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Dong L, Sun T, Yang J, Zhou Y, Liu X, Liu Z, Lv H, Ma Z, Chen Y. Remimazolam has similar anesthetic effect and superior safety compared to propofol in elderly patients: A meta-analysis of randomized controlled trials. World J Surg 2024. [PMID: 38955808 DOI: 10.1002/wjs.12273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/16/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The superiority between remimazolam and propofol for anesthesia is controversial in elderly patients (≥60 years). This meta-analysis aimed to systematically compare anesthetic effect and safety profile between remimazolam and propofol in elderly patients under any surgery. METHODS Cochrane Library, Web of Science, and PubMed were searched until December 25, 2023 for relevant randomized controlled trials. RESULTS Ten studies with 806 patients receiving remimazolam (experimental group) and 813 patients receiving propofol (control group) were included. Time to loss of consciousness [standard mean difference (SMD) (95% confidence interval (CI): 1.347 (-0.362, 3.055), p = 0.122] and recovery time [SMD (95% CI): -0.022 (-0.300, 0.257), p = 0.879] were similar between experimental and control groups. Mean arterial pressure at baseline minus 1 min after induction [SMD (95% CI): -1.800 (-3.250, -0.349), p = 0.015], heart rate at baseline minus 1 min after induction [SMD (95% CI): -1.041 (-1.537, -0.545), p < 0.001], incidences of hypoxemia [relative risk (RR) (95% CI): 0.247 (0.138, 0.444), p < 0.001], respiratory depression [RR (95% CI): 0.458 (0.300, 0.700), p < 0.001], bradycardia [RR (95% CI): 0.409 (0.176, 0.954), p = 0.043], hypotension [RR (95% CI): 0.415 (0.241, 0.714), p = 0.007], and injection pain [RR (95% CI): 0.172 (0.113, 0.263), p < 0.001] were lower in the experimental group compared to the control group. Postoperative nausea and vomiting was not different between groups [RR (95% CI): 1.194 (0.829, 1.718), p = 0.341]. Moreover, this meta-analysis displayed a low risk of bias, minimal publication bias, and good robustness. CONCLUSION Remimazolam shows comparative anesthetic effect and better safety profile than propofol in elderly patients under any surgery.
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Affiliation(s)
- Liyun Dong
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Tianze Sun
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Jiecheng Yang
- Child Care, Merice Cody Public School, Toronto, Ontario, Canada
| | - Yue Zhou
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Xinyan Liu
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Zhijie Liu
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Hangyu Lv
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Zhen Ma
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Yongxue Chen
- Department of Anaesthesia, Handan Central Hospital, Handan, China
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Uchiyama M, Mori K, Abe T, Imaki S. Risk factors for clinically important traumatic brain injury in minor head injury in older people. Am J Emerg Med 2024; 80:156-161. [PMID: 38608468 DOI: 10.1016/j.ajem.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/26/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The incidence of traumatic brain injury (TBI) in older individuals is increasing with an increase in the older population. For older people, the required medical interventions and hospitalization following minor head injury have negative impacts, which have not been reported in literature up till now. We aimed to investigate the risk factors for clinically important traumatic brain injury (ciTBI) in older patients with minor head injury. METHODS This is a retrospective single-center cohort study. Older patients aged ≥65 years presenting with head injury and a Glasgow Coma Scale (GCS) score of ≥13 upon arrival at the hospital between January 1, 2018, and October 31, 2021, were included. Patients with an injury duration of ≥24 h were excluded. The primary outcome was defined as ciTBI (including death, surgery, intubation, medical interventions, and hospital stays of ≥2 nights). Multiple logistic regression analysis was conducted to identify the risk factors. RESULTS A total of 296 patients were included initially, and 6 of them were excluded subsequently. ciTBI was identified in 62 cases. According to the results of the multiple logistic regression analysis, GCS scores of ≤14 (OR 3.72, 95% CI 1.89-7.30), high-risk mechanisms of injury (OR 2.80, 95% CI 1.39-5.64), vomiting (OR 5.01, 95% CI 1.19-21.1), and retrograde amnesia (OR 6.90, 95% CI 3.37-14.1) were identified as risk factors. CONCLUSION In older patients with minor head injury, GCS ≤14, high-risk mechanisms of injury, vomiting, and retrograde amnesia are risk factors for ciTBI.
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Affiliation(s)
- Makoto Uchiyama
- Department of Emergency Medicine, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama-shi, Kanagawa 221-0855, Japan; Department of Surgery, Shin-Kuki General Hospital, 418-1 Kamihayami, Kuki-shi, Saitama 346-8530, Japan.
| | - Kosuke Mori
- Department of Emergency Medicine, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama-shi, Kanagawa 221-0855, Japan
| | - Takeru Abe
- Center for Integrated Science and Humanities, Fukushima Medical University, 1 Hikariga-oka, Fukushima-shi, Fukushima 960-1295, Japan.
| | - Shohei Imaki
- Department of Emergency Medicine, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama-shi, Kanagawa 221-0855, Japan.
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Ahmer W, Imtiaz S, Alam DM, Ahmed K, Sajid B, Yousuf J, Asnani S, Fahim MAA, Ali R, Mansoor M, Safdar MT, Anjum MU, Hasanain M, Larik MO. Remimazolam versus propofol for sedation in gastrointestinal endoscopy and colonoscopy within elderly patients: a meta-analysis of randomized controlled trials. Eur J Clin Pharmacol 2024; 80:493-503. [PMID: 38261005 DOI: 10.1007/s00228-024-03624-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024]
Abstract
PURPOSE Propofol has become the sedative of choice for endoscopy and colonoscopy. However, it has shown associations with various adverse effects, specifically in the geriatric population. In contrast, remimazolam is a novel benzodiazepine, demonstrating a superior clinical safety profile. Hence, this systematic review and meta-analysis aims to clarify the efficacy and safety of remimazolam versus propofol in elderly patients (≥ 60 years) undergoing gastrointestinal endoscopic and colonoscopy procedures. METHODS Electronic databases including PubMed, Cochrane Library, ScienceDirect, and Google Scholar were explored from inception till January 7, 2024. The Cochrane Risk of Bias Tool for Randomized Controlled Trials (RoB-2) was utilized to evaluate the quality of each included study reported in this meta-analysis. RESULTS Seven randomized control trials were included, resulting in the pooling of 1,466 patients (remimazolam: 731 patients; propofol: 735 patients). Propofol demonstrated a significantly lower time to loss of consciousness (P < 0.00001, 4 studies, 784 patients) and a greater sedation success after first dose (P = 0.05, 5 studies, 1,271 patients). Remimazolam reported a significantly lower risk of bradycardia (P = 0.02, 5 studies, 1,323 patients), hypoxemia (P < 0.00001, 6 studies, 1,389 patients), and pain on injection site (P < 0.00001, 5 studies, 1,184 patients). No statistically significant differences in sedation time, number of supplemental doses, procedural parameters, and other adverse outcomes were reported. CONCLUSION As per the results of our analyses, propofol demonstrated comparatively superior efficacy, however, remimazolam demonstrated comparatively superior safety. The debatable evidence generated from this meta-analysis may not currently be powerful enough to advocate for the use of remimazolam in elderly patients undergoing gastrointestinal procedures; hence, further comprehensive studies are necessary in order to arrive at a robust conclusion.
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Affiliation(s)
- Wania Ahmer
- Department of Medicine, Dow Medical College, Karachi, Pakistan
| | - Sahar Imtiaz
- Department of Medicine, Dow Medical College, Karachi, Pakistan
| | | | - Khadija Ahmed
- Department of Medicine, Dow Medical College, Karachi, Pakistan
| | - Barka Sajid
- Department of Medicine, Sindh Medical College, Karachi, Pakistan
| | - Juvairia Yousuf
- Department of Medicine, Dow Medical College, Karachi, Pakistan
| | - Sunny Asnani
- Department of Medicine, Sindh Medical College, Karachi, Pakistan
| | | | - Rahmeen Ali
- Department of Medicine, Dow Medical College, Karachi, Pakistan
| | - Marium Mansoor
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Muhammad Talha Safdar
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | | | | | - Muhammad Omar Larik
- Department of Medicine, Dow International Medical College, Karachi, Pakistan.
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Sidhu R, Turnbull D, Haboubi H, Leeds JS, Healey C, Hebbar S, Collins P, Jones W, Peerally MF, Brogden S, Neilson LJ, Nayar M, Gath J, Foulkes G, Trudgill NJ, Penman I. British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy. Gut 2024; 73:219-245. [PMID: 37816587 PMCID: PMC10850688 DOI: 10.1136/gutjnl-2023-330396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023]
Abstract
Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.
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Affiliation(s)
- Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - David Turnbull
- Department of Anaesthetics, Royal Hallamshire Hospital, Sheffield, UK
| | - Hasan Haboubi
- Department of Gastroenterology, University Hospital Llandough, Llandough, South Glamorgan, UK
- Institute of Life Sciences, Swansea University, Swansea, UK
| | - John S Leeds
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Chris Healey
- Airedale NHS Foundation Trust, Keighley, West Yorkshire, UK
| | - Srisha Hebbar
- Department of Gastroenterology, University Hospital of North Midlands, Stoke-on-Trent, Staffordshire, UK
| | - Paul Collins
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Wendy Jones
- Specialist Pharmacist Breastfeeding and Medication, Portsmouth, UK
| | - Mohammad Farhad Peerally
- Digestive Diseases Unit, Kettering General Hospital; Kettering, Kettering, Northamptonshire, UK
- Department of Population Health Sciences, College of Life Science, University of Leicester, Leicester, UK
| | - Sara Brogden
- Department of Gastroenterology, University College London, UK, London, London, UK
| | - Laura J Neilson
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, Tyne and Wear, UK
| | - Manu Nayar
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Jacqui Gath
- Patient Representative on Guideline Development Group and member of Independent Cancer Patients' Voice, Sheffield, UK
| | - Graham Foulkes
- Patient Representative on Guideline Development Group, Manchester, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - Ian Penman
- Centre for Liver and Digestive Disorders, Royal Infirmary Edinburgh, Edinburgh, Midlothian, UK
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Hayashi M, Norii T, Albright D, Crandall C. Incidence of adverse events for procedural sedation and analgesia for cardioversion using thiopental in elderly patients: a multicenter prospective observational study. Acute Med Surg 2023; 10:e812. [PMID: 36606061 PMCID: PMC9807845 DOI: 10.1002/ams2.812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/11/2022] [Indexed: 01/04/2023] Open
Abstract
Aim The incidence and characteristics of thiopental-related adverse events (AEs) in elderly patients during procedural sedation and analgesia (PSA) have not been well studied. We aimed to characterize thiopental-related AE in elderly patients during PSA and compare the incidence of AE in elderly patients with non-elderly adults. Methods This is a secondary analysis of the Japanese Procedural Sedation and Analgesia Registry (JPSTAR). We included all adult patients who received thiopental for PSA in the emergency departments and excluded patients who received concomitant sedative(s) in addition to thiopental or patients with missing body weight data. We compared the incidence of AE between the non-elderly (18-64 years) and elderly groups (≥65 years). Results The JPSTAR had data on 379 patients who received thiopental for PSA and included 311 patients for analysis. Most (222/311, 71.3%) were elderly. Cardioversion was the most common reason for PSA (96.1%). The AE incidence between groups overall was similar, however, hypoxia was significantly more frequent in the elderly compared with the non-elderly group (10.3% versus 2.2%; adjusted odds 5.63, 95% confidence interval 1.27-25.0). The initial and total doses of thiopental were significantly lower in the elderly group than in the non-elderly group (1.95 mg/kg versus 2.21 mg/kg and 2.33 mg/kg versus 2.93 mg/kg, respectively). Conclusions Although elderly patients received lower doses of thiopental, hypoxic events were significantly more frequent in this group compared with the non-elderly patients. However, the AE incidence was similar.
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Affiliation(s)
- Minoru Hayashi
- Department of Emergency MedicineFukui Prefectural HospitalFukuiJapan
| | - Tatsuya Norii
- Department of Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Danielle Albright
- Department of Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Cameron Crandall
- Department of Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
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Liu F, Cheng X, Wang Y, Li K, Peng T, Fang N, Pasunooti KK, Jun S, Yang X, Wu J. Effect of remimazolam tosilate on the incidence of hypoxemia in elderly patients undergoing gastrointestinal endoscopy: A bi-center, prospective, randomized controlled study. Front Pharmacol 2023; 14:1131391. [PMID: 37144222 PMCID: PMC10151819 DOI: 10.3389/fphar.2023.1131391] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
Background: Remimazolam tosilate is a new ultra-short-acting benzodiazepine sedative medicine. In this study, we evaluated the effect of remimazolam tosilate on the incidence of hypoxemia during sedation in elderly patients undergoing gastrointestinal endoscopy. Methods: Patients in the remimazolam group received an initial dose of 0.1 mg/kg and a bolus dose of 2.5 mg of remimazolam tosilate, whereas patients in the propofol group received an initial dose of 1.5 mg/kg and a bolus dose of 0.5 mg/kg of propofol. Patients received ASA standard monitoring (heart-rate, non-invasive blood pressure, and pulse oxygen saturation) during the entire examination process. The primary outcome was the incidence of moderate hypoxemia (defined as 85%≤ SpO2< 90%, >15s) during the gastrointestinal endoscopy. The secondary outcomes included the incidence of mild hypoxemia (defined as SpO2 90%-94%) and severe hypoxemia (defined as SpO2< 85%, >15s), the lowest pulse oxygen saturation, airway maneuvers used to correct hypoxemia, patient's hemodynamic as well as other adverse events. Results: 107 elderly patients (67.6 ± 5.7 years old) in the remimazolam group and 109 elderly patients (67.5 ± 4.9 years old) in the propofol group were analyzed. The incidence of moderate hypoxemia was 2.8% in the remimazolam group and 17.4% in the propofol group (relative risk [RR] = 0.161; 95% confidence interval [CI], 0.049 to 0.528; p < 0.001). The frequency of mild hypoxemia was less in the remimazolam group, but not statistically significant (9.3% vs. 14.7%; RR = 0.637; 95% CI, 0.303 to 1.339; p = 0.228). There was no significant difference in the incidence of severe hypoxemia between the two groups (4.7% vs. 5.5%; RR = 0.849; 95% CI, 0.267 to 2.698; p = 0.781). The median lowest SpO2 during the examination was 98% (IQR, 96.0%-99.0%) in patients in the remimazolam group, which was significantly higher than in patients in the propofol group (96%, IQR, 92.0%-99.0%, p < 0.001). Patients in the remimazolam group received more drug supplementation during endoscopy than patients in the propofol group (p = 0.014). There was a statistically significant difference in the incidence of hypotension between the two groups (2.8% vs. 12.8%; RR = 0.218; 95% CI, 0.065 to 0.738; p = 0.006). No significant differences were found in the incidence of adverse events such as nausea and vomiting, dizziness, and prolonged sedation. Conclusion: This study explored the safety of remimazolam compared with propofol during gastrointestinal endoscopy in elderly patients. Despite the increased supplemental doses during sedation, remimazolam improved risk of moderate hypoxemia (i.e., 85%≤ SpO2 < 90%) and hypotension in elderly patients.
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Affiliation(s)
- Fang Liu
- Department of Anaesthesiology, Qilu Hospital of Shandong University, Jinan, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyan Cheng
- Department of Anaesthesiology, Weifang People’s Hospital (The First Affiliated Hospital of Weifang Medical University), Weifang, China
| | - Yingjie Wang
- Department of Anaesthesiology, Qilu Hospital of Shandong University, Jinan, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kai Li
- Department of Anaesthesiology, Qilu Hospital of Shandong University, Jinan, China
| | - Tianliang Peng
- Department of Anaesthesiology, Weifang People’s Hospital (The First Affiliated Hospital of Weifang Medical University), Weifang, China
| | - Ningning Fang
- Department of Anaesthesiology, Qilu Hospital of Shandong University, Jinan, China
| | - Kalyan K. Pasunooti
- School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
- Department of Pharmacology and Molecular Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Seungho Jun
- Division of Cardiology, Johns Hopkins University Medical Institutions, Baltimore, MD, United States
| | - Xiaomei Yang
- Department of Anaesthesiology, Qilu Hospital of Shandong University, Jinan, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Xiaomei Yang, ; Jianbo Wu,
| | - Jianbo Wu
- Department of Anaesthesiology, Qilu Hospital of Shandong University, Jinan, China
- Department of Anaesthesiology and Perioperative Medicine, Qilu Hospital Dezhou Hospital, Shandong University, Dezhou, China
- *Correspondence: Xiaomei Yang, ; Jianbo Wu,
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Komasawa N. Challenges for interprofessional simulation-based sedation training courses: Mini review. Acute Med Surg 2023; 10:e913. [PMID: 38152161 PMCID: PMC10752690 DOI: 10.1002/ams2.913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/04/2023] [Accepted: 12/11/2023] [Indexed: 12/29/2023] Open
Abstract
Sedation for invasive procedures is given for various clinical purposes to patients of all ages worldwide. However, sedation is a continuum to general anesthesia and contains severe inherent risks leading to mortality. Providing a simulation-based sedation training course (SEDTC) to various medical staff could be an effective strategy to improve patient and medical safety associated with sedation. The SEDTC generally includes basic airway management such as upper airway obstruction release or rapid response action toward excessive sedation, utilizing problem-based learning or simulators. However, participation alone in the SEDTC can only achieve Level 1 (reaction) or 2 (learning) in the Kirkpatrick model. A patient safety improvement of Level 3 (transfer) or 4 (result) of the Kirkpatrick model can be achieved when all members related to sedation undergo experiential learning and reach a consensus. Accordingly, in-hospital interprofessional SEDTC focusing on a resilience approach is essential to achieve effective sedation patient safety in Level 3 or 4 of the Kirkpatrick model.
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Affiliation(s)
- Nobuyasu Komasawa
- Community Medicine Education Promotion Office, Faculty of MedicineKagawa UniversityIkenobeKita‐gunKagawaJapan
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Shirane S, Funakoshi H, Takahashi J, Homma Y, Norii T. Association between capnography and recovery time after procedural sedation and analgesia in the emergency department. Acute Med Surg 2023; 10:e901. [PMID: 37900991 PMCID: PMC10604570 DOI: 10.1002/ams2.901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 09/09/2023] [Accepted: 10/05/2023] [Indexed: 10/31/2023] Open
Abstract
Aim Capnography is recommended for use in procedural sedation and analgesia (PSA); however, limited studies assess its impact on recovery time. We investigated the association between capnography and the recovery time of PSA in the emergency department (ED). Methods This study was a secondary analysis of a multicenter PSA patient registry including eight hospitals in Japan. We included all patients who received PSA in the ED between May 2017 and May 2021 and divided the patients into capnography and no-capnography groups. The primary outcome was recovery time, defined as the time from the end of the procedure to the cessation of monitoring. The log-rank test and multivariable analysis using clustering for institutions were performed. Results Of the 1265 screened patients, 943 patients who received PSA were enrolled and categorized into the capnography (n = 150, 16%) and no-capnography (n = 793, 84%) groups. The median recovery time was 40 (interquartile range [IQR]: 25-63) min in the capnography group and 30 (IQR: 14-55) min in the no-capnography group. In the log-rank test, the recovery time was significantly longer in the capnography group (p = 0.03) than in the no-capnography group. In the multivariable analysis, recovery time did not differ between the two groups (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77-1.17; p = 0.61). Conclusion In this secondary analysis of the multicenter registry of PSA in Japan, capnography use did not associate with shorter recovery time in the ED.
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Affiliation(s)
- Shogo Shirane
- Department of Emergency and Critical Care MedicineTokyobay Urayasu Ichikawa Medical CenterChibaJapan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care MedicineTokyobay Urayasu Ichikawa Medical CenterChibaJapan
| | - Jin Takahashi
- Department of Emergency and Critical Care MedicineTokyobay Urayasu Ichikawa Medical CenterChibaJapan
| | - Yosuke Homma
- Department of Emergency MedicineChiba Kaihin Municipal HospitalChibaJapan
| | - Tatsuya Norii
- Department of Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
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Hu B, Jiang K, Shi W, Xiao S, Zhang S, Zhang Y, Zhou Y, Tan C, Tan S, Zou X. Effect of Remimazolam Tosilate on Respiratory Depression in Elderly Patients Undergoing Gastroscopy: A Multicentered, Prospective, and Randomized Study. Drug Des Devel Ther 2022; 16:4151-4159. [PMID: 36506792 PMCID: PMC9733689 DOI: 10.2147/dddt.s391147] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022] Open
Abstract
Background Remimazolam tosilate (RT) is a new type of γ-aminobutyric acid subtype A (GABAA) receptor agonist, having the possibility to be an ideal sedative drug for procedural sedation. At present, there are few studies on the effect of RT on respiratory depression in elderly patients. We aimed to evaluate the effect of RT on respiratory depression in elderly patients undergoing gastroscopy. Methods This prospective, randomized, single-blinded trial recruited patients from eight centers in China between May 2022 and July 2022. A total of 346 elderly patients undergoing gastroscopy were randomly divided into RT group (0.2 mg/kg) or propofol group (1.5 mg/kg), respectively. The primary outcome was the incidence of respiratory depression. Secondary outcomes include the incidence of sedative-related adverse events, the success rate of sedation, time to fully alert, time to loss of consciousness (LOC), time to ready for discharge, as well as the the patients, endoscopists and anethetists' satisfaction. Results The incidence of respiratory depression was significantly reduced in the RT group compared with the propofol group (9.8% vs 17.9%, P=0.042). The time of LOC and fully alert in the RT group were longer than that in the propofol group (P < 0.05). The incidences of hypotention (50.9% vs 32.4%, P=0.001) and hypotension requiring treatment (5.8% vs 1.7%, P=0.031) were significantly higher in the propofol group than that in the RT group. The incidence and severity of injection pain were more frequently recorded in the propofol group than that in the RT group (40.5% vs 12.1%, P<0.05). There were no statistically significant differences between the two groups in terms of sedation success rates, time to ready for discharge, endoscopists and anethetists' satisfaction and other sedative-related adverse events. Conclusion RT may be a suitable alternative sedative agent for elderly patients undergoing gastroscopy due to its safety profile.
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Affiliation(s)
- Bailong Hu
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, People’s Republic of China,College of Anesthesiology, Guizhou Medical University, Guiyang, People’s Republic of China
| | - Ke Jiang
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, People’s Republic of China
| | - Wenyan Shi
- Department of Anesthesiology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, People’s Republic of China
| | - Shixiang Xiao
- Department of Anesthesiology, The First People’ s Hospital of Bijie City, Bijie, People’s Republic of China
| | - Shili Zhang
- Department of Anesthesiology, Dali Bai Autonomous Prefecture People’s Hospital, Dali, People’s Republic of China
| | - Yongguo Zhang
- Department of Anesthesiology, The People’s Hospital of Qiannan, Qiannan, People’s Republic of China
| | - Yuancheng Zhou
- Department of Anesthesiology, The First People’s Hospital of Guiyang, Guiyang, People’s Republic of China
| | - Chengwei Tan
- Department of Anesthesiology, The Second People’s Hospital of Guiyang, Guiyang, People’s Republic of China
| | - Songjiang Tan
- Department of Anesthesiology, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, People’s Republic of China
| | - Xiaohua Zou
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, People’s Republic of China,College of Anesthesiology, Guizhou Medical University, Guiyang, People’s Republic of China,Correspondence: Xiaohua Zou; Songjiang Tan, Fax +86-851-86771013, Email ;
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10
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Liu X, Ding B, Shi F, Zhang Y, Liu L, Sha Y, Zhao T. The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial. Drug Des Devel Ther 2021; 15:4675-4685. [PMID: 34819721 PMCID: PMC8606755 DOI: 10.2147/dddt.s339535] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/07/2021] [Indexed: 02/02/2023] Open
Abstract
Objective The optimal sedation regime during endoscopy remains controversial, especially for elderly outpatients. In this study, we compared the efficacy and safety between remimazolam tosilate (RT) and etomidate-propofol (EP) in elderly outpatients undergoing colonoscopy. Methods A total of 260 elderly outpatients undergoing sedative colonoscopy were randomized into two groups. Patients in the RT group received a 0.075-mg/kg maintenance dose of remimazolam following an initial dose of 0.15 mg/kg, whereas patients in the EP group (10 mL:20 mg etomidate plus 10 mL:100 mg propofol) received a 0.05-mL/kg maintenance dose following an initial dose of 0.1 mL/kg to maintain a Modified Observer’s Assessment of Alertness/Sedation score of ≤3 during the procedure. The primary endpoint was the success of the procedure. Secondary endpoints included time metrics, hemodynamics, consumption of fentanyl, etomidate, propofol, and remimazolam, intraoperative body movement, patient and endoscopist satisfaction scores, supplemental dose of sedative and fentanyl, and incidence and severity of adverse events. Results The procedure success rate was 96.52% in the RT group and 100% in the EP group. The difference in procedure success rate between the RT and EP groups was −3.48% (95% confidence interval: −6.81%, −0.15%). Four patients in the RT group required rescue midazolam. Compared with patients in the RT group, the onset time of the EP group was significantly lower (p < 0.05), whereas time to fully alert (p = 0.001), ready for discharge (p = 0.001), and hospital discharge (p = 0.002) were all significantly higher in the EP group. However, there were no significant differences in procedure time (p = 0.846) or cecal intubation time (p = 0.320) between the two groups. Although the frequency of intraoperative body movement was higher in the RT group, the difference was not significant (p = 0.508). There were no significant differences in patients’ demographic and baseline characteristics, supplemental doses of sedative and fentanyl, or patient and endoscopist satisfaction scores (p > 0.05). Muscular tremor and pain on injection were recorded more frequently in the EP group (p < 0.05). However, there were no significant differences in hypoxia, respiratory depression, or incidence of postoperative nausea and vomiting. The severity of adverse events was all mild (grade 1) across both groups. Conclusion RT may have non-inferior efficacy and a higher safety profile than EP in elderly outpatients undergoing colonoscopy, which suggests that RT may be more suitable for elderly outpatients undergoing colonoscopy.
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Affiliation(s)
- Xianwen Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Baofeng Ding
- Department of Anaesthesiology, Liaocheng Second People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Fu Shi
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Yang Zhang
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Lei Liu
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
| | - Yongwei Sha
- Department of Anaesthesiology, Guanxian Central Hospital, Liaocheng, Shandong, People's Republic of China
| | - Tonghang Zhao
- Department of Anaesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, People's Republic of China
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11
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Homma Y, Norii T, Kanazawa T, Hoshino A, Arino S, Takase H, Albright D, Funakoshi H. A mini-review of procedural sedation and analgesia in the emergency department. Acute Med Surg 2020; 7:e574. [PMID: 33042561 PMCID: PMC7538695 DOI: 10.1002/ams2.574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/05/2020] [Indexed: 11/25/2022] Open
Abstract
Procedural sedation and analgesia (PSA) is performed for a variety of indications in emergency departments (EDs). Although the practice of PSA in the ED is somewhat unique from other clinical areas, there is currently no guideline for this practice in Japan. Policy statements and guidelines for PSA have been published in Europe and North America. These guidelines suggest first evaluating patients carefully before performing PSA, and then deciding on target sedative level and choice of medications. Patient evaluation requires a combination of continuous visual observation by trained medical staff to assess the depth of sedation and respiration with noninvasive measurements of blood pressure, continuous electrocardiography monitoring, and pulse oximetry. Sedative selection should be based on its characteristics, peak time, effectiveness, and risks. It is important to administer sedatives and analgesics in small, incremental doses while keeping a close eye on the patient’s reaction to avoid adverse events (AEs) until the planned sedation level is reached. Further, additional attention is needed for special populations such as pediatric and elderly patients. PSA is a key element for patient‐centered care in emergency medicine. In this manuscript, we review the available evidence for PSA in the EDs, including guidelines for evaluation, monitoring, pharmacology, AEs, and special populations such as pediatric and elderly patients.
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Affiliation(s)
- Yosuke Homma
- Department of Emergency and Critical Care Medicine Tokyo Bay Urayasu Ichikawa Medical Center Urayasu Chiba Japan
| | - Tatsuya Norii
- Department of Emergency Medicine University of New Mexico Albuquerque New Mexico United States
| | - Takeshi Kanazawa
- Department of Medical Education Kyushu University Graduate School of Medical Sciences Fukuoka Japan
| | - Atsumi Hoshino
- Surgical Intensive Care Unit Nippon Medical School Hospital Tokyo Japan
| | - Satoshi Arino
- Department of Pediatric Emergency and Critical Care Medicine Tokyo Metropolitan Children's Medical Center Tokyo Japan
| | - Hiroshi Takase
- Emergency and Critical Care Department Sendai City Hospital Miyagi Japan
| | - Danielle Albright
- Department of Emergency Medicine University of New Mexico Albuquerque New Mexico United States
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine Tokyo Bay Urayasu Ichikawa Medical Center Urayasu Chiba Japan
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