and 48 h at movement). Patients in both groups had similar narcotic needs after 24 h, mean arterial pressure, SA time, and patient satisfaction ( $P>0.05$ ). Conclusions. FNB has more advantages in reducing VAS scores postoperatively at 24 h at rest and the odds of some adverse effects. A better quality RCT is needed to properly compare FNB with FICB.

Application effects of remimazolam and propofol on elderly patients undergoing hip replacement

Objective

To explore the anesthetic and analgesic effects of remimazolam and propofol in elderly patients undergoing hip replacement and their effects on respiratory and circulatory systems, stress and cognitive function.

Methods

Sixty elderly patients undergoing elective hip replacement in the hospital were selected as the research subjects, and they were divided into the remimazolam group and the propofol group according to the admission sequence of patients. The remimazolam group was anesthetized with remimazolam, and the propofol group was anesthetized with propofol. The anesthesia-related indicators, perioperative pain degree [Visual Analogue Scale (VAS)], circulatory indicators [heart rate, mean arterial pressure (MAP)] before anesthesia (T₀), immediately before laryngeal mask insertion (T₁), at 5 min after laryngeal mask insertion (T₂), at 30 min after laryngeal mask insertion (T₃) and at 5 min after laryngeal mask removal (T₄), stress response indicators (plasma epinephrine, norepinephrine, cortisol) before anesthesia induction and at 24 h and 72 h after surgery, cognitive function [Mini-Mental State Examination (MMSE)] and adverse reactions were compared between the two groups.

Results

Among the 60 enrolled patients, only 1 case was excluded due to withdrawal, thus 30 cases in the remimazolam group and 29 cases in the propofol group were included. There were statistically significant differences in the heart rate, MAP, plasma epinephrine, norepinephrine, cortisol and VAS score in the two groups from the aspects of interaction effect and time-point effect (P < 0.05). The heart rate and MAP at T₁, T₂ and T₃ in the two groups were significantly decreased compared with those at T₀, but the heart rate and MAP in the remimazolam group at T₁, T₂ and T₃ were significantly higher than those in the propofol group (P < 0.05). There were no statistical differences in the anesthesia time, awakening time and extubation time between the remimazolam group and the propofol group (P > 0.05). The levels of plasma epinephrine, norepinephrine and cortisol in the two groups were significantly higher at 24 h and 72 h after surgery than those before anesthesia induction, and the above levels were significantly lower in the remimazolam group than those in the propofol group (P < 0.05). The VAS scores at each time point in the two groups were significantly reduced compared to before surgery, but there was no statistically significant difference between the two groups after surgery (P > 0.05). The MMSE scores of the two groups were significantly lower at 1 d and 3 d after surgery compared with those before anesthesia induction, but the score in the remimazolam group was significantly higher than that in the propofol group (P < 0.05). In addition, the incidence rates of adverse reactions were significantly lower in the remimazolam group compared to the propofol group (P < 0.05).

Conclusion

Compared with propofol, remimazolam can achieve equivalent anesthetic and analgesic effects in elderly patients undergoing hip replacement. However, the latter one can significantly relieve respiratory and circulatory suppression, stress response and cognitive dysfunction, with good safety.

Trial registration

This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 31/12/2021 with the registration number ChiCTR2100055039.

Retrospective Comparison of Postoperative Fascia Iliaca Block and Multimodal Drug Injection on Early Function of the Knee in Femoral Fractures Using Retrograde Intramedullary Nailing

Introduction

There is a common concern about the pain and rehabilitation of the knee after femoral retrograde intramedullary nailing. It is essential for early postoperative knee function required for physical self-maintenance in daily life. And a favorable rehabilitation of the knee usually promotes the quality of life. However, early rehabilitation is absent or insufficient for many patients in postoperative management. This retrospective study aims to evaluate the effect of early knee function improvement in comparison to postoperative fascia iliaca blocking (FIB) and multimodal drug injection (MDI). Patients and Methods. A retrospective analysis of 41 patients receiving femoral fracture treatment with retrograde intramedullary nailing, was performed during 2018–2020. 19 patients were treated with MDI as postoperative analgesia, and 22 patients were treated with FIB. Rehabilitation started on the first postoperative day and lasted for 3 months. Visual analog scale (VAS), the range of motion (ROM) of the knee, and single assessment numeric evaluation (SANE) were assessed.

Results

There was no significant difference shown in any of the demographic, fracture types, and operative time. All patients performed regular and voluntary knee rehabilitation and weight-bearing at home following the instruction from the orthopedic staff. Pain in the FIB group at postoperative 1-day was milder (1.7 ± 1.1), compared with that in the MDI group (2.8 ± 1.3, p=0.038). There was a significant difference in VAS between two groups at postoperative 1-month (p=0.031), with a peak score in the FIB group (3.3 ± 0.9). At postoperative 3-month, both groups had pain relief with similar VAS (p=0.465). The ROM of the knee in both groups was continuously improved during the first three months. The SANE in the MDI group was significantly different compared with FIB at 1-month (p=0.026). However, scores of SANE were similar in both groups at 3 months (p=0.541). All patients were identified as fractures union at 9-month or 12-month follow-up.

Conclusion

The knee pain was commonly experienced in this series of retrograde femoral nailings. Both MDI and FIB provided immediate and effective pain control after femoral fracture surgery. MDI was more beneficial to continuous pain control and knee rehabilitation in the early follow-up. The extent of pain relief and knee function improvement reached the same level at postoperative 3-month.