Clinical Pharmacokinetics and Pharmacodynamics of Propofol

Comparison of total intravenous anesthesia and inhalational anesthesia in patients undergoing liver surgery: a systematic review and meta-analysis

BACKGROUND

The impact of choosing between inhalational anesthetics and propofol for maintenance anesthesia in liver transplantation or liver resections remains uncertain.

METHODS

A systematic search was conducted on PubMed, Scopus, Embase, Web of Science, and the Cochrane Library on September 5, 2023, adhering to the Cochrane Handbook and PRISMA guidelines.

RESULTS

Fifteen randomized controlled trials and five observational studies, comprising 1,602 patients, were included. The statistical analysis was categorized into three groups: liver transplantation (four studies), living donor hepatectomy (four studies), and liver mass hepatectomy (twelve studies). The liver mass hepatectomy group was further subdivided based on the performance of the Pringle maneuver and the use of pharmacological preconditioning. Statistically significant results are described below. In liver transplant recipients, propofol anesthesia was associated with lower AST levels on the first postoperative day. Hepatic donors anesthetized with propofol had higher total infusion volumes and intraoperative urine output. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher peak AST and ALT levels compared to those who received pharmacological preconditioning. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher AST and ALT levels on both the first and third postoperative days, increased total infusion volumes, and shorter hospital stays, when compared to pharmacological conditioning.

CONCLUSIONS

Our findings do not offer sufficient evidence to inform clinical practice. The choice between propofol-based and inhalational anesthesia should be tailored to the individual patient's condition and the nature of the procedure being performed.

REGISTRATION

PROSPERO ID: CRD42023460715.

Effects of dexmedetomidine and propofol on the key endotypes of OSA: A randomized, single-blind, placebo-controlled, crossover trial

BACKGROUND

Drug-induced sleep has been shown to facilitate the diagnosis of obstructive sleep apnea (OSA). However, the effects of commonly used sedatives, such as dexmedetomidine and propofol, on the endotypic traits of OSA remained unclear.

OBJECTIVE

We aim to investigate the impact of dexmedetomidine and propofol on OSA endotypic traits.

METHODS

We conducted a randomized, single-blind, placebo-controlled, crossover trial in adult patients with OSA, comparing the OSA endotypic traits and polysomnography parameters among the interventions of placebo, dexmedetomidine and propofol.

RESULTS

16 patients completed the trial and were enrolled for analysis. Both dexmedetomidine and propofol worsened pharyngeal collapsibility as indicated by a lower Vpassive (mean difference: 6.1 [95 % CI -9.1 to -3.0]%eupnea for dexmedetomidine versus placebo, p = 0.040; -16.5 [95 % CI -24.1 to -9.0]%eupnea for propofol versus placebo, p < 0.001), with propofol causing a greater effect (-10.4 [95 % CI -17.8 to -3.2]%eupnea for propofol versus dexmedetomidine, p < 0.001). Dexmedetomidine maintained upper airway gain, while propofol diminished it compared to placebo (p = 0.001). Both dexmedetomidine and propofol increased arousal threshold (p = 0.006 and p < 0.001, respectively). Dexmedetomidine had no effect on loop gain, whereas propofol elevated it (p = 0.004). Compared to placebo, dexmedetomidine had no impact on apnea-hypopnea index (AHI) or saturation of peripheral oxygen (SpO2). During propofol sedation, AHI in stages N1 (p < 0.001), N2 (p < 0.001) and the entire NREM (p = 0.038) sleep showed increases, and nadir SpO2 for NREM stage exhibited a decrease (p = 0.006).

CONCLUSIONS

Dexmedetomidine had less impact on OSA endotypic traits compared to propofol, and had no negative effects on AHI and SpO2.

Exhaled propofol monitoring for plasma drug prediction in rats

While propofol can be detected in exhaled breath in rats, robust evidence supporting its correlation with plasma concentrations or its use in predicting plasma levels remains lacking. In this study, eighteen mechanically ventilated rats were divided into three groups and injected with low (Group BL, n = 6), medium (Group BM, n = 6), or high (Group BH, n = 6) doses of propofol. The propofol concentration in exhaled breath (Ce-pro) was determined online using vacuum ultraviolet time-of-flight mass spectrometry (VUV-TOF MS), while the propofol concentration in plasma (Cp-pro) were measured using high-performance liquid chromatograph. The results indicated that after propofol injection, the peak Ce-pro was 5.87 ± 1.67 ppbv, 16.54 ± 7.22 ppbv, and 25.40 ± 3.68 ppbv, respectively. Across the different dose groups, Cmax of Ce-pro and Cp-pro were linearly correlated (P BL = 0.032, P BM = 0.031, P BH = 0.049). Tmax of Ce-pro was 1.22 ± 0.17 min, 1.28 ± 0.13 min, and 1.33 ± 0.01 min, respectively (P = 0.341), similar to the Tmax of Cp-pro (1.00 ± 0.00 min). After natural logarithm transformation, the correlation between LN(Ce-pro) and LN(Cp-pro) was well fitted by a linear model, withR B L 2 = 0.94,R B M 2 = 0.95,R B H 2 = 0.98, andR A L L 2 = 0.96. Using the obtained regression equation LN(Cp-pro) = 1.42*LN(Ce-pro)-1.70, the predicted Cp-pro values showed excellent agreement with the actual values within groups (ICCBL = 0.92; ICCBM = 0.97, ICCBH = 0.99, all P < 0.001). This study demonstrates a strong correlation between exhaled and plasma propofol concentrations in rats, indicating that exhaled concentrations can be effectively used to estimate plasma levels.

Molecular Precision Medicine: Application of Physiologically Based Pharmacokinetic Modeling to Predict Drug-Drug Interactions Between Lidocaine and Rocuronium/Propofol/Paracetamol

The perioperative period, encompassing preoperative, intraoperative, and postoperative phases, is crucial for comprehensive patient care. During this time, the use of opioids and other drugs can lead to drug-drug interactions (DDIs), potentially resulting in adverse drug reactions (ADRs) that increase morbidity, mortality, and healthcare costs. This study investigates the drug-drug interactions (DDIs) between rocuronium, propofol, paracetamol, and lidocaine, focusing on the CYP-mediated metabolism of these drugs in the perioperative context, where these drugs are frequently co-administered. Using physiologically based pharmacokinetic (PBPK) modeling through the GastroPlus™ software and in vitro experiments with Hep G2 cells, we aimed to assess potential toxicities and pharmacokinetic interactions. Cellular viability assays revealed significant toxicity when lidocaine was combined with propofol and rocuronium, while paracetamol exhibited no considerable impact on viability. PBPK simulations confirmed moderate interactions with rocuronium and weak interactions with propofol but no relevant interactions with paracetamol. These findings emphasize the need for dose adjustments in perioperative settings to enhance patient safety, particularly with propofol and rocuronium, while supporting the co-administration of lidocaine and paracetamol. These findings show the importance of moving towards a personalized medicine model, adjusting the clinical use of lidocaine according to individual patient needs, thus promoting safer and more effective perioperative care and moving beyond the "one-size-fits-all" approach in anesthetic management.

Postoperative delirium under general anaesthesia by remimazolam versus propofol: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Remimazolam, an ultra-short-acting benzodiazepine, has similar clinical effects to propofol for sedation in general anaesthesia. However, it remains uncertain whether remimazolam could increase postoperative delirium (POD) compared with propofol.

OBJECTIVES

The purpose of our study was to compare the incidence of POD between remimazolam and propofol as sedative agents in general anaesthesia.

STUDY DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were searched for prospective RCTs published through September 16, 2024. RCTs reporting the incidence of POD and comparing remimazolam with propofol for general anaesthesia were included. Odds ratio (ORs) were calculated using a random-effects model. The primary outcome was the incidence of POD. The secondary outcomes included time to extubation, awakening time, and adverse events such as intraoperative hypotension.

RESULTS

A total of six RCTs involving 1107 patients were included in this meta-analysis. For the primary outcome, the incidence of POD did not differ between the remimazolam and propofol groups (OR, 0.92; 95 % confidence interval [CI], 0.58-1.44). Regarding the secondary outcomes, remimazolam was associated with a lower incidence of intraoperative hypotension compared with propofol (OR, 0.31; 95 % CI, 0.21-0.46). There were no significant differences in other secondary outcomes. In the sensitivity analysis on three RCTs including only older patients (≥60 years old), there was no significant difference in the incidence of POD (OR, 1.00; 95 % CI, 0.52-1.93).

CONCLUSION

Perioperative remimazolam administration did not increase POD and reduced the risk of intraoperative hypotension compared to propofol. Further large-scale RCTs are warranted to explore the association of remimazolam and POD. Systematic review protocol: PROSPERO CRD42024544122.

Improving pediatric magnetic resonance imaging safety by enhanced non-technical skills and team collaboration

BACKGROUND

Safe pediatric magnetic resonance imaging (MRI) ideally relies on non-sedative techniques, as avoiding risky sedation is inherently safer. However, in practice, sedation often becomes unavoidable, particularly for younger children or those with anxiety, to ensure motion-free, high-quality imaging. This narrative review explores the current practices and proposes strategies to enhance safety in pediatric MRI examinations.

METHODS

We identified and analyzed 247 studies addressing various aspects of pediatric MRI safety, including sedation protocols, patient monitoring, and team-based management approaches.

RESULTS

Safe sedation requires careful drug selection tailored to individual needs, continuous monitoring, and robust emergency preparedness. While efforts are underway to minimize sedation, safer drug protocols and improved monitoring technologies remain essential. Assembling dedicated MRI teams trained in both technical and non-technical skills-such as situational awareness, communication, and teamwork-supports these strategies. Structured team briefings covering monitoring procedures, emergency scenarios, response protocols, and specific resuscitation roles are also critical. Developing a strong organizational culture that promotes patient safety and continuous learning from incident reports helps ensure ongoing improvements.

CONCLUSIONS

Achieving safe pediatric MRI examinations requires balancing the need for sedation with the goal of minimizing its use. Strengthening collaboration, refining sedation protocols, and implementing advanced safety monitoring systems are essential steps. Further advancements in imaging technologies are also necessary to reliably obtain high-quality scans without sedation, reducing risks and improving patient outcomes.

Pharmacokinetic and Pharmacodynamic Changes in the Older Adults: Impact on Anesthetics

Anesthesiologists are increasingly required to care for frail older adults patients. A detailed knowledge of the influence of age on the pharmacokinetics and dynamics of the anesthetic drugs is essential for optimal safety and care. For most of the anesthetic drugs, the older adults need lower doses to achieve the same plasma concentrations, and at any given plasma and effect-site concentration, they will have more profound clinical effects than younger patients. Caution is required, with close monitoring of clinical effects and active titration of dose administration to achieve the desired level of effect, ideally following the "start low, go slow" principle.

Mechanism of dexmedetomidine in brain injury of infant rats via the IRE1α/NF-κB/CHOP pathway

OBJECTIVE

We investigated the mechanism of Dexmedetomidine (Dex) in infant rats with brain injury.

METHODS

The infant rats underwent brain injury modelling. The motor function, spatial learning and memory abilities in rats, and the hippocampal CA1 region Nissl body level and apoptosis were evaluated by behavioural tests and histological stainings. Levels of the hippocampal CA1 region p-IRE1α, nuclear/cytoplasmic p65, CHOP, Bax and Bcl-2 proteins were determined by Western blot.

RESULTS

Propofol anaesthesia caused brain injury in infant rats. Dex increased the hippocampal CA1 region Nissl body level, abated cell apoptosis, reduced p-IRE1α, ATF6, p-PERK/PERK and CHOP levels, decreased the Bax protein level, elevated the Bcl-2 protein level, and alleviated brain injury in infant rats. After ERS induction and the NF-κB pathway inhibition, the hippocampal CA1 region nuclear/cytoplasmic p65 ratio, CHOP level, and apoptosis were reduced in infant rats with brain injury treated with Dex, while the learning and memory abilities of rats were enhanced.

CONCLUSION

Dex reduced the hippocampal CA1 region cell apoptosis and enhanced learning and memory abilities by inhibiting the ERS-mediated IRE1α/NF-κB/CHOP pathway, thereby alleviating brain injury in infant rats.

The Role of P53 in Myocardial Ischemia-Reperfusion Injury

PURPOSE

P53 is one of the key tumor suppressors. In normal cells, p53 is maintained at low levels by the ubiquitination of the ubiquitinated ligase MDM2. In contrast, under stress conditions such as DNA damage and ischemia, the interaction between p53 and MDM2 is blocked and activated by phosphorylation and acetylation, thereby mediating the trans-activation of p53 through its target genes to regulate a variety of cellular responses. Previous studies have shown that the expression of p53 is negligible in normal myocardium, tends to increase in myocardial ischemia and is maximally induced in ischemia-reperfused myocardium, demonstrating a possible key role of p53 in the development of MIRI. In this review, we detail and summarize recent studies on the mechanism of action of p53 in MIRI and describe the therapeutic agents targeting the relevant targets to provide new strategies for the prevention and treatment of MIRI.

METHODS

We collected 161 relevant papers mainly from Pubmed and Web of Science (search terms "p53" and "myocardial ischemia-reperfusion injury"). After that, we selected pathway studies related to p53 and classified them according to their contents. We eventually analyzed and summarized them.

RESULTS AND CONCLUSION

In this review, we detail and summarize recent studies on the mechanism of action of p53 in MIRI and validate its status as an important intermediate affecting MIRI. On the one hand, p53 is regulated and modified by multiple factors, especially non-coding RNAs; on the other hand, p53 regulates apoptosis, programmed necrosis, autophagy, iron death and oxidative stress in MIRI through multiple pathways. More importantly, several studies have reported medications targeting p53-related therapeutic targets. These medications are expected to be effective options for the alleviation of MIRI, but further safety and clinical studies are needed to convert them into clinical applications.

Pharmacokinetics and pharmacodynamics of ciprofol after continuous infusion in elderly patients

BACKGROUND

Ciprofol, a novel intravenous anesthetic, which has primarily been used for the induction and maintenance of general anesthesia in adults, is characterized by rapid onset, short duration of action, and quick and smooth recovery. However, the pharmacokinetic characteristics of continuous infusions and the correlation between the plasma concentration and the bispectral index (BIS) in elderly patients are still unknown.

METHOD

In this randomized, controlled study, thirty elderly patients (62-78 years old) undergoing elective gastrointestinal tumor resection were treated with propofol (N = 15) or ciprofol (N = 15) as sedatives during anesthesia. After induction, ciprofol/propofol was continuously infused intravenously until the end of the operation. Perioperative vital signs, injection pain, adverse events (AEs), BIS values, eyelid reflex disappearance times, and recovery times were recorded. The plasma concentrations of ciprofol and propofol were measured by liquid chromatography tandem mass spectrometry (LC‒MS/MS) and the pharmacokinetics were determined by noncompartmental analysis.

RESULTS

Both drugs caused a decrease in blood pressure and heart rate after induction. Eight cases (53. 3%) of hypotension and 3 cases (20%) of bradycardia occurred in the propofol group, while 8 cases (53. 3%) of hypotension and 5 cases (33. 3%) of bradycardia occurred in the ciprofol group. At intubation, the ciprofol group experienced fewer fluctuations in blood pressure than the propofol group. Ciprofol resulted in only one case (6.7%) of mild injection pain, less than that produced by propofol (10/15, 66.7%) (P < 0.05). Anesthesia induction was successfully completed with both drugs, and there were no significant differences in eyelash reflex disappearance or recovery time between the two groups. The plasma concentrations during maintenance were relatively stable in both groups (propofol 1.78 ± 0.67 μg/mL, ciprofol 0.71 ± 0.23 μg/mL), and a suitable depth of sedation was achieved with a BIS of 40-60. The pharmacokinetic (PK) parameters for ciprofol are listed as follows: Maximum Plasma Concentration (Cmax) 6.02 ± 2.13 μg/ml; Time to Maximum Concentration (Tmax) 0.18 ± 0.62 min; Apparent Volume of Distribution (Vz) 3.96 ± 0.84 L/kg; Total Clearance (CL) 0.83 ± 0.14 L/h/kg; Half-life (t½) 3.47 ± 1.85 h; Area Under the Curve (AUC) 5000 ± 900 L/h/kg; Terminal Elimination Rate Constant (λz) 0.23 ± 0.07 1/h. Similar to propofol, the plasma concentration of ciprofol was linearly correlated with the BIS.

CONCLUSION

Ciprofol, a novel intravenous anesthetic, can be safely and effectively used in elderly patient continuous infusion with minimal injection pain. Plasma concentrations of ciprofol correlate well with BIS values, helping control sedation depth. For elderly patients undergoing gastrointestinal tumor surgery, an optimal maintenance dose of 0.8 mg/kg/h is recommended.

TRIAL REGISTRATION

This clinical trial (registration No: ChiCTR2100047580, https://www.chictr.org.cn . The pre-registration date was June 20, 2021, and the review approval and official case solicitation began in December 2021; Retrospectively registered) was conducted in accordance with the World Medical Congress Declaration of Helsinki and Good Clinical Practice guidelines. All study subjects provided written informed consent.

Development and validation of machine-learning models for predicting the risk of hypertriglyceridemia in critically ill patients receiving propofol sedation using retrospective data: a protocol

INTRODUCTION

Propofol is a widely used sedative-hypnotic agent for critically ill patients requiring invasive mechanical ventilation (IMV). Despite its clinical benefits, propofol is associated with increased risks of hypertriglyceridemia. Early identification of patients at risk for propofol-associated hypertriglyceridemia is crucial for optimising sedation strategies and preventing adverse outcomes. Machine-learning (ML) models offer a promising approach for predicting individualised patient risks of propofol-associated hypertriglyceridemia.

METHODS AND ANALYSIS

We propose the development of an ML model aimed at predicting the risk of propofol-associated hypertriglyceridemia in ICU patients receiving IMV. The study will use retrospective data from four Mayo Clinic sites. Nested cross validation (CV) will be employed, with a tenfold inner CV loop for model tuning and selection as well as an outer loop using leave-one-site-out CV for external validation. Feature selection will be conducted using Boruta and least absolute shrinkage and selection operator-penalised logistic regression. Data preprocessing steps include missing data imputation, feature scaling and dimensionality reduction techniques. Six ML algorithms will be tuned and evaluated. Bayesian optimisation will be used for hyperparameter selection. Global model explainability will be assessed using permutation importance, and local model explainability will be assessed using SHapley Additive exPlanations.

ETHICS AND DISSEMINATION

The proposed ML model aims to provide a reliable and interpretable tool for clinicians to predict the risk of propofol-associated hypertriglyceridemia in ICU patients. The final model will be deployed in a web-based clinical risk calculator. The model development process and performance measures obtained during nested CV will be described in a study publication to be disseminated in a peer-reviewed journal. The proposed study has received ethics approval from the Mayo Clinic Institutional Review Board (IRB #23-0 07 416).

Correlation between the Observer's Assessment of Alertness/Sedation score and bispectral index in patients receiving propofol titration during general anesthesia induction

OBJECTIVES

To explore the relationship between the Observer's Assessment of Alertness/Sedation (OAAS) score and the bispectral index (BIS) during propofol titration for general anesthesia induction and analyze the impact of BIS monitoring delay on anesthetic depth assessment.

METHODS

This study was conducted among 90 patients (ASA class I-II) undergoing elective surgery under general anesthesia. For anesthesia induction, the patients received propofol titration at the rate of 0.5 mg·kg-1·min-1 till OAAS scores of 4, 3, 2, and 1 were reached. After achieving an OAAS score of 1, remifentanil (2 μg·kg⁻¹) and rocuronium (0.6 mg·kg⁻¹) were administered, and tracheal intubation was performed 2 min later. BIS values, mean arterial pressure (MAP), heart rate (HR), and propofol dosage at each OAAS score were recorded, and the correlation between OAAS scores and BIS values was analyzed. The diagnostic performance of BIS values for determining when the OAAS score reaches 1 was analyzed using ROC curve.

RESULTS

All the patients successfully completed tracheal intubation. BIS values of the patients at each of the OAAS scores differed significantly (P<0.01), and the mean BIS value decreased by 4.08, 8.32, 5.43 and 5.24 as the OAAS score decreased from 5 to 4, from 4 to 3, from 3 to 2, and from 2 to 1, respectively. There was a significant correlation between the OAAS score and BIS values (ρ=0.775, P<0.001). The median BIS value for an OAAS score of 1 was 76, at which point 83.33% of the patients had BIS values exceeding 60. ROC curve analysis showed that for determining an OAAS score of 1, BIS value, at the optimal cutoff value of 84, had a sensitivity of 88.9%, a specificity of 73.3%, and an area under the curve of 0.842 (0.803-0.881).

CONCLUSIONS

OAAS score during induction of general anesthesia is strongly correlated with BIS value and is a highly sensitive and timely indicator to compensate for the delay in BIS monitoring.

Computational frameworks transform antagonism to synergy in optimizing combination therapies

While drug combinations are increasingly important in disease treatment, predicting their therapeutic interactions remains challenging. This review systematically analyzes computational methods for predicting drug combination effects through multi-omics data integration. We comprehensively assess key algorithms including DrugComboRanker and AuDNNsynergy, and evaluate integration approaches encompassing kernel regression and graph networks. The review elucidates artificial intelligence applications in predicting drug synergistic and antagonistic effects.

Insights into anesthesia administration for elderly individuals undergoing painless gastroenteroscopy: A bibliometric study

BACKGROUND

Administering anesthesia to elderly patients undergoing gastroenteroscopy necessitates careful attention due to age-related physiological changes and an increased risk of complications.

AIM

To analyze the research trends in anesthesia management for elderly patients undergoing gastroenteroscopy.

METHODS

We performed a literature search using the Web of Science database to identify articles published between 2004 and 2023. Bibliometric and visual analyses were conducted using CiteSpace, R, and VOSviewer to explore the current research landscape of anesthesia administration in painless gastroenteroscopy for elderly patients and to identify future research directions by examining trends and emerging hotspots in this domain.

RESULTS

A total of 800 articles were examined, revealing a rising trend in annual publication counts. The United States led with 181 articles, followed by China with 112, collectively contributing over 35% of the studies among the top ten countries. The majority of publications appeared in the United States journals, with the top three being Gastrointestinal Endoscopy [impact factor (IF) = 7.7, H-index = 26], Digestive Diseases and Sciences (IF = 3.1), and Endoscopy (IF = 9.3). Six primary research clusters were identified: Obstructive sleep apnea and airway management, surveillance and risk factors, colorectal cancer examination and treatment, sedation and safety of propofol and midazolam, patient satisfaction, and mortality and complications. These findings underscore the pivotal focus areas in anesthesia for elderly patients undergoing gastroenteroscopy.

CONCLUSION

A comprehensive understanding of current research trends and hotspots will aid anesthesiologists in developing more evidence-based practices, thereby improving the safety and outcomes for elderly patients undergoing gastroenteroscopy.

Protocol for the development and validation of machine-learning models for predicting the risk of hypertriglyceridemia in critically ill patients receiving propofol sedation using retrospective data

Introduction

Propofol is a widely used sedative-hypnotic agent for critically-ill patients requiring invasive mechanical ventilation (IMV). Despite its clinical benefits, propofol is associated with increased risks of hypertriglyceridemia. Early identification of patients at risk for propofol-associated hypertriglyceridemia is crucial for optimizing sedation strategies and preventing adverse outcomes. Machine learning (ML) models offer a promising approach for predicting individualized patient risks of propofol-associated hypertriglyceridemia.

Methods and analysis

We propose the development of a ML model aimed at predicting the risk of propofol-associated hypertriglyceridemia in ICU patients receiving IMV. The study will utilize retrospective data from four Mayo Clinic sites. Nested cross-validation (CV) will be employed, with a 10-fold inner CV loop for model tuning and selection as well as an outer loop using leave-one-site-out CV for external validation. Feature selection will be conducted using Boruta and LASSO-penalized logistic regression. Data preprocessing steps include missing data imputation, feature scaling, and dimensionality reduction techniques. Six ML algorithms will be tuned and evaluated. Bayesian optimization will be used for hyperparameter selection. Global model explainability will be assessed using permutation importance, and local model explainability will be assessed using SHapley Additive exPlanations (SHAP).

Ethics and dissemination

The proposed ML model aims to provide a reliable and interpretable tool for clinicians to predict the risk of propofol-associated hypertriglyceridemia in ICU patients. The final model will be deployed in a web-based clinical risk calculator. The model development process and performance measures obtained during nested cross-validation will be described in a study publication to be disseminated in a peer-reviewed journal. The proposed study has received ethics approval from the Mayo Clinic Institutional Review Board (IRB #23-007416).

Strengths and limitations of this study

Robust external validation using a nested cross-validation (CV) framework will help assess the generalizability of models produced from the modeling pipeline across different hospital settings.A diverse set of machine learning (ML) algorithms and advanced hyperparameter tuning techniques will be employed to identify the most optimal model configuration.Integration of feature explainability will enhance the clinical applicability of the ML models by providing transparency in predictions, which can improve clinician trust and encourage adoption.Reliance on retrospective data may introduce biases due to inconsistent or erroneous data collection, and the computational intensity of the validation approach may limit replication and future model expansion in resource-constrained settings.

Induction Agents for Tracheal Intubation in Critically Ill Patients

OBJECTIVES

Concise definitive review of the use of induction agents in critically ill patients undergoing tracheal intubation and their association with outcomes.

DATA SOURCES

Original publications were retrieved through a PubMed search with search terms related to induction agents for tracheal intubation in critically ill patients.

STUDY SELECTION

We included randomized controlled trials and observational studies that reported patient outcomes.

DATA EXTRACTION

Data from included studies, including choice of induction agents and clinically relevant outcomes, were extracted.

DATA SYNTHESIS

Etomidate and ketamine have been the most studied induction agents in critical care during last years. Recent studies on etomidate investigated the clinical impact of its recognized adrenal suppression in terms of morbidity and mortality. Etomidate may carry a non-negligible mortality risk without definitive hemodynamic benefits compared with ketamine. Available data then support the use of ketamine over etomidate, since the difference in the hemodynamic profile seems to be of minor clinical relevance. No multicenter randomized studies are available comparing propofol to other induction agents but evidence from a large observational study identified an association of propofol with post-intubation cardiovascular instability in critically ill patients. Despite the observational nature of these findings cannot exclude the role of confounders, the association of propofol with post-induction cardiovascular instability is pharmacologically plausible, justifying its avoidance in favor of drugs with a better safety profile in critical care such as ketamine.

CONCLUSIONS

Although no definitive conclusions can be drawn based on the available evidence, recent evidence pointed out the potential negative effect of etomidate on survival and the association of propofol with cardiovascular instability. Ketamine may be considered the drug with a safer profile, widespread availability and low cost but future research should provide definitive data on optimal drug selection, its dosage in the context of critical illness and concomitant interventions to minimize the risk of peri-intubation complications.

Sedation during dynamic bronchoscopy for expiratory central airway collapse: Which is the ideal protocol?

OBJECTIVE

To compare sedation protocols for dynamic bronchoscopy (DB) in the evaluation of expiratory central airway collapse (ECAC).

MATERIALS AND METHODS

This observational study included adult patients (≥18 years) referred to Mayo Clinic, Jacksonville, FL, from March 2023 to July 2024, for suspected ECAC. Patients were grouped based on sedation protocols: propofol (Protocol 1), remimazolam (Protocol 2), and remimazolam/fentanyl (Protocol 3). The primary outcome was the quality of assessment during DB, rated on a 4-point Likert scale (1 = poor, 4 = excellent). Secondary outcomes included anesthesia duration and post-anesthesia care unit (PACU) length of stay. Statistical analyses included Fisher's exact test, ordinal logistic regression, and Kruskal-Wallis tests.

RESULTS

Seventy-three patients met the inclusion criteria. Overall, DB quality of assessment was significantly associated with sedation protocol (P=0.01 Ordinal regression results suggest that protocol 3 (remimazolam/fentanyl) may be comparable to protocol 1 (propofol) (OR0.40, 95%CI 0.12-1.33, P = 0.13), with both showing a tendency for better performance than protocol 2 (remimazolam) (OR0.14, 95%CI 0.04-0.46 P=0.002 vs protocol 3; OR0.35, 95%CI 0.09-0.29 P=0.115 vs protocol 1). No significant differences were found in PACU length of stay among the three protocols (P = 0.13). No post-procedural complications were reported.

CONCLUSION

Protocol 3 (remimazolam/fentanyl) demonstrated significantly higher odds of achieving a better quality of assessment compared to Protocol 2 (remimazolam) and showed comparable performance to Protocol 1 (propofol). These findings suggest that remimazolam/fentanyl is an effective sedation option for DB, providing improved assessment quality without increasing PACU stay. Larger prospective studies are necessary to confirm these results.

Parameters Predictive of Propofol-Associated Acute Pancreatitis in Critically Ill Patients with COVID-19 Pneumonia: A Retrospective Cohort Study

BACKGROUND

Propofol, a commonly used agent for short- and long-term sedation, is associated with acute pancreatitis. The main indirect mechanism of propofol-associated acute pancreatitis is by inducing hypertriglyceridemia. Patients with severe coronavirus disease 2019 (COVID-19) pneumonia often require prolonged mechanical ventilation and sedation. We examined the incidence rate of acute pancreatitis among critically ill adults with COVID-19 pneumonia on mechanical ventilation receiving propofol. In addition, we attempted to determine cutoff levels of serum triglycerides and doses of propofol that are predictive of propofol-associated acute pancreatitis.

METHODS

This was a multicenter retrospective cohort study using a large dataset of hospitalized patients with COVID-19. The collected data included the number of days on propofol, cumulative doses of propofol, peak levels of serum triglycerides, serum lipase levels, and abdominal imaging findings. We used receiver-operating characteristic analysis in conjunction with Youden's index to identify the optimal thresholds for propofol administration parameters and levels of triglycerides that would provide maximal sensitivity and specificity for predicting acute pancreatitis.

RESULTS

Out of 499 critically ill patients with COVID-19 pneumonia, 154 met the inclusion criteria. Six (4%) patients had suspected acute pancreatitis based on elevated serum lipase levels. Cutoff values greater than 688 mg/dL for peak level of triglycerides, 4.5 days on propofol, 3007 mg/day for average daily propofol dose, and 24 113 mg for cumulative propofol dose were associated with high risk of suspected acute pancreatitis. The negative predictive values for suspected acute pancreatitis using these cutoffs ranged from 98% to 100%.

CONCLUSIONS

Propofol use in critically ill COVID-19 patients is associated with a low incidence rate of acute pancreatitis. We identified cutoff values for serum triglycerides and cumulative propofol dose that are linked to higher risk of propofol-associated pancreatitis. More research is needed to examine the true incidence of propofol-associated pancreatitis and help develop optimal cutoff values for certain parameters to help guide safe propofol administration.

A Systematic Review and Meta-Analysis of Prophylactic Vasopressors for the Prevention of Peri-Intubation Hypotension

BACKGROUND/OBJECTIVES

Peri-intubation hypotension is a known complication of endotracheal intubation. In the hospital setting, peri-intubation hypotension has been shown to increase hospital mortality and length of stay. The use of prophylactic vasopressors at the time of sedation induction to prevent peri-intubation hypotension has been raised. This systematic review and meta-analysis aims to review the safety and efficacy of this practice.

METHODS

The study was fully registered with PROSPERO on 13 October 2022, and screening for eligibility was initiated on 20 September 2024. Randomized controlled trials, along with retrospective or prospective cohort studies, were included in the search. The terms "peri-intubation hypotension", "vasopressors", "intubation", and "anesthesia induced hypotension" were used to search the title/summary in PubMed, Cochrane Library, and Google Scholar databases. An assessment of bias for each study was conducted using the Newcastle-Ottawa Quality Assessment Scale. The primary outcome was the rate of hypotension peri-intubation. Any complications secondary to hypotension or vasopressors were the secondary outcome.

RESULTS

We identified 13 studies, which were all randomized controlled studies, to include in the final analysis. The risk ratio for preventing peri-intubation hypotension was 1.6 (95% CI, 1.2-2.14) with the use of prophylactic phenylephrine while giving propofol versus no prophylactic vasopressors and 1.28 (95% CI 1.03-1.60) with the use of ephedrine.

CONCLUSIONS

These findings suggest that in patients undergoing intubation in the operating room with propofol, prophylactic vasopressors given with induction for intubation decrease the odds of hypotension.

The median effective dose of ciprofol combined with sufentanil in suppressing the laryngeal mask airway insertion response in both young and older adult patients

BACKGROUND

Ciprofol, a novel intravenous anesthetic, exhibits similar sedation mechanisms and pharmacokinetic properties to propofol. However, ciprofol demonstrates greater potency and is associated with reduced injection pain compared to propofol. Given the varying sensitivities to anesthetic agents across different age groups, this study aims to determine the median effective dose (ED50) of ciprofol required to suppress the laryngeal mask airway (LMA) insertion response in both young and older adult patients, as well as to assess its potential adverse reactions.

METHODS

In this study, 46 patients scheduled for surgery under general anesthesia with LMA insertion were recruited. Upon entering the operating room, patients were intravenously administered ciprofol (0.4 mg·kg- 1) and sufentanil (0.3 µg·kg- 1), followed by LMA insertion after three minutes. To derive robust confidence intervals for both ED50 and ED95, we performed an analysis using a logistic regression model combined with bootstrap resampling.

RESULTS

In the young adult group, the ED50 and ED95 of ciprofol for suppressing the LMA insertion response were 0.38 mg·kg- 1 (95% CI, 0.35-0.41) and 0.46 mg·kg- 1 (95%CI, 0.40-0.56), respectively. In the older adult group, the respective ED50 and ED95 were 0.29 mg·kg- 1 (95% CI, 0.26-0.32) and 0.37 mg·kg- 1 (95% CI, 0.30-0.78). Regarding adverse reactions, although there were differences in the incidence of injection pain, hypotension, and bradycardia between the young and older groups, no statistically significant differences were observed between the two groups.

CONCLUSION

In this study, significant differences were observed in the ED50 of ciprofol for suppressing the LMA insertion response between young and older adult patients. The ED50 of ciprofol for young adult patients was 0.38 mg·kg- 1 (95% CI, 0.35-0.41), while for older adult patients it was0.29 mg·kg- 1 (95% CI, 0.26-0.32).

TRIAL REGISTRATION

This study was registered on February 17, 2024, with the China Clinical Trial Registration Center ( www.chictr.org.cn ; Registration Number: ChiCTR2400080891).

Comparing Cognitive Recovery of Remimazolam versus Propofol in Elderly Patients Undergoing Colonoscopy: A Randomized Controlled Trial

Background

Remimazolam, a novel ultra-short-acting benzodiazepine, shows promise for procedural sedation. This study compared the cognitive recovery of remimazolam versus propofol in elderly patients undergoing colonoscopy.

Patients and Methods

In this prospective, randomized, double-blind, controlled trial, 228 patients aged ≥ 65 years undergoing outpatient colonoscopies were recruited. Patients received intravenous sufentanil 0.05 μg/kg, followed by either remimazolam 0.2 mg/kg or propofol 1 mg/kg for sedation induction. The assigned study drug (remimazolam 0.1 mg/kg or propofol 0.5 mg/kg) was titrated to maintain a Modified Observer's Assessment of Alertness/Sedation scale score < 3 during the procedure. The primary outcome was the incidence of cognitive recovery, assessed using the Postoperative Quality of Recovery Scale (PostopQRS) cognitive domain on postoperative day 3. Secondary outcomes included overall and other PostopQRS domains recovery, time to discharge, patient satisfaction, and adverse events.

Results

Cognitive recovery on day 3 was similar between remimazolam (84.2%) and propofol (85.1%) groups (risk ratio = 0.99; 95% CI: 0.89-1.11; p = 0.854). No significant differences were observed in overall recovery, other domains, or discharge time. Remimazolam patients reported higher satisfaction (p = 0.001) and experienced lower incidences of hypotension (21.9% vs 53.5%; p < 0.001), hypoxemia (6.1% vs 16.7%; p = 0.024), and injection site pain (15.8% vs 41.2%; p < 0.001) compared to propofol.

Conclusion

In elderly patients undergoing colonoscopy, remimazolam demonstrated comparable cognitive recovery to propofol, with higher patient satisfaction and a more favorable safety profile. Remimazolam may be the preferred alternative to propofol for procedural sedation in this vulnerable population.

Trial Registration

The Chinese Clinical Trial Registry, ChiCTR2200066689.

ICU patient-on-a-chip emulating orchestration of mast cells and cerebral organoids in neuroinflammation

Propofol and midazolam are the current standard of care for prolonged sedation in Intensive Care Units (ICUs). However, the effects and mechanism of these sedatives in brain tissue are unclear. Herein, the development of an ICU patient-on-a-chip platform to elucidate those effects is reported. The humanized neural tissue compartment combines mast cells differentiated from human induced pluripotent stem cells (hiPSCs) with cerebral organoids in a three-dimensional (3D) matrix, which is covered with a membrane populated with human cerebral microvascular endothelial cells (hCMEC/D3) that separates the tissue chamber from the vascular lumen, where sedatives were infused for four days to evaluate neurotoxicity and cell-mediated immune responses. Subsequent to propofol administration, gene expressions of CD40 and TNF-α in mast cells, AIF1 in microglia and GFAP/S100B/OLIG2/MBP in macroglia were elevated, as well as NOS2, CD80, CD40, CD68, IL6 and TNF-α mediated proinflammation is noted in cerebral organoids, which resulted in higher expressions of GJB1, GABA-A and NMDAR1 in the tissue construct of the platform. Besides, midazolam administration stimulated expression of CD40 and CD203c+ reactivated mast cell proliferation and compromised BBB permeability and decreased TEER values with higher barrier disruption, whereas increased populations of CD11b+ microglia, higher expressions of GFAP/DLG4/GJB1 and GABA-A-/NMDAR1- identities, as well as glutamate related neurotoxicity and IL1B, IFNG, IFNA1, IL6 genes mediated proinflammation, resulting in increased apoptotic zones are observed in cerebral organoids. These results suggest that different sedatives cause variations in cell type activation that modulate different pathways related to neuroinflammation and neurotoxicity in the ICU patient-on-chip platform.

The influence of anesthetic drug strategy on the incidence of post-induction hypotension in elective, non-cardiac surgery - A prospective observational cohort study

STUDY OBJECTIVES

To identify the influence of modifiable factors in anesthesia induction strategy on post-induction hypotension (PIH), specifically the type, dosage and speed of administration of induction agents. A secondary aim was to identify patient related non-modifiable factors associated with PIH.

DESIGN

Single-center, prospective observational cohort study.

SETTING

Operating room.

PATIENTS

Adult, ASA I-IV patients undergoing elective, non-cardiac surgery under general anesthesia (GA).

INTERVENTIONS

None.

MEASUREMENTS

Continuous non-invasive blood pressure using finger-cuff technology. PIH was defined as mean arterial pressure (MAP) <65 mmHg ≥1 min, and, separately, as a > 30 % decrease from baseline MAP ≥1 min.

MAIN RESULTS

Study measurements were performed in 760 patients, of which 720 were suitable for analysis. A total of 238 patients (33.1 %) experienced PIH according to the 65 mmHg threshold, and 287 (39.9 %) using the 30 % decrease in MAP threshold. Remifentanil administration was associated with increased risk of PIH according to either definition (MAP <65 mmHg: OR 1.88, 95 %CI 1.31-2.69, p < 0.001, 30 % MAP decrease: OR 1.66, 95 %CI 1.15-2.40, p = 0.007). Pre-emptive vasopressor use (before or during first minute of GA) was associated with reduced risk of PIH (MAP <65 mmHg: OR 0.65, 95 %CI 0.45-0.95, p = 0.027, MAP 30 % decrease: OR 0.58, 95 %CI 0.40-0.84, p = 0.004). Speed of propofol bolus administration, propofol bolus dose, and esketamine use were not associated with PIH in multivariable analysis. Propofol bolus dose decreased with increasing age and American Society of Anesthesiologists physical status classification.

CONCLUSIONS

PIH was common in this patient cohort, regardless of the definition used. Two of the five examined modifiable factors were associated with PIH: remifentanil infusion was associated with an increased risk, and pre-emptive vasopressor use was associated with a decreased risk of PIH. No association between propofol dose and PIH was found, most likely due dose adjustment based on clinical assessment rather than a true absence of effect.

CLINICAL REGISTRATION NUMBER

This study was registered in the Dutch Medical Research in Humans (OMON) register on 18 June 2019 (ID: NL7810). The study was approved by the Medical Ethics Committee of the Amsterdam UMC, location AMC, the Netherlands in December 2018 (NL 6748.018.18; 2018).

Effects of dexmedetomidine versus propofol on outcomes in critically ill patients with different sedation depths: a propensity score-weighted cohort study

OBJECTIVE

We explored the effects of dexmedetomidine (DEX) versus propofol on outcomes in critically ill patients and to assess whether these effects are dissimilar under different sedation depths.

METHODS

A stabilized inverse probability of treatment weighting cohort study was conducted using data from the Medical Information Mart for Intensive Care IV database from 2008 to 2019. Adult intensive care unit (ICU) patients who were administered DEX or propofol as the primary sedative were identified. Various statistical methods were used to evaluate the effects of DEX versus propofol on outcomes.

RESULTS

Data on 107 and 2318 patients in DEX and propofol groups, respectively, were analyzed. Compared to the propofol group, the DEX group exhibited longer ventilator-free days on day 28 and a shorter ICU stay. Conversely, it showed null associations of DEX with the risk of 90-day ICU mortality, the odds of persistent organ dysfunction on day 14 and acute kidney injury, and the duration of vasopressor-free days on day 28. Subgroup analyses revealed that DEX positively impacted persistent organ dysfunction on day 14, ventilator-free days on day 28, and ICU stay in the subgroup with a Richmond Agitation Sedation Scale (RASS) score of ≥-2. However, DEX negatively impacted 90-day ICU mortality, persistent organ dysfunction on day 14, and ventilator-free days on day 28 in the subgroup with a RASS score of <-2.

CONCLUSION

Our results indicated that, compared with propofol, DEX had beneficial and adverse impacts on certain ICU outcomes in critically ill patients, and these impacts appeared to depend on sedation depths.

Pharmacological Prevention of Postoperative Delirium in Adults: A Review of Recent Literature

PURPOSE OF REVIEW

Postoperative delirium (POD) is a common complication that has important implications for surgical patients, often leading to both short- and long-term cognitive deficits, worse outcomes, and increased healthcare costs. Given these implications, there may be a benefit in reducing the incidence of POD. Pharmacologic interventions may have the potential to reduce the risk of a patient developing POD.

RECENT FINDINGS

Recently studied therapies include dexmedetomidine, propofol, haloperidol, ketamine, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, acetaminophen, melatonin/ramelteon, corticosteroids, midazolam, physostigmine, and neostigmine. In addition, the implementation of regional anesthesia and reduction of overall anesthetic depth have been examined. Of these therapies, dexmedetomidine has been studied the most and has the most supporting evidence for prevention of POD, but current studies lack clarity on optimal dosing and timing of dexmedetomidine administration. Acetaminophen, corticosteroids, and melatonin/ramelteon are other plausible medications that have potential for reducing POD incidence, but they all require further investigation. Reduction of anesthetic depth and regional anesthetics are options for anesthetic management that show promise but still lack enough supporting evidence in recent literature to receive a strong recommendation. Future research should focus on identifying optimal strategies for the implementation of the pharmacological options listed, including doses and timing of administration. Attention should be given to dexmedetomidine given its promise demonstrated by recent literature.

Choice of Postintubation Sedation Strategy by Sex: A Conjoint Analysis

PURPOSE

To assess if patient sex is an important attribute in physician decision-making for postintubation sedation strategies in the emergency department and intensive care units.

METHODS

We designed a survey of eight fictional cases utilizing a fractional factorial design varying fictional patient sex, race/ethnicity, and history of substance use disorder. We surveyed emergency medicine and critical care fellows and attendings at three geographically diverse academic medical centers in the US. We analyzed data using conjoint analysis to assess importance weights (IW). For this analysis, we compared physician beliefs of stated importance of sex to IW derived from cases.

FINDINGS

Eighty-six participants started the survey; 75 (87.2%) participants completed demographic information and at least one vignette and were included in analysis. Most physicians were white, male, worked primarily in an emergency department and were attending physicians. Sex had the lowest weight in affecting decisions when considering using midazolam (IW = 3.2%) or propofol (IW = 3.6%) as postintubation sedation strategies, and the second lowest weight when considering fentanyl (IW = 7.3%). Respondents stated they believed physicians rarely considered patient sex when making decisions about postintubation sedation.

IMPLICATIONS

Physicians managing postintubation sedation reported sex rarely affected decision-making when choosing propofol, midazolam, or fentanyl as sedation strategies, despite evidence that these medications are metabolized differently in females. Further research is needed to identify ideal postintubation sedation strategies that account for patient sex.

Effectiveness and safety of remimazolam tosilate versus propofol for sedation in patients undergoing gastrointestinal endoscopy: a randomized controlled trial

BACKGROUND

Remimazolam tosilate is a new type of benzodiazepine currently used for gastrointestinal endoscopy and can be combined with alfentanil.

AIM

This trial compared the effectiveness and safety of remimazolam with alfentanil to propofol with alfentanil in patients undergoing gastrointestinal endoscopy.

METHOD

One hundred and sixty-six patients were randomly divided into propofol-alfentanil anaesthesia (Group P) and remimazolam-alfentanil anaesthesia (Group R). The primary outcomes were perioperative haemodynamic variables, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and oxygen saturation (SpO2) preoperatively (T0); after anaesthesia induction (T1); when the gastroscope passed through the oropharynx (T2); 3 min (T3), 5 min (T4) and 7 min (T5) after T2; at the end of surgery (T6); and when patients successfully awakened (T7). The secondary outcomes included induction and awakening time, patient satisfaction, operator satisfaction, and adverse event occurrences.

RESULTS

Compared with those in Group P, the SBP in Group R was significantly higher at T1, T2, T3, and T6 (P < 0.05); the DBP and MAP were significantly higher at T1, T2, T3, T5, and T6 (P < 0.05); the HR was significantly faster at T1 to T6 (P < 0.05); the SpO2 was significantly higher at T1 to T4 (P < 0.05); the incidences of hypoxemia, hypotension, and drug injection pain were significantly lower in Group R (P < 0.05); the incidence of hiccups was higher (P < 0.05); the awakening time was shorter in Group R (P < 0.05); and the operator satisfaction score was high (P < 0.05).

CONCLUSION

Compared to propofol with alfentanil, remimazolam with alfentanil can be used safely and effectively for sedation in patients undergoing gastrointestinal endoscopy, with less impact on the patient's circulatory and respiratory systems and a lower incidence of adverse events.

TRIAL REGISTRATION

This trial protocol was registered in the Chinese Clinical Trial Registry (ChiCR2300077252, date: 2023-11-02).

Comparing the haemodynamic effects of high- and low-dose opioid anaesthesia: a secondary analysis of a randomised controlled trial

Post-induction hypotension (MAP < 65 mmHg) occurs frequently and is usually caused by the cardiovascular adverse effects of the anaesthetic induction drugs used. We hypothesize that a clinically significant difference in the incidence and severity of hypotension will be found when different doses of propofol and remifentanil are used for induction of anaesthesia.

METHODS

This is a secondary analysis of a randomised controlled trial wherein four groups (A-D) of patients received one out of four different combinations of propofol and remifentanil, titrated to a predicted equipotency in probability of tolerance to laryngoscopy (PTOL) according to the Bouillon interaction model. In group A, a high dose of propofol and a low dose of remifentanil was administered, and across the groups this ratio was gradually changed until it was reversed in group D. Mean and systolic arterial blood pressure (MAP, SAP) were compared at four time points (Tbaseline, Tpost-bolus, T3min, Tnadir) within and between groups Heart rate, bispectral index (BIS) and the incidence of hypotension were compared.

RESULTS

Data from 76 patients was used. At Tpost-bolus a statistically significant lower MAP and SAP was found in group A versus D (p = 0.011 and p = 0.002). A significant higher heart rate was found at T3min and Tnadir between groups A and B when compared to groups C and D (p = < 0.001 and p = 0.002). A significant difference in BIS value was found over all groups at T3min and Tnadir (both p < 0.001). All other outcomes did not differ significantly between groups.

CONCLUSION

Induction of anaesthesia with different predicted equipotent combinations of propofol and remifentanil did result in statistically different but clinically irrelevant differences in haemodynamic endpoints during induction of anaesthesia. Our study could not identify preferable drug combinations that decrease the risk for hypotension after induction, although they all yield a similar predicted PTOL.

Remimazolam Use in Cardiac Anesthesia: A Narrative Review

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.

Propofol Ameliorates Spinal Cord Injury Process by Mediating miR-672-3p/TNIP2 Axis

Propofol has been found to have a protective effect against spinal cord injury (SCI). However, the underlying molecular mechanism of propofol regulating SCI process remains unclear. In this study, lipopolysaccharide (LPS)-induced PC12 cells were used to build SCI cell models. Cell viability and apoptosis were determined by cell counting kit 8 assay, flow cytometry, and caspase-3 activity detection. The protein levels of apoptosis-related markers and TNFAIP3 interacting protein 2 (TNIP2) were assessed using western blot analysis, and the levels of inflammatory factors were detected using ELISA. Cell oxidative stress was evaluated by measuring malondialdehyde (MDA) and reactive oxygen species (ROS) levels. The expression of microRNA (miR)-672-3p was examined by quantitative real-time PCR. SCI rat models were constructed to assess the effect of propofol in vivo. We found that propofol treatment promoted viability, while inhibited apoptosis, inflammation and oxidative stress of LPS-induced PC12 cells. Propofol decreased miR-672-3p expression, and miR-672-3p overexpression eliminated the inhibiting effect of propofol on LPS-induced PC12 cell injury. Besides, miR-672-3p targeted TNIP2, and TNIP2 knockdown reversed the protective effect of miR-672-3p inhibitor or propofol against LPS-induced PC12 cell injury. In vivo experiments, propofol treatment enhanced the motor function recovery and inhibited apoptosis of SCI rat models. In conclusion, propofol increased TNIP2 level by reducing miR-672-3p expression, thereby alleviating LPS-induced PC12 cell injury and improving the motor function of SCI rat models.

Impact of Propofol Administered before Extubation on Respiratory Adverse Events in Pediatric Patients Undergoing Tonsillectomy and Adenoidectomy: A Randomized Controlled Trial

Aims/Background Perioperative respiratory adverse events (PRAEs) are common in pediatric anesthesia, especially in otolaryngology procedures. In this randomized controlled trial, we investigated the impact of administering propofol before extubation on PRAEs in pediatric patients undergoing tonsillectomy and adenoidectomy. Methods We enrolled children aged 3 to 8 years old, of American Society of Anesthesiologists (ASA) classes I to III, scheduled for tonsillectomy, and randomly divided them into propofol and control groups. The subjects in the propofol group received multiple small doses of propofol (0.5 mg/kg per dose, total 1-2 mg/kg) until the patient resumed regular spontaneous breathing and exhibited no bodily movements. The subjects in the control group received 0.15 mL/kg of saline. The primary outcome was the rate of PRAEs, such as laryngospasm, bronchospasm, breath-holding spell, severe coughing, desaturation, and airway obstruction, post-extubation. The secondary outcomes were the extubation time, pre-extubation Richmond Agitation-Sedation Scale (RASS) score, end-tidal sevoflurane concentration at extubation, incidence of postoperative agitation, time to consciousness, and Face, Legs, Activity, Cry, and Consolability (FLACC) pain score in the recovery room. Results were reported with risk ratios (RR) and their 95% confidence intervals (CI), as well as the p-values indicating statistical significance. Results A total of 239 patients were included, including 119 in the propofol group and 120 in the control group. Our findings indicated no significant difference in the rate of PRAEs between the two groups (5.9% vs 10.8%, RR: 0.54, 95% CI: 0.23 to 1.31, p = 0.17). However, the propofol group showed a notable decrease in moderate to severe coughs (13.4% vs 60.0%, RR: 0.22, 95% CI: 0.14 to 0.36, p < 0.001) and postoperative agitation (4.2% vs 60.8%, RR: 0.07, 95% CI: 0.03 to 0.17, p < 0.001). Conclusion This trial demonstrated that while administering repeated small doses of propofol before extubation does not significantly reduce respiratory adverse events in children undergoing tonsillectomy and adenoidectomy, it does significantly reduce the incidence of severe coughing, improving postoperative recovery and clinical outcomes. Moreover, propofol helps reduce postoperative agitation, enhancing the safety and effectiveness of postoperative care, and maintaining its valuable clinical role in postoperative management. Clinical Trial Registration ClinicalTrials.gov (NCT05769842).

Comparative effects of ciprofol and propofol on perioperative outcomes: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The ideal anesthetic agents for sedation, considering their respiratory and cardiovascular benefits and other perioperative or postoperative outcomes, are still unclear. This systematic review and meta-analysis aimed to evaluate whether ciprofol has advantages over propofol for sedation, particularly concerning respiratory and cardiovascular outcomes and other relevant perioperative measures.

METHODS

We conducted a comprehensive search of PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, and two Chinese databases for randomized controlled trials comparing intravenous ciprofol and propofol for sedation. The primary outcome was the incidence of adverse respiratory events. Secondary outcomes included incidences of injection pain, hypotension, hypertension, bradycardia during surgery, perioperative nausea and vomiting, and postoperative awakening time. A random-effects model was used for more than four studies; otherwise, we employed the random-effects model with the Hartung-Knapp-Sidik-Jonkman adjustment.

RESULTS

Intravenous ciprofol resulted in fewer adverse respiratory events than propofol (Risk Ratio [RR = 0.44]; 95% Confidence Interval [95% CI 0.35-0.55], p < 0.001, I2 = 45%, low quality). It also showed a lower incidence of injection pain (RR = 0.12; 95% CI 0.08‒0.17, p < 0.001, I2 = 36%, low quality), intraoperative hypotension (RR = 0.64; 95% CI 0.52-0.77, p < 0.001, I2 = 58%, low quality), and nausea and vomiting than propofol (RR = 0.67; 95% CI 0.49-0.92; p = 0.01, I2 = 0%, moderate quality). However, no significant differences were observed for hypertension, bradycardia, and awakening time.

CONCLUSIONS

Ciprofol may be more effective than propofol in minimizing perioperative respiratory adverse events and maintaining hemodynamic stability during sedation without prolonging recovery time.

The potency-ratio of ciprofol and propofol under procedural sedation and anesthesia for outpatient hysteroscopy during cervical dilation: a study using up-and-down sequential allocation method

BACKGROUND

Ciprofol(HSK3486) is a novel 2,6-disubstituted phenol derivate, a short-acting intravenous sedative, which has similar efficacy characteristics as propofol with less incidence of side effect. Both ciprofol and propofol are often used in outpatient hysteroscopic surgery for sedation. However, the relative potency of these two drugs has not been fully determined in this context.

OBJECTIVE

Our study aimed to investigate the potency-ratio of ciprofol and propofol under procedural sedation and anesthesia in restraining reaction of outpatient hysteroscopy dilatation.

METHODS

The ED50 (effective dose in 50% of subjects) value for ciprofol and propofol were calculated by Up-and-Down Sequential Allocation Method. 60 healthy patients undergoing daytime hysteroscopy were randomly divided into two groups, which were intravenously injected with ciprofol at an initial dose of 0.4 mg/kg (group C) or propofol at an initial dose of 2 mg/kg (group P) at 2 min after intravenous injection of sufentanil 0.15ug/kg. A successful response is defined as the absence of patient movement in the case of cervical dilation. Conversely, the presence of patient movement is defined as failure. After successful or failed responses, each follow-up patient in the corresponding group was reduced or increased with propofol 0.5 mg/kg or ciprofol 0.1 mg/kg, respectively.

RESULTS

The estimated ED50 value for ciprofol and propofol in restraining reaction of hysteroscopy dilatation was 0.444 mg/kg (95% CI, 0.385-0.503 mg/kg) and 1.985 mg/kg (95% CI, 1.801-2.170 mg/kg), respectively. The incidence of respiratory depression, hypoxemia and injection pain in ciprofol was significantly lower than those in propofol.

CONCLUSION

The ED50 of ciprofol and propofol in preventing hysteroscopy dilatation reaction was 0.444 mg/kg (95% CI, 0.385-0.503 mg/kg) and 1.985 mg/kg (95% CI, 1.801-2.170 mg/kg) for outpatient hysteroscopy. The potency-ratio of ciprofol and propofol observed in our study was 1.0:4.5(95%CI,1:3.9-1:5.1).

TRIAL REGISTRATION

The study was registered at Chinese Clinical Trial Registry http//www.chictr.org.cn/ (Registration date19/11/22 Trial ID ChiCTR2200065954).

The efficacy and safety of remimazolam in painless colonoscopy: a prospective, randomized clinical trial

Purpose

Remimazolam is a new type of ultra-short-effect intravenous anesthetic, that may provide adequate sedation for endoscopy while causing less cardiovascular or respiratory disturbance than propofol. The aim of this clinical study was to compare the efficacy and safety of two different doses of remimazolam with propofol for sedation during colonoscopy.

Patients and methods

225 subjects, aged 18 to 80 years, with American Society of Anesthesiology physical status I-III, were scheduled to undergo colonoscopy. All the subjects were randomly assigned to three groups, Low-Rem group (low dose remimazolam, 0.15 mg/kg, iv, n = 75), High-Rem group (high dose remimazolam, 0.2 mg/kg, iv, n = 75), and Propofol group (propofol 2 mg/kg, iv, n = 75). Every individual in this trial was given nalbuphine hydrochloride (0.2 mg/kg, iv) before administration of remimazolam or propofol. The primary outcome was the success rate of sedation. Haemodynamic parameters and adverse events were recorded to evaluate safety. Satisfaction of sedation from patients, anesthesiologists and gastroenterologists were also recorded.

Results

The success rate of colonoscopy procedure was 100% in both High-Rem and Propofol groups, but it was 89% in Low-Rem group (p < 0.05). Furthermore, the induction time of anesthesia was shorter in Propofol group, when compared to the Low-Rem group and the High-Rem group (p < 0.05). The recovery time in Low-Rem group, High-Rem group, and Propofol group was 2.33, 2.43, and 3.21 min (p < 0.05) respectively, and the time of discharge was 25.00, 25.01, and 27.56 min (p < 0.05) respectively. Simultaneously, the incidence of adverse events such as hypotension, bradycardia, and respiratory depression in the remimazolam groups were significantly lower than that in the propofol group. No significant differences were observed among the three groups in Ramsay scale, BPS-NI scale, and Limb movement classification. Moreover, patients, anesthesiologists, and gastroenterologists were all satisfied with the sedation process.

Conclusion

Remimazolam can be used safely and effectively for colonoscopy. 0.2 mg/kg remimazolam and propofol have the same sedation success rate and more stable hemodynamics and fewer side effects than propofol.

Clinical trial registration

ChiCTR2100054053.

Ciprofol versus propofol for anesthesia induction in cardiac surgery: a randomized double-blind controlled clinical trial

BACKGROUND

Ciprofol, a novel intravenous general anesthetic with a chemical structure similar to propofol, exhibits significantly enhanced potency. It offers a rapid onset, reduced incidence of injection pain, and has comparable effects on heart rate and blood pressure to propofol. However, clinical data on its use for anesthesia induction in cardiac surgery remain limited.

METHODS

Seventy-eight patients undergoing coronary artery bypass grafting or valve replacement surgery were randomly assigned to receive either ciprofol (N = 40) or propofol (N = 38) for anesthesia induction. Variables recorded included changes in mean arterial pressure and heart rate during anesthesia, alterations in the oxygenation index and lactic acid concentration before and 10 min after anesthesia induction, and the incidence of adverse events such as bradycardia, hypotension, and injection pain.

RESULTS

The incidence of anesthesia-induced injection pain was significantly lower in the ciprofol group compared to the propofol group (3% vs. 18%, P < 0.05). The incidence of other adverse events was similar between the groups. No significant differences in hemodynamics or oxygenation index were observed during anesthesia induction between ciprofol and propofol.

CONCLUSIONS

Ciprofol demonstrated a significantly lower incidence of injection pain compared to propofol, potentially improving patient comfort during anesthesia induction. Additionally, ciprofol showed comparable circulatory stability to propofol during anesthesia induction in cardiac surgery, suggesting it may be a suitable alternative to propofol for this application.

TRIAL REGISTRATION

The trial was registered at the ClinicalTrials.gov on 03/10/2024 (NCT06312345).

The efficacy and safety of ciprofol versus propofol in patients undergoing painless hysteroscopy: a randomized, double-blind, controlled trial

BACKGROUND

Studies have reported that ciprofol has the advantage of reducing injection pain compared to propofol during gastroscopy, colonoscopy, and fiberoptic bronchoscopy. The effect of ciprofol on the injection pain in painless hysteroscopy needs to further explore.

METHODS

A double-blind randomized controlled trial (RCT) was designed, and patients were recruited from the First Central Hospital of Baoding from March 2024 to June 2024. The eligible participants were allocated into ciprofol group (ciprofol combined with alfentanil) and propofol group (propofol combined with alfentanil) at 1:1 ratio. The primary outcome was injection pain. The secondary outcomes included sedation success rate, anesthesia success rate, adverse events, patient satisfaction, and comparison of vital signs before and after administration.

RESULTS

A total of 217 participants were included for analysis, with 109 participants in the ciprofol group and 108 participants in the propofol group. The injection pain rate of ciprofol group (18.35%) was significantly lower than the propofol group (40.74%). Both the ciprofol group and propofol group had 100% of the sedation success rate. The anesthesia success rate between the two groups was comparable (P > 0.05). The rate of adverse events was lower (27.52% vs. 45.37%) and patient satisfaction was higher (9.84 ± 0.45 vs. 9.65 ± 0.85) in the ciprofol group than the propofol group. In addition, values of systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in propofol group were significantly lower than those in ciprofol group at the time of cervical dilation and consciousness recovery.

CONCLUSIONS

Ciprofol exhibits comparable efficacy to that of propofol, and is associated with less injection pain rate, fewer adverse events, higher patient satisfaction, and more stable hemodynamics when used for general anesthesia during the painless hysteroscopy.

CLINICAL TRIAL NUMBER

NCT06413862.

Effects of acepromazine, xylazine and propofol on spinal reflexes in healthy dogs

BACKGROUND

In the neurological examination, it is crucial to identify the possible location of the lesion in order to determine the appropriate treatment process. In aggressive animals, chemical restraint may be necessary due to their non-cooperative behaviour. However, sedatives may distort the results of examinations. Therefore, a drug should be found that has minimal impact on the examination results.

OBJECTIVES

To investigate the effects of acepromazine, xylazine, and propofol on spinal reflexes in healthy dogs.

METHODS

In a randomized, blinded study, ten native adult mixed-breed dogs were participated in three groups with a 1-week washout period between each group. Before performing each step, the spinal reflexes were evaluated. Then, in the first group, acepromazine (0.05 mg/kg, IM), in the second group, xylazine (1 mg/kg, IM), and in the third group, propofol (3 mg/kg, IV for initial bolus and 0.1 mg/kg/min for maintenance) were injected for sedation. The spinal reflexes were reevaluated at maximum sedation and at 15, 30, and 45 min thereafter.

RESULTS

Acepromazine increased the patellar reflex and decreased the panniculus reflex. Xylazine increased the cranial tibial reflex and decreased the panniculus reflex, while propofol decreased the withdrawal, and extensor carpi radialis reflexes, and suppressed the palpebral and gag reflexes.

CONCLUSIONS

The drugs used in the present study did not have a significant impact on the most important reflexes evaluated in neurological examinations. Among the drugs, acepromazine has the least effects compared to other drugs, making it a suitable choice for sedation.

The effect of intravenous magnesium sulphate infusion on total intravenous anesthesia with propofol in adult dogs: A randomized, blinded trial

OBJECTIVE

To evaluate cardiopulmonary, arterial blood gas and propofol-sparing effects of magnesium sulfate (MgSO4) constant rate infusion (CRI) in mechanically ventilated dogs maintained under total intravenous anesthesia with propofol.

STUDY DESIGN

Blinded, randomized, clinical trial.

ANIMALS

A total of 24 healthy adult dogs.

METHODS

Dogs were premedicated with intramuscular acepromazine (0.05 mg kg-1) and morphine (0.5 mg kg-1), followed by an intravenous (IV) bolus of saline or MgSO4 (50 mg kg-1 over 15 minutes) and propofol (given to effect to induce anesthesia). Anesthesia was maintained with an IV propofol infusion (beginning at 0.3 mg kg-1 minute-1, adjusted as necessary). Concurrently, one of three IV infusions were administered: GS (0.9% NaCl), GM30 (MgSO4, 30 mg kg-1 hour-1) or GM80 (MgSO4, 80 mg kg-1 hour-1). Propofol induction and maintenance doses were recorded. The following variables were recorded at baseline (T0), after bolus treatment (T1), after beginning mechanical ventilation (T5) and every 15 minutes until the end of the procedure (T15-T120): mean arterial pressure, heart rate, peripheral oxygen saturation, end-tidal partial pressure of CO2, temperature, blood gas variables, indirect calorimetry and extubation time. Values of p < 0.05 were considered significant.

RESULTS

Propofol induction bolus dose was lower in GM30 (31.2%, p = 0.04) and GM80 (38.9%, p = 0.003) than in GS. The maintenance propofol infusion rate in GM80 was 16.9% lower (p = 0.03), resulting in fewer propofol CRI rescues during the perioperative period. GM30 and GM80 exhibited faster extubation times than GS (46.2%, p = 0.002 and 48.9%, p = 0.001, respectively).

CONCLUSIONS AND CLINICAL RELEVANCE

Infusion of a 50 mg kg-1 bolus, followed by CRI of MgSO4 (30 and 80 mg kg-1 hour-1), reduces the propofol induction and maintenance (CRI) requirement, maintaining cardiorespiratory stability and reducing the time required to extubation.

Solubilization techniques used for poorly water-soluble drugs

About 40% of approved drugs and nearly 90% of drug candidates are poorly water-soluble drugs. Low solubility reduces the drugability. Effectively improving the solubility and bioavailability of poorly water-soluble drugs is a critical issue that needs to be urgently addressed in drug development and application. This review briefly introduces the conventional solubilization techniques such as solubilizers, hydrotropes, cosolvents, prodrugs, salt modification, micronization, cyclodextrin inclusion, solid dispersions, and details the crystallization strategies, ionic liquids, and polymer-based, lipid-based, and inorganic-based carriers in improving solubility and bioavailability. Some of the most commonly used approved carrier materials for solubilization techniques are presented. Several approved poorly water-soluble drugs using solubilization techniques are summarized. Furthermore, this review summarizes the solubilization mechanism of each solubilization technique, reviews the latest research advances and challenges, and evaluates the potential for clinical translation. This review could guide the selection of a solubilization approach, dosage form, and administration route for poorly water-soluble drugs. Moreover, we discuss several promising solubilization techniques attracting increasing attention worldwide.

Management of T cell responses by anesthetic drugs-propofol & isoflurane in perioperative breast cancer patients: A prospective hospital-based study

Background & objectives The choice of anesthetic for better perioperative conservation of immune responses has always been contentious. This study investigated the differential impact of the intravenous anesthetic, propofol, and the volatile anesthetic, isoflurane on the T cell immune responses, if any, among individuals going through perioperative breast cancer. Methods Perioperative blood samples (preoperative, intraoperative and postoperative) collected from participants with breast cancer in two arms namely isoflurane arm (n=50) and the propofol arm (n=50) were analyzed for T cell immune response using flow cytometry and ELISA. The interactions of anesthetics with CD4/CD8 were probed with molecular docking and molecular dynamic (MD) simulations. Results Linear mixed model analysis showed that isoflurane in comparison to propofol inhibited CD4+ helper (Th) [β-coefficient: -8.75; 95% CI: -13.00 to -4.51] and CD19+ B cell (β: -7.51; 95% CI: -15.46 to 0.44) frequencies during the intraoperative period in perioperative breast cancer patients. Further, interleukin (IL)-10 and IL-12 were significantly increased during the intra- and postoperative periods in the isoflurane group as compared to the propofol group. Molecular docking (MD) validated propofol's better binding energy with CD4/CD8 than isoflurane. MD simulations propagated that in contrast to isoflurane, propofol formed a more compact and stabilized structure with CD4/CD8, making the amino acid residues on the surface of CD4/CD8 inaccessible for any interaction. Interpretation & conclusions The clinical observations and the in silico findings exhibited that propofol in comparison to isoflurane better regulated T cell immuno-inflammatory response in perioperative breast cancer patients.

Propofol-Induced Hyperglycemia in the Critically Ill: An Unfamiliar Side Effect of a Common Anesthetic

Hyperglycemia is associated with increased in-hospital morbidity and mortality, especially in critically ill intensive care unit (ICU) patients. Propofol, a common anesthetic used in the ICU, may cause hyperglycemia by inducing insulin resistance, reducing insulin-stimulated glucose uptake in muscles, and attenuating insulin-mediated suppression of hepatic glucose. We present the case of a 58-year-old female who was admitted for sepsis secondary to cellulitis but required intubation for respiratory failure. She was provided propofol for sedation and went on to develop propofol-induced hyperglycemia. This is one of the few documented human cases demonstrating the association between propofol and hyperglycemia. There are animal-based studies that demonstrate this effect as well. This case report highlights the fact that propofol-induced hyperglycemia should be a consideration when deciding sedation strategies in critically ill patients.

Application of dexmedetomidine combined with propofol-etomidate mixture in radical gastrectomy under general anesthesia

BACKGROUND

Gastric cancer is the third most common malignant tumor with the second highest mortality rate in the world, and radical gastrectomy is the main treatment method, but the operation needs a long period of time to carry out and has strong surgical trauma stimulation, which is likely to cause sympathetic nerve excitement and stress reaction in the body. Therefore, the selection of appropriate anesthetic medication regimen and anesthesia method has an important impact on the intraoperative management and postoperative recovery of patients. This study aims to compare the clinical effects of dexmedetomidine alone in combination with propofol, etomidate and propofol-etomidate mixture in the treatment of radical gastrectomy for gastric cancer.

METHODS

A total of 90 patients undergoing elective radical gastrectomy were randomly divided into the propofol group (group P), the etomidate group (group E), and the etomidate-propofol mixture group (group PE). Anesthesia induction was performed under the monitoring of bispectral index anesthesia depth. The same pumping drugs were used in 3 groups: 0.1 to 0.3 μg/kg·min remifentanil, 0.5 μg/kg·h dexmedetomidine, and 5 to 10 μg/kg·min rocuronium. The primary outcome indicator was the hemodynamic conditions. The secondary outcome indicators included awakening time and time to accurately answer questions after operation, the prevalence of postoperative respiratory depression and adverse events, the incidence of postoperative cognitive dysfunction, and preoperative and postoperative Montreal Cognitive Assessment and Mini-Mental State Examination scores.

RESULTS

Among the 3 groups of patients, the use rate of vasoactive drugs in group P was higher (P < .05); the systolic blood pressure, diastolic blood pressure, and heart rate of group P at T1 to T4 were significantly lower than those of groups E and PE (P < .05); the systolic blood pressure, diastolic blood pressure, and heart rate of group E in T2, T4, and T6 were significantly higher than those of groups P and PE (P < .05). The wake-up time after operation and the time to accurately answer the questions were longer in group E than in groups P and PE (P < .05). The incidence of postoperative respiratory depression in group P was higher than that in groups E and PE (P < .05). The Montreal Cognitive Assessment score of group P was lower than that of groups E and PE 7 days after operation (P < .05).

CONCLUSION

Dexmedetomidine combined with propofol-etomidate mixture is a better anesthesia drug combination.

Sequential Deactivation Across the Hippocampus-Thalamus-mPFC Pathway During Loss of Consciousness

How consciousness is lost in states such as sleep or anesthesia remains a mystery. To gain insight into this phenomenon, concurrent recordings of electrophysiology signals in the anterior cingulate cortex and whole-brain functional magnetic resonance imaging (fMRI) are conducted in rats exposed to graded propofol, undergoing the transition from consciousness to unconsciousness. The results reveal that upon the loss of consciousness (LOC), there is a sharp increase in low-frequency power of the electrophysiological signal. Additionally, fMRI signals exhibit a cascade of deactivation across a pathway including the hippocampus, thalamus, and medial prefrontal cortex (mPFC) surrounding the moment of LOC, followed by a broader increase in brain activity across the cortex during sustained unconsciousness. Furthermore, sliding window analysis demonstrates a temporary increase in synchrony of fMRI signals across the hippocampus-thalamus-mPFC pathway preceding LOC. These data suggest that LOC may be triggered by sequential activities in the hippocampus, thalamus, and mPFC, while wide-spread activity increases in other cortical regions commonly observed during anesthesia-induced unconsciousness may be a consequence, rather than a cause of LOC. Taken together, the study identifies a cascade of neural events unfolding as the brain transitions into unconsciousness, offering insight into the systems-level neural mechanisms underpinning LOC.

Efficacy and safety of a generic remifentanil formulation versus fentanyl and Ultiva during general anaesthesia: A phase III, prospective, multi-centric, observer-blind, randomised controlled trial

Background and Aims

Remifentanil and fentanyl are potent opioid analgesics commonly used during surgery due to their distinct pharmacological profiles. This study aimed to compare the efficacy and safety of a generic remifentanil (test drug) with fentanyl and Ultiva (innovator formulation) during general anaesthesia in the Indian population.

Methods

This phase III, multi-centre (n = 13), randomised, three-arm, comparative study was conducted from 24 November 2021 to 31 March 2022. Eligible subjects scheduled for elective therapeutic and diagnostic surgical procedures (n = 314) were randomised into generic remifentanil, Ultiva, and fentanyl groups. An independent anaesthetist blinded to treatment allocation assessed efficacy and safety parameters. The primary efficacy endpoint was haemodynamic response during specific activities (endotracheal intubation, skin incision, skin closure, and extubation).

Results

The study groups exhibited no significant differences in demographic and baseline characteristics. Heart rate was similar between the remifentanil and Ultiva groups measured during laryngeal intubation, skin incision, skin closure, and extubation (P > 0.05 in all four procedures). Heart rate was significantly higher in the fentanyl group in comparison to the remifentanil group during laryngeal intubation (P = 0.035), skin incision (P = 0.017), skin closure (P = 0.001), and extubation (P = 0.026). The need for vasopressor and anti-cholinergic drugs was similar between groups, and no subject required naloxone administration.

Conclusion

Our study's findings demonstrated that generic remifentanil is non-inferior to fentanyl and equivalent to Ultiva for general anaesthesia in Indian patients undergoing various surgical and diagnostic procedures. Remifentanil offers advantages in terms of optimum haemodynamic stability, fast equilibrating analgesia, and rapid emergence from sedation, making it a suitable alternative to fentanyl.

Comparison of a single intravenous infusion of alfentanil or sufentanil combined with target-controlled infusion of propofol for daytime hysteroscopy: a randomized clinical trial

Background

The administration of either alfentanil or sufentanil as a single injection, combined with target-controlled infusion (TCI) of propofol, represents a frequently employed anesthetic regimen for daytime hysteroscopy.

Objectives

This study was designed to evaluate and compare the safety and efficacy of alfentanil and sufentanil in the context of daytime hysteroscopy.

Design

A total of 160 patients, scheduled for daytime hysteroscopy, were randomly allocated into two groups: Group A and Group S respectively received alfentanil 10 μg/kg or sufentanil 0.15 μg/kg as a single intravenous injection. Both groups were given propofol with TCI for sedation.

Methods

Monitoring of vital signs was conducted from pre-anesthesia through to 2 h postoperatively. The primary outcome measured was hypoxemia, defined as SpO2 levels below 92% for a duration of 30 s, which necessitated manual positive pressure ventilation. Secondary outcomes included various perioperative complications, such as postoperative nausea and vomiting (PONV) occurring 2 h after surgery, as well as hemodynamic indicators, NRS scores for pain, and other anesthesia-related data. This comprehensive dataset was meticulously documented and subsequently analyzed for comparative purposes.

Results

The analyses revealed that Group A had a significantly lower incidence of hypoxemia (p = 0.002) and PONV (p = 0.021). Additionally, group A demonstrated overall more stable blood pressure and heart rate, as well as higher SpO2 levels.

Conclusion

For daytime hysteroscopy, alfentanil at a dose of 10 μg/kg is safer than sufentanil at a dose of 0.15 μg/kg when combined with propofol TCI.

Trial registration

This study was registered with the Chinese Clinical Trial Registry (The URL of registration is https://www.chictr.org.cn/showproj.html?proj=177784; registration number: ChiCTR2200063939). The date of first registration was September 21, 2022.

Neuronal excitation-inhibition imbalance in the basolateral amygdala is involved in propofol-mediated enhancement of fear memory

Posttraumatic stress disorder (PTSD) is associated with glutamatergic neuron hyperactivation in the basolateral amygdala (BLA) brain area, while GABAergic interneurons in the BLA modulate glutamatergic neuron excitability. Studies have shown that propofol exerts its effects through potentiation of the inhibitory neurotransmitter γ-aminobutyric acid. The neuronal mechanism by which propofol anesthesia modulates fear memory is currently unknown. Here, we used optogenetics and chemogenetics to suppress glutamatergic neurons or activate GABAergic interneurons in the BLA to assess alterations in neuronal excitation-inhibition balance and investigate fear memory. The excitability of glutamatergic neurons in the BLA was significantly reduced by the suppression of glutamatergic neurons or activation of GABAergic interneurons, while propofol-mediated enhancement of fear memory was attenuated. We suggest that propofol anesthesia could reduce the excitability of GABAergic neurons through activation of GABAA receptors, subsequently increasing the excitability of glutamatergic neurons in the mice BLA; the effect of propofol on enhancing mice fear memory might be mediated by strengthening glutamatergic neuronal excitability and decreasing the excitability of GABAergic neurons in the BLA; neuronal excitation-inhibition imbalance in the BLA might be important in mediating the enhancement of fear memory induced by propofol.

The influence of depth of sedation on motor evoked potentials monitoring in youth from 4 to 23 years old: preliminary data from a prospective observational study

Introduction

The influence of various levels of sedation depth on motor evoked potentials (MEP) reproducibility in youth is still unclear because of a lack of data. We tested the hypothesis that a deeper level of total intravenous anesthesia (TIVA) [bispectral index (BIS) 40 ± 5 compared to 60 ± 5] can affect surgeon-directed MEP and their interpretation in youths.

Methods

All patients received TIVA combined with propofol and remifentanil. TIVA was initially maintained at a BIS level of 60 ± 5. The sedation anesthesia was deepened to BIS level 40 ± 5 before the skin incision. MEP were recorded and interpreted at both BIS levels. The primary endpoint was to evaluate the effect of the depth of sedation on the MEP reproducibility directed and interpreted by the surgical team in each patient separately. The secondary endpoint was to compare the relativized MEP parameters (amplitude and latency) in percentage at various levels of sedation in each patient separately. We planned to enroll 150 patients. Due to the COVID-19 pandemic, we decided to analyze the results of the first 50 patients.

Results

The surgical team successfully recorded and interpreted MEP in all 50 enrolled patients in both levels of sedation depth without any clinical doubts. The MEP parameters at BIS level 40 ± 5, proportionally compared with the baseline, were latency 104% (97-110%) and the MEP amplitudes 84.5% (51-109%).

Conclusion

Preliminary data predict that deeper sedation (BIS 40 ± 5) does not affect the surgical team's interpretation of MEP in youth patients. These results support that surgeon-directed MEP may be an alternative when neurophysiologists are unavailable.

Early sedation using ciprofol for intensive care unit patients requiring mechanical ventilation: a pooled post-hoc analysis of data from phase 2 and phase 3 trials

BACKGROUND

Ciprofol was approved for use in intensive care unit (ICU) patients requiring sedation during mechanical ventilation in July 2022. A pooled post-hoc analysis of phase 2 and phase 3 trials was conducted primarily to explore hypotension-free outcome in ICU patients who required mechanical ventilation and achieved the target light sedation goal at an early stage after being sedated with ciprofol or propofol.

METHODS

All eligible ICU patients who were expected to require sedation for 6-24 h were randomly assigned in a 2:1 ratio to either a ciprofol or propofol group. Ciprofol or propofol was initially infused at loading doses of 0.5 or 1.0 mg/kg followed by maintenance doses of 0.3 or 1.5 mg/kg/h. Ciprofol or propofol dosages were adjusted up or down at rates of 0.05-0.10 mg/kg/h or 0.25-0.50 mg/kg/h, respectively, to achieve the target light sedation (a Richmond Agitation-Sedation Scale of -2 to + 1). The primary post-hoc outcome was the hypotension-free rate in patients who had achieved the target sedation goal after 30-min administration of ciprofol or propofol.

RESULTS

In total, 174 patients were enrolled for pooled post-hoc analysis, of whom 116 and 58 were assigned to the ciprofol and propofol groups, respectively. The hypotension-free rate was significantly higher in patients who achieved the target sedation goal after 30-min administration of ciprofol (93.0% vs. 81.0%, P = 0.018), and especially in the subgroups of males and patients aged < 65 years. Multivariable analysis revealed that ciprofol treatment, a younger age and lower baseline body mass index were independent favorable predictors for a higher hypotension-free rate in patients who achieved the target sedation goal after 30-min of drug administration. Moreover, hypotension-free patients who reached the target sedation level after 30 min had a more favorable short-term prognosis including a lower incidence of drug-related treatment-emergent adverse events, shorter time to extubation and fewer dose adjustments of ciprofol or propofol (all P < 0.05).

CONCLUSION

ICU patients undergoing mechanical ventilation and sedated with ciprofol had significantly lower rate of hypotension during the early phase of achieving light sedation during a 6-24 h period, leading to a more favorable short-term prognosis (within 24 h).

TRIAL REGISTRATION

Phase 2 trial (clinicaltrials.gov, NCT04147416. Registered November 1, 2019, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04147416 ) and phase 3 trial (clinicaltrials.gov, NCT04620031. Registered November 6, 2020, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04620031 ).