Efficacy and safety of remimazolam-based sedation for intensive care unit patients undergoing upper gastrointestinal endoscopy: a cohort study

Endoscopy Sedation Challenges in Patients With Hepatic Encephalopathy: A Focused Review on Propofol and Selective Use of Benzodiazepines

BACKGROUND

Hepatic encephalopathy (HE) presents a significant challenge in gastrointestinal endoscopy sedation due to impaired liver function, which alters drug metabolism and increases the risk of adverse effects. In the absence of clear guidelines and specific biomarkers for diagnosis and assessment of HE, there is insufficient evidence to formulate standardized protocols for management, diagnosis, and sedation during endoscopy.

AREAS OF UNCERTAINTY

Rigid protocols for sedation are difficult to implement due to wide variation in patient age, comorbidities, and disease severity, which creates a "gray zone." This leaves decisions heavily reliant on the clinician's preference or experience, patient characteristics, and institutional protocols. This review highlights the strengths and limitations of propofol, midazolam, and remimazolam in efforts to improve sedation strategies for endoscopic procedures in patients with HE.

DATA SOURCES

A review was conducted using PubMed and Scopus databases, keeping in view recent publications. Only primary research studies were considered for this review. Inclusion was based on the relevance of patient side effects, sedation outcomes, and safety profiles, with a particular focus on gastrointestinal endoscopy procedures and their implications in HE.

RESULTS

Propofol remains preferred in patients with HE, demonstrating manageable cardiovascular and respiratory events without worsening encephalopathy. However, its safety requires careful consideration in this high-risk population. The combination of propofol with adjuncts, such as esketamine, has shown potential in mitigating adverse effects and optimizing sedation protocols in challenging cases. Midazolam, though historically used, is not recommended in HE due to exacerbation of encephalopathy and unfavorable safety profiles. While remimazolam shows promise, no evidence in HE populations precludes definitive conclusions about its efficacy and safety.

CONCLUSIONS

Future research should focus on optimizing sedation protocols according to the needs of HE patients, including tools for risk stratification and guidelines considering individual patient profiles. Furthermore, studies must be performed to evaluate remimazolam's outcomes and safety profiles, both as a standalone sedative and in combination with other agents.

Characterizing tumor biology and immune microenvironment in high-grade serous ovarian cancer via single-cell RNA sequencing: insights for targeted and personalized immunotherapy strategies

Background

High-grade serous ovarian cancer (HGSOC), the predominant subtype of epithelial ovarian cancer, is frequently diagnosed at an advanced stage due to its nonspecific early symptoms. Despite standard treatments, including cytoreductive surgery and platinum-based chemotherapy, significant improvements in survival have been limited. Understanding the molecular mechanisms, immune landscape, and drug sensitivity of HGSOC is crucial for developing more effective and personalized therapies. This study integrates insights from cancer immunology, molecular profiling, and drug sensitivity analysis to identify novel therapeutic targets and improve treatment outcomes. Utilizing single-cell RNA sequencing (scRNA-seq), the study systematically examines tumor heterogeneity and immune microenvironment, focusing on biomarkers influencing drug response and immune activity, aiming to enhance patient outcomes and quality of life.

Methods

scRNA-seq data was obtained from the GEO database in this study. Differential gene expression was analyzed using gene ontology and gene set enrichment methods. InferCNV identified malignant epithelial cells, while Monocle, Cytotrace, and Slingshot software inferred subtype differentiation trajectories. The CellChat software package predicted cellular communication between malignant cell subtypes and other cells, while pySCENIC analysis was utilized to identify transcription factor regulatory networks within malignant cell subtypes. Finally, the analysis results were validated through functional experiments, and a prognostic model was developed to assess prognosis, immune infiltration, and drug sensitivity across various risk groups.

Results

This study investigated the cellular heterogeneity of HGSOC using scRNA-seq, focusing on tumor cell subtypes and their interactions within the tumor microenvironment. We confirmed the key role of the C2 IGF2+ tumor cell subtype in HGSOC, which was significantly associated with poor prognosis and high levels of chromosomal copy number variations. This subtype was located at the terminal differentiation of the tumor, displaying a higher degree of malignancy and close association with stage IIIC tissue types. The C2 subtype was also associated with various metabolic pathways, such as glycolysis and riboflavin metabolism, as well as programmed cell death processes. The study highlighted the complex interactions between the C2 subtype and fibroblasts through the MK signaling pathway, which may be closely related to tumor-associated fibroblasts and tumor progression. Elevated expression of PRRX1 was significantly connected to the C2 subtype and may impact disease progression by modulating gene transcription. A prognostic model based on the C2 subtype demonstrated its association with adverse prognosis outcomes, emphasizing the importance of immune infiltration and drug sensitivity analysis in clinical intervention strategies.

Conclusion

This study integrates molecular oncology, immunotherapy, and drug sensitivity analysis to reveal the mechanisms driving HGSOC progression and treatment resistance. The C2 IGF2+ tumor subtype, linked to poor prognosis, offers a promising target for future therapies. Emphasizing immune infiltration and drug sensitivity, the research highlights personalized strategies to improve survival and quality of life for HGSOC patients.

Comparative Study of Remimazolam and Midazolam During Sedated Upper Gastrointestinal Endoscopy: A Propensity Score Matching Analysis

AIM

This study aimed to compare the use of remimazolam and midazolam in upper gastrointestinal endoscopy in Japan as a sub-analysis of data from an investigator-initiated clinical trial of remimazolam.

METHODS AND RESULTS

Patients in two groups were matched using propensity score matching. We evaluated the time from the end of the gastrointestinal endoscopy until discharge, the time from the end of the procedure until awakening, and adverse events. Overall, 36 participants from the clinical trial population who underwent upper gastrointestinal endoscopy using remimazolam and 199 patients who underwent the procedure with midazolam during the same period were included in this study. Following propensity score matching, 34 patients in both groups were matched. The median time from the end of the procedure until awakening was 27.0 min (23.0-40.5 min) in the midazolam group (Group M) and 0 min (0-5.0 min) in the remimazolam group (Group R); the median time from the end of the upper gastrointestinal endoscopy until discharge was 39.0 min (35.0-52.5 min) in Group M and 5.0 min (0-5.0 min) in Group R (p < 0.01). Reported adverse events were hypotension and hypoxemia in one patient in Group R.

CONCLUSION

Compared with midazolam, remimazolam significantly shortened the time to patient awakening and duration until the patient could leave the endoscopy room. Trial Registration: The main study (REM-IICT JP1) is registered with the Japan Registry of Clinical Trails: jRCT2031200360.

Remimazolam

Remimazolam is a new reversible γ-aminobutyric acid type A agonist benzodiazepine that displays a fast onset of action, short recovery time with a safe cardiopulmonary profile and favorable pharmacokinetics in comparison with other intravenous sedatives.

Remimazolam in intensive care unit: Potential applications and considerations

This manuscript explores the potential use of Remimazolam in the intensive care unit (ICU) and critical care units, considering its pharmacological characteristics, clinical applications, advantages, and comparative effectiveness over current sedatives and anesthetics. We reviewed existing PubMed and Google Scholar literature to find relevant studies on Remimazolam in ICU. We created search criteria using a combination of free text words, including Remimazolam, critical care, intensive care, sedation, anesthesia, pharmacokinetics, and pharmacodynamics. Relevant articles published in the English language were analyzed and incorporated. Remimazolam is an ultra-short-acting benzodiazepine derivative promising for sedation and anesthesia. It is a safer option for hemodynamically unstable, elderly, or liver or kidney issues. It also has comparable deep sedation properties to propofol in the ICU. Furthermore, it reduces post-procedural delirium and patient comfort and reduces the need for additional sedatives in pediatric patients. In conclusion, Remimazolam is an excellent alternative to current sedatives and anesthetics in the ICU. Its cost is comparable to that of current medications. Further research on its long-term safety in the ICU and its broader application and incorporation into routine use is necessary.

Remimazolam for sedation in gastrointestinal endoscopy: A comprehensive review

Worldwide, a majority of routine endoscopic procedures are performed under some form of sedation to maximize patient comfort. Propofol, benzodiazepines and opioids continue to be widely used. However, in recent years, Remimazolam is gaining immense popularity for procedural sedation in gastrointestinal (GI) endoscopy. It is an ultra-short-acting benzodiazepine sedative which was approved by the Food and Drug Administration in July 2020 for use in procedural sedation. Remimazolam has shown a favorable pharmacokinetic and pharmacodynamic profile in terms of its non-specific metabolism by tissue esterase, volume of distribution, total body clearance, and negligible drug-drug interactions. It also has satisfactory efficacy and has achieved high rates of successful sedation in GI endoscopy. Furthermore, studies have demonstrated that the efficacy of Remimazolam is non-inferior to Propofol, which is currently a gold standard for procedural sedation in most parts of the world. However, the use of Propofol is associated with hemodynamic instability and respiratory depression. In contrast, Remimazolam has lower incidence of these adverse effects intra-procedurally and hence, may provide a safer alternative to Propofol in procedural sedation. In this comprehensive narrative review, highlight the pharmacologic characteristics, efficacy, and safety of Remimazolam for procedural sedation. We also discuss the potential of Remimazolam as a suitable alternative and how it can shape the future of procedural sedation in gastroenterology.

Assessment of sedation by automated pupillometry in critically ill patients: a prospective observational study

BACKGROUND

Quantitative measurement of pupil change has not been assessed against the Richmond Agitation and Sedation Scale (RASS) and spectral edge frequency (SEF) during sedation. The aim of this study was to evaluate pupillometry against these measures in sedated critically ill adult patients.

METHODS

In ventilated and sedated patients, pupillary variables were measured by automated pupillometry at each RASS level from -5 to 0 after discontinuation of hypnotics, while processed electroencephalogram variables were displayed continuously and SEF was recorded at each RASS level. Correlations were made between percentage pupillary light reflex (%PLR) and RASS, and between %PLR and SEF. The ability of %PLR to differentiate light sedation (RASS ≥-2), moderate (RASS =-3), and deep sedation (RASS ≤-4) was assessed by areas under receiver operating characteristic (ROC) curves.

RESULTS

A total of 163 paired measurements were recorded in 38 patients. With decreasing sedation depth, median %PLR increased progressively from 20% (interquartile range 17-25%) to 36% (interquartile range 33-40%) (P<0.001). Strong correlations were found between %PLR and RASS (Rho=0.635) and between %PLR and SEF (R=0.641). Area under the curve (AUC) of 0.87 with a %PLR threshold of 28% differentiated moderate/light sedation from deep sedation with sensitivity of 83% and specificity of 83%. An AUC of 0.82 with a threshold of 31% distinguished light sedation from moderate/deep sedation with a sensitivity of 81% and a specificity of 75%.

CONCLUSIONS

Quantitative assessment of %PLR correlates with other indicators of sedation depth in critically ill patients.