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Lee S, Oh C, Jung J, Hong B, Jo Y, Lee S, Lim C, Baek S, Shin M, Seo H, Chung W. Retrospective comparison of the effects of remimazolam and dexmedetomidine on postoperative delirium in elderly patients undergoing orthopedic surgery of the lower extremities under spinal anesthesia. J Anesth 2024:10.1007/s00540-024-03386-6. [PMID: 39182205 DOI: 10.1007/s00540-024-03386-6] [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: 12/14/2023] [Accepted: 08/01/2024] [Indexed: 08/27/2024]
Abstract
PURPOSE Remimazolam is often used for perioperative sedation due to its rapid onset and offset. However, the possible association between remimazolam and postoperative delirium (POD) remains undetermined. The present study evaluated whether remimazolam increased the incidence of POD compared with dexmedetomidine in elderly patients undergoing orthopedic surgery of the lower extremities. METHODS This retrospective study included patients aged ≥ 65 years who had undergone orthopedic surgery of the lower extremities under spinal anesthesia from January 2020 to November 2022 and were sedated with continuous intravenous infusion of dexmedetomidine or remimazolam. The incidence of POD was assessed through a validated comprehensive review process of each patient's medical records. The effect of remimazolam on the occurrence of POD compared with dexmedetomidine was evaluated by propensity score weighted multivariable logistic models. RESULTS A total of 447 patients were included in the final analysis. The crude incidence of POD within 3 days after surgery was 7.5% (17/226) in the dexmedetomidine group and 11.8% (26/221) in the remimazolam group, increasing to 9.7% (22/226) and 15.8% (35/221), respectively (p = 0.073), within 5 days. The multivariable models showed that, compared with dexmedetomidine, intraoperative sedation with remimazolam significantly increased the occurrence of POD within 3 days (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.31 to 3.82, p = 0.003) and 5 days (OR 2.10, 95% CI 1.32 to 3.40, p = 0.002). CONCLUSION Compared with dexmedetomidine, remimazolam infusion may be associated with a higher risk of POD in elderly patients undergoing orthopedic surgery of the lower extremities under spinal anesthesia.
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Affiliation(s)
- Soomin Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jinsik Jung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Yumin Jo
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Sunyeul Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - ChaeSeong Lim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Sujin Baek
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Myungjong Shin
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hyungseok Seo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kyung Hee University Gangdong Hospital, Kyung Hee University, Seoul, Republic of Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea.
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Fujimoto D, Obata N, Mizobuchi S. Effectiveness of remimazolam in preventing postoperative delirium in elderly patients with proximal femoral fractures. J Anesth 2024; 38:475-482. [PMID: 38530454 DOI: 10.1007/s00540-024-03339-z] [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: 11/22/2023] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Elderly patients with proximal femoral fractures are known to be a high-risk group for postoperative delirium (POD). The aim of this study was to determine the association of the benzodiazepine drug remimazolam with POD in elderly patients with proximal femoral fractures. METHODS In this single-center retrospective observational study, we included patients aged 65 years or older who underwent general anesthesia for proximal femoral fractures. We collected data for the incidence of POD within 3 days after surgery. We also obtained data for complications, preoperative blood examinations, maintenance anesthetic and intraoperative vital data. The occurrence of POD in patients who received remimazolam for general anesthesia (remimazolam group) was compared to that in patients who received general anesthesia with other anesthetic agents (other group). We finally conducted a multivariate analysis to assess the independent association of remimazolam with the risk of POD. RESULTS A total of 230 patients, including 54 patients who received remimazolam for maintenance anesthesia, were included in this study. The incidence of POD in the patients was 26.1%. The incidence of delirium within 3 days after surgery was significantly lower in the remimazolam group than in the other group (14.8% vs. 29.5%, p = 0.03). The multivariate analysis showed that the use of remimazolam independently reduced the occurrence of POD (adjusted odds ratio = 0.42, p = 0.04). CONCLUSION This retrospective observational study showed that the use of remimazolam is independently associated with a reduced incidence of POD. Remimazolam may be considered as an option to reduce POD in elderly patients with proximal femoral fractures.
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Affiliation(s)
- Daichi Fujimoto
- Department of Anesthesiology, Hyogo Prefectural Tamba Medical Center, 2002-7 Hikami-Cho Iso, Tamba, Hyogo, 669-3495, Japan.
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan.
| | - Norihiko Obata
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan
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Masui K. Remimazolam: its clinical pharmacology and evolving role in anesthesia and sedation practice. Curr Opin Anaesthesiol 2024; 37:344-351. [PMID: 38841907 DOI: 10.1097/aco.0000000000001384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Remimazolam is a novel benzodiazepine anesthetic/sedative, designed as a rapidly metabolized carboxylic acid. Since its recent launch, the role of remimazolam in modern anesthesia and sedation practice is still evolving. This review aims to outline the clinical pharmacology and clinical utility of remimazolam to elucidate its potential advantages and limitations. RECENT FINDINGS Remimazolam is "short-acting" but not ultra-short-acting compared with propofol based on context-sensitive decrement times. But compared to propofol, the availability of the benzodiazepine antagonist, flumazenil, is considered an advantage, particularly in certain emergency situations such as in patients with difficult airways. However, because flumazenil is shorter acting than remimazolam when remimazolam accumulates or is present in a high concentration, the reappearance of remimazolam sedation may occur after the initial reversal of anesthesia/sedation from flumazenil administration. Although it is beneficial that remimazolam causes less respiratory depression and hypotension than propofol, serious respiratory depression and hypotension can still occur. Remimazolam administration causes minimal or no pain on injection. Remimazolam is associated with less postoperative nausea and vomiting than inhaled anesthetics, but propofol is clearly superior in this regard. The anesthetic/sedative effects may be prolonged by severe hepatic impairment; remimazolam tolerance can occur in long-term benzodiazepine users. SUMMARY Remimazolam may be beneficial to use in procedural sedation and general anesthesia for patients with difficult airways or hemodynamic instability. Further clinical studies with remimazolam are warranted to identify the potential benefits in other settings and patient populations.
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Affiliation(s)
- Kenichi Masui
- Department of Anesthesiology, Yokohama City University School of Medicine, Yokohama, Japan
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Muncan B, Bennett-Guerrero E. Remimazolam Use in Cardiac Anesthesia: A Narrative Review. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00511-1. [PMID: 39218766 DOI: 10.1053/j.jvca.2024.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/16/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024]
Abstract
Remimazolam, a novel ultra-short-acting intravenous benzodiazepine, has garnered recent attention for its use as a general anesthetic. This narrative review aims to summarize and analyze the available literature on the effects of remimazolam use in cardiac surgical patients, including its effects on hemodynamics, safety in patients with baseline myocardial dysfunction, and impact on postoperative management including time to emergence and extubation. Finally, there is discussion regarding potential drawbacks of adopting remimazolam as a routine anesthetic for cardiac surgery.
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Affiliation(s)
- Brandon Muncan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Medicine, Stanford, CA
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D'Andria Ursoleo J, Licheri M, Barucco G, Losiggio R, Frau G, Pieri M, Monaco F. Remimazolam for anesthesia and sedation in cardiac surgery and for cardiac patients undergoing non-cardiac surgery: a systematic-narrative hybrid review. Minerva Anestesiol 2024; 90:682-693. [PMID: 38771145 DOI: 10.23736/s0375-9393.24.17943-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Remimazolam, an ultra-short-acting benzodiazepine recognized and approved as an anesthetic and sedative in multiple countries, offers a distinctive pharmacokinetic profile, boasting advantages such as rapid onset, short action duration, and rapid recovery. These attributes may contribute to enhanced hemodynamic stability and a diminished risk of respiratory depression compared to other sedatives. EVIDENCE ACQUISITION We conducted the first comprehensive systematically structured narrative review to evaluate the role and potential application of remimazolam in cardiac surgery. Twenty-one studies published from 2021 to 2023 delved into remimazolam's application in open cardiac surgery, cardiac catheterization or electrophysiology laboratories, and high-risk cardiovascular patients undergoing non-cardiac surgery. EVIDENCE SYNTHESIS Overall, remimazolam usage was apparently linked to potentially superior hemodynamic stability compared to other hypnotic drugs. However, findings regarding the reduction in postoperative delirium incidence with remimazolam and the doses of remimazolam for anesthesia induction and maintenance were inconsistent across the studies. CONCLUSIONS Though remimazolam has demonstrated potential safety, efficacy, and ease-of-use for both anesthesia induction and maintenance in cardiac surgery patients and high-risk cardiovascular patients undergoing non-cardiac surgery, further research is imperative to delve into specific patient subgroups (e.g., the elderly or emergent procedures) so as to ascertain optimal dose ranges to suit diverse clinical scenarios.
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Affiliation(s)
- Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gaia Barucco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosario Losiggio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanna Frau
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy -
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Yamaguchi S, Ishida Y, Sasaki T, Higuchi S, Bito K, Oe K. Remimazolam for simultaneous percutaneous mitral valve clip and percutaneous left atrial appendage closure in an elderly patient with impaired cardiac function: A case report. Clin Case Rep 2024; 12:e9215. [PMID: 39040608 PMCID: PMC11260761 DOI: 10.1002/ccr3.9215] [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] [Received: 05/04/2024] [Revised: 07/11/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024] Open
Abstract
Remimazolam is a short-acting benzodiazepine sedative with a short half-life and little circulatory depression. The safe use of remimazolam in the anesthetic management of an elderly patient with impaired cardiac function is reported. The patient's hemodynamics remained stable, and the patient was managed without serious complications. Remimazolam may be an option for sedation in elderly patients with reduced cardiac function.
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Affiliation(s)
- Sumika Yamaguchi
- Department of AnesthesiologyShowa University School of MedicineTokyoJapan
| | - Yusuke Ishida
- Department of AnesthesiologyShowa University School of MedicineTokyoJapan
| | - Tomomi Sasaki
- Department of AnesthesiologyShowa University School of MedicineTokyoJapan
| | - Satoshi Higuchi
- Department of AnesthesiologyTokyo Saiseikai Central HospitalTokyoJapan
| | - Kiyoko Bito
- Department of AnesthesiologyShowa University School of MedicineTokyoJapan
| | - Katsunori Oe
- Department of AnesthesiologyShowa University School of MedicineTokyoJapan
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Kim J, Lee S, Park B, Sim WS, Ahn HJ, Park MH, Jeong JS. Effect of remimazolam versus propofol anesthesia on postoperative delirium in neurovascular surgery: study protocol for a randomized controlled, non-inferiority trial. Perioper Med (Lond) 2024; 13:56. [PMID: 38877533 PMCID: PMC11177377 DOI: 10.1186/s13741-024-00415-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/09/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Remimazolam is a short-acting benzodiazepine newly approved for the induction and maintenance of general anesthesia. Remimazolam emerges as an ideal drug for the neurosurgical population due to its rapid emergence, enabling early neurological assessment, and its ability to maintain perfusion pressure, which is crucial for preventing cerebral ischemia. However, the use of benzodiazepine has been associated with an increased risk of postoperative delirium (POD). There is currently limited evidence about the relationship between remimazolam-based total intravenous anesthesia (TIVA) and POD. METHODS In this double-blind, randomized, non-inferiority trial, we plan to include 696 adult patients with American Society of Anesthesiologists physical status class I to III, undergoing elective neurovascular surgery under general anesthesia. After informed consent, the patients will be randomized to receive either remimazolam or propofol-based TIVA with a 1:1 ratio. The primary outcome is the incidence of POD within 5 days after surgery. Secondary outcomes include subtypes, number of positive assessments and severity of POD, emergence agitation, intraoperative awareness and undesirable patient movement, intraoperative hypotension, and postoperative cognitive function. The data will be analyzed in modified intention to treat. DISCUSSION This trial will evaluate the effect of remimazolam on the development of POD compared to propofol anesthesia. The results of this trial will provide evidence regarding the choice of optimal anesthetics to minimize the risk of POD in neurosurgical patients. TRIAL REGISTRATION The study protocol was prospectively registered at the Clinical trials ( https://clinicaltrials.gov , NCT06115031, principal investigator: Jiseon Jeong; date of first registration: November 2, 2023, before the recruitment of the first participant.
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Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seungwon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Boram Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi-Hye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Gillis H, McKee C, Chenault K, Corridore M, Tobias JD. Preliminary Experience With Remimazolam for Procedural Sedation and as an Adjunct to General Anesthesia During Diagnostic and Interventional Cardiac Procedures. Cardiol Res 2024; 15:12-17. [PMID: 38464705 PMCID: PMC10923259 DOI: 10.14740/cr1595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/12/2024] [Indexed: 03/12/2024] Open
Abstract
Background Remimazolam is a benzodiazepine which, like midazolam, has sedative, anxiolytic, and amnestic properties. Ester metabolism results in a half-life of 5 - 10 min, a limited context sensitive half-life, and rapid recovery when the infusion is discontinued. Methods Following the Institutional Review Board (IRB) approval, we performed a retrospective chart review of patients who received remimazolam in the cardiac catheterization, cardiac magnetic resonance imaging (MRI), and electrophysiology suites. The primary objective was to assess efficacy and safety. The secondary objective was to describe bolus and infusion dosing of remimazolam and the need for adjunctive agents to optimize procedural sedation conditions. Results The study cohort included 26 patients with a median age of 18 years and a total of 33 anesthetic encounters. The most common procedures were endomyocardial biopsy or isolated hemodynamic assessment (right or left heart catheterization). Remimazolam was the primary agent for sedation in 82% of the procedures. The majority of cases (25 encounters, 76%) included a bolus dose of remimazolam prior to the start of an infusion. For those patients who received a starting bolus dose, dosing typically ranged between 30 and 110 µg/kg. Continuous infusion rates of remimazolam varied from 5 to 20 µg/kg/min. No adverse hemodynamic or respiratory effects were noted. Midazolam, fentanyl, and dexmedetomidine were the most frequently used adjunctive agents. One patient required transition to general anesthesia due to the need for a surgical intervention based on the findings of the cardiac catheterization. All other patients were effectively sedated. Conclusions Our preliminary experience demonstrates that remimazolam effectively provided sedation for diagnostic and therapeutic cardiovascular procedures. Future studies are needed to further define dosing parameters for both bolus dosing and continuous infusion as well as to compare remimazolam to other commonly used for procedural sedation in patients with congenital and acquired heart disease.
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Affiliation(s)
- Holly Gillis
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher McKee
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kristin Chenault
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Marco Corridore
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Ma ZM, Hu JH, Ying YY, Chen X, Xu JY, Huo WW, Liu H, Ji FH, Peng K. Effect of remimazolam on electroencephalogram burst suppression in elderly patients undergoing cardiac surgery: Protocol for a randomized controlled noninferiority trial. Heliyon 2024; 10:e23879. [PMID: 38192765 PMCID: PMC10772712 DOI: 10.1016/j.heliyon.2023.e23879] [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] [Received: 06/28/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
Background Postoperative delirium (POD) is a common complication following cardiac surgery and increases postoperative morbidity and mortality. Intraoperative electroencephalogram (EEG) burst suppression suggests excessively deep anesthesia and predicts POD. Use of remimazolam provides a stable hemodynamic status and an appropriate depth of anesthesia. We aim to assess remimazolam administered for anesthesia and sedation in elderly patients having cardiac surgery. Methods This is a randomized controlled clinical trial with noninferiority design. A total of 260 elderly patients aged equal to or greater than 60 years undergoing cardiac surgery will be randomly allocated to receive remimazolam or propofol (1:1) for general anesthesia and postoperative sedation until extubation. The primary outcome is the cumulative time with EEG burst suppression which is obtained from the SedLine system. The noninferiority margin is 2.0 min. The secondary outcomes include the POD occurrence within the first 5 days postoperatively and the duration of perioperative hypotension. Discussion This noninferiority trial is the first to evaluate the effect of perioperative remimazolam administration on EEG burst suppression, POD occurrence, and duration of hypotension in elderly patients who undergo cardiac surgery. Trial registration Chinese Clinical Trial Registry (ChiCTR2200056353).
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Affiliation(s)
- Zheng-min Ma
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jing-hui Hu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Yao-yu Ying
- Department of Medical Affairs, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Department of Epidemiology and Biostatistics, Soochow University Medical College, Suzhou, China
| | - Xian Chen
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jing-ya Xu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Wen-wen Huo
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Fu-hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
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Affiliation(s)
- Naoyuki Hirata
- Department of Anesthesiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan.
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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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Ma Y, Li C, Peng W, Wan Q. The influence of delirium on mortality and length of ICU stay and analysis of risk factors for delirium after liver transplantation. Front Neurol 2023; 14:1229990. [PMID: 37869144 PMCID: PMC10585150 DOI: 10.3389/fneur.2023.1229990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/13/2023] [Indexed: 10/24/2023] Open
Abstract
Objective To analyze the incidence, timing, risk factors and prognosis of delirium after liver transplantation (LT). Methods The clinical data of 321 patients undergoing LT in the Third Xiangya Hospital of Central South University from January 2018 to December 2022 were collected to investigate the incidence, onset, and risk factors for post-LT delirium and the impact of delirium on LT recipients' prognosis by statistical analysis. Results The incidence of post-LT delirium was 19.3% (62/321), and the median interval between LT and onset of delirium was 20.1 h. Univariate analysis showed that pre-LT variables (Model for End Stage Liver Disease (MELD) score, hospital stay, hepatic encephalopathy, infection, white blood cell (WBC) count, lymphocyte count, abnormal potassium, lactulose use), intraoperative variables (red blood cell transfusion, remimazolam use, dexmedetomidine use) and post-LT variables (hypernatraemia, acute rejection, reoperation, basiliximab use, tacrolimus concentration) were associated with post-LT delirium. Multivariate logistic regression analysis revealed that MELD score at LT ≥22 [OR = 3.400, 95% CI:1.468-7.876, p = 0.004], pre-LT hepatic encephalopathy [OR = 3.224, 95% CI:1.664-6.244, p = 0.001], infection within 2 months prior to LT [OR = 2.238, 95% CI:1.151-4.351, p = 0.018], acute rejection [OR = 2.974, 95% CI:1.322-6.690, p = 0.008], and reoperation [OR = 11.919, 95% CI:2.938-48.350, p = 0.001] were independent risk factors for post-LT delirium. Post-LT delirium was reduced in LT recipients exposing to intraoperative remimazolam [OR = 0.287, 95% CI: 0.113-0.733, p = 0.009] or ≥ 25 μg of intraoperative dexmedetomidine [OR = 0.441, 95% CI 0.225-0.867, p = 0.018]. As for clinical outcomes, patients with delirium had a higher percentage of staying at the (ICU) ≥7 d after LT than those without delirium [OR = 2.559, 95% CI 1.418-4.617, p = 0.002]. Conclusion The incidence of delirium was high and the onset of delirium was early after LT. Risk factors for post-LT delirium included high MELD score at LT, pre-LT hepatic encephalopathy and infections, acute rejection and reoperation. Intraoperative use of remimazolam or dexmedetomidine reduced post-LT delirium. Delirium had a negative impact on the length of ICU stay.
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Affiliation(s)
- Ying Ma
- Department of Transplant Surgery, The Third Xiangya Hospital of Central South University, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Cuiying Li
- Department of Transplant Surgery, The Third Xiangya Hospital of Central South University, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Weiting Peng
- Class 2, Grade 2019, 8-Year Clinical Medicine Program, Xiangya School of Medicine, Central South University, Changsha, China
| | - Qiquan Wan
- Department of Transplant Surgery, The Third Xiangya Hospital of Central South University, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, The Third Xiangya Hospital of Central South University, Changsha, China
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Narumi S, Ishida Y, Igarashi S, Sekiguchi S, Kawachi A, Tomino M. Anesthesia using remimazolam during coronary artery bypass surgery in a patient with decreased left ventricular function. Clin Case Rep 2023; 11:e7970. [PMID: 37767150 PMCID: PMC10520288 DOI: 10.1002/ccr3.7970] [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] [Received: 05/31/2023] [Revised: 07/06/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Key Clinical Message Remimazolam is a new benzodiazepine sedative and has the characteristic of causing minimal effects on circulation. This case indicates that it can be considered as an option for anesthesia management of patients with decreased cardiac function. Abstract Some patients who undergo cardiac surgery have reduced cardiac function, which can often make anesthesia management difficult owing to severe hypotension at the time of anesthesia induction. Therefore, it is important to select drugs that cause minimal circulatory depression. On the other hand, in 2020, the use of remimazolam, a short-acting benzodiazepine sedative, was approved in Japan, and reports of its use in various patients have been increasing. This drug has the characteristic of causing minimal effects on circulation. We here report the safe use of remimazolam in the anesthesia management of a patient with decreased cardiac function who was diagnosed as having angina pectoris. The patient was a 73-year-old man scheduled for coronary artery bypass graft (CABG) surgery. Remimazolam was used for sedation purposes during anesthesia induction. During surgery, there were no significant hemodynamic changes and the patient remained in stable cardiovascular condition. Our present case indicates that remimazolam can be considered as an option for anesthesia management in CABG for patients with decreased cardiac function.
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Affiliation(s)
- Shingo Narumi
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Yusuke Ishida
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Sae Igarashi
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | | | - Aya Kawachi
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Mikiko Tomino
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
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Lee S, Kang HY, Ahn YN, You AH. Comparison of the Incidence of Postoperative Acute Kidney Injury Following the Administration of Remimazolam or Sevoflurane in Elderly Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial. J Pers Med 2023; 13:jpm13050789. [PMID: 37240959 DOI: 10.3390/jpm13050789] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/20/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND We evaluated the incidence of postoperative acute kidney injury (AKI) and complications when remimazolam (RMMZ) or sevoflurane (SEVO) were used in elderly patients undergoing total knee arthroplasty. METHODS Seventy-eight participants aged ≥65 were randomly allocated to either the RMMZ or SEVO group. The primary outcome was the incidence of AKI on postoperative day (POD) 2. The secondary outcomes included intraoperative heart rate (HR), blood pressure (BP), total drug administered, emergence time, postoperative complications on POD 2, and hospital length of stay (HLOS). RESULTS The incidence of AKI was comparable between the RMMZ and SEVO groups. The doses of intraoperative remifentanil, vasodilators, and additional sedatives were significantly higher in the RMMZ group than in the SEVO group. Overall intraoperative HR and BP tended to remain higher in the RMMZ group. The emergence time in the operating room was significantly faster in the RMMZ group; however, the time required for an Aldrete score ≥ 9 was comparable between the RMMZ and SEVO groups. Postoperative complications and HLOS were comparable between the RMMZ and SEVO groups. CONCLUSION RMMZ may be recommended for patients who are expected to decrease in intraoperative vital signs. However, stable hemodynamics with RMMZ were not sufficient to influence the prevention of AKI.
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Affiliation(s)
- Sangho Lee
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea
| | - Hee Yong Kang
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea
| | - Ye Na Ahn
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea
| | - Ann Hee You
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea
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Yang JJ, Lei L, Qiu D, Chen S, Xing LK, Zhao JW, Mao YY, Yang JJ. Effect of Remimazolam on Postoperative Delirium in Older Adult Patients Undergoing Orthopedic Surgery: A Prospective Randomized Controlled Clinical Trial. Drug Des Devel Ther 2023; 17:143-153. [PMID: 36712948 PMCID: PMC9880012 DOI: 10.2147/dddt.s392569] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Background Postoperative delirium is common in older adult patients and associated with a poor prognosis. The use of benzodiazepine was identified as an independent risk factor for delirium, but there is no randomized controlled trial regarding the relationship between remimazolam, a new ultra-short acting benzodiazepine, and postoperative delirium. We designed a randomized controlled trial to evaluate if remimazolam increases the incidence of postoperative delirium compared with propofol in older adult patients undergoing orthopedic surgery with general anesthesia. Patients and Methods We enrolled 320 patients aged more than 60 with American Society of Anesthesiologists physical status I-III who underwent orthopedic surgery. Patients were randomized to two groups to receive intraoperative remimazolam or propofol, respectively. Our primary outcome was the incidence of delirium within 3 days after surgery. Secondary outcome was emergence quality including the incidence of emergence agitation, extubation time, and length of post-anesthesia care unit (PACU) stay. Adverse events were also recorded. Results The incidence of postoperative delirium was 15.6% in the remimazolam group and 12.4% in the propofol group (Risk ratio, 1.26; 95% CI, 0.72 to 2.21; Risk difference, 3.2%; 95% CI, -4.7% to 11.2%; P = 0.42). No significant differences were observed for time of delirium onset, duration of delirium, and delirium subtype between the two groups. Patients in remimazolam group had a lower incidence of hypotension after induction and consumed less vasoactive drugs intraoperatively, but had a longer postoperative extubation time and PACU stay. Conclusion General anesthesia with remimazolam was not associated with an increased incidence of postoperative delirium compared with propofol in older adult patients undergoing orthopedic surgery.
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Affiliation(s)
- Jin-Jin Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China
| | - Lei Lei
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China
| | - Di Qiu
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Sai Chen
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Li-Ka Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Jing-Wei Zhao
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Yuan-Yuan Mao
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China,Correspondence: Jian-Jun Yang, Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, People’s Republic of China, Tel +8613783537619, Email
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Kaneko S, Sato S, Morimoto T, Ichinomiya T, Murata H, Yoshitomi O, Hara T. Response to a letter to the editor by Aoki et al.: Critical considerations, including overfitting in regression models and confounding in study designs for delirium follow-up. J Anesth 2023; 37:323-324. [PMID: 36670281 DOI: 10.1007/s00540-023-03167-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 01/21/2023]
Affiliation(s)
- Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Takayuki Morimoto
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Osamu Yoshitomi
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Critical considerations, including overfitting in regression models and confounding in study designs for delirium follow-up. J Anesth 2022; 37:321-322. [PMID: 36562814 DOI: 10.1007/s00540-022-03157-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
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