Efficacy and safety of supplemental intravenous lidocaine for sedation in gastrointestinal endoscopic procedures: systematic review and meta-analysis of randomized controlled trials

Effect of Intravenous Lidocaine Infusion on Propofol Dose and Perioperative Pain During Moderate Sedation-Analgesia for Hysteroscopy: A Randomized Controlled Trial

Purpose

In China, the majority of hysteroscopic procedures require moderate sedation and analgesia. The efficacy of intravenous lidocaine in reducing the need for sedatives and alleviating perioperative pain during hysteroscopy remains equivocal. This study aims to determine whether the intravenous administration of lidocaine can reduce the required dose of propofol and enhance perioperative pain management.

Patients and Methods

We conducted a prospective, single-center, double-blind randomized controlled trial involving patients with ASA I-II undergoing hysteroscopy. Forty patients were randomly assigned in a 1:1 ratio to either receive an intravenous bolus dose of 1.5 mg/kg lidocaine, followed by a continuous intravenous infusion at 4 mg/kg/h until the conclusion of the procedure, or an equivalent volume of normal saline. Propofol was then titrated to maintain a MOAA/S score of ≤ 2.

Results

Compared with the control group, the lidocaine group showed a 13.8% decrease in the total dose of propofol (140.0[120.0, 155.0] mg vs 162.5[140.0, 197.5] mg), which was statistically significant (P = 0.014). The induction dose of propofol was 1.37 (1.29, 1.56) mg/kg in the lidocaine group and 1.61 (1.48, 1.94) mg/kg in the control group, respectively (P = 0.001). However, no significant differences were observed between the groups regarding the supplemental dose of propofol (P = 0.062), the number of involuntary movements during hysteroscopy (P = 0.384), or postoperative pain scores (T0: P = 0.628; T1: P = 0.886; T2: P = 0.711). Additionally, the incidence of intraoperative hypoxia (P = 1.000) and fatigue scores (T0: P = 0.878; T1: P = 0.401; T2: P = 0.056) between the two groups were not statistically significant.

Conclusion

Intravenous lidocaine reduces the dose requirements of propofol during the induction phase of anesthesia. However, it does not have a significant influence on alleviating intraoperative and postoperative pain during hysteroscopic procedures.

Efficacy of Low-Dose Scopolamine and Palonosetron in Reducing Immediate Post-Gastrointestinal Endoscopy Nausea and Vomiting: A Prospective, Randomized, Controlled Study

This study aimed to assess the incidence of post-discharge nausea and vomiting (PDNV) following sedation with nalbuphine and etomidate and to evaluate the prophylactic effects of scopolamine in reducing PDNV. A two-stage prospective clinical trial was conducted. The first part involved an observational study of 77 subjects to assess the PDNV incidence post-sedation with nalbuphine, etomidate, and propofol. The second part compared the effectiveness of palonosetron 0.075 mg (P group), scopolamine 0.1 mg (S group), and their combination (PS group) in reducing PDNV. The primary endpoint was the incidence of PDNV within 8 h post-sedation. Secondary outcomes included PDNV frequency and severity at 8-24, 0-24, and 24-48 h and side effects of medications. The incidence of PDNV within 8 h post-sedation was 37.66% (29/77). The PS group showed a significantly lower PDNV rate of 2.56% within 8 h, compared to the P group (35.71%, P < .001), S group (19.64%, P < .001), and control group (38.39%, P < .001), respectively. The S group (19.64%) also had a lower rate than the P group (35.71%, P = .007) and the control group (38.39%, P = .002). Subgroup analysis suggested a potential differential effect of palonosetron in reducing vomiting among male patients undergoing gastrointestinal procedures. The combination therapy was also associated with fewer cases of mild or no nausea and vomiting. In summary, the incidence of PDNV following sedation with nalbuphine and etomidate was notably high. The combination of scopolamine and palonosetron was more effective in preventing PDNV, with implications for improved post-sedation care.

Efficacy and safety of sedation with dexmedetomidine in adults undergoing gastrointestinal endoscopic procedures: systematic review and meta-analysis of randomized controlled trials

Background: The sedative role of dexmedetomidine (DEX) in gastrointestinal endoscopic procedures is unclear. We performed this systematic review and meta-analysis to assess the efficacy and safety of sedation with DEX during gastrointestinal endoscopic procedures with a view to providing evidence-based references for clinical decision-making. Methods: The PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) that compared DEX with different sedatives comparators (such as propofol, midazolam, and ketamine) for sedation in a variety of adult gastrointestinal endoscopic procedures from inception to 1 July 2022. Standardized mean difference (SMD) and weighted mean difference (WMD) with 95% confidence interval (CI) or pooled risk ratios (RR) with 95% CI were used for continuous outcomes or dichotomous outcomes, respectively, and a random-effect model was selected regardless of the significance of the heterogeneity. Results: Forty studies with 2,955 patients were assessed, of which 1,333 patients were in the DEX group and 1,622 patients were in the control (without DEX) group. The results suggested that the primary outcomes of sedation level of DEX are comparable to other sedatives, with similar RSS score and patient satisfaction level, and better in some clinical outcomes, with a reduced risk of body movements or gagging (RR: 0.60; 95% CI: 0.37 to 0.97; p = 0.04; I2 = 68%), and a reduced additional requirement for other sedatives, and increased endoscopist satisfaction level (SMD: 0.41; 95% CI: 0.05 to 0.77; p = 0.03; I2 = 86%). In terms of secondary outcomes of adverse events, DEX may benefit patients in some clinical outcomes, with a reduced risk of hypoxia (RR:0.34; 95% CI: 0.20 to 0.55; p < 0.0001; I2 = 52%) and cough (RR: 0.25; 95% CI: 0.12 to 0.54; p = 0.0004; I2 = 0%), no significant difference in the risk of hypotension, while an increased risk of bradycardia (RR: 3.08; 95% CI: 2.12 to 4.48; p < 0.00001; I2 = 6%). Conclusion: This meta-analysis indicates that DEX is a safe and effective sedative agent for gastrointestinal endoscopy because of its benefits for patients in some clinical outcomes. Remarkably, DEX is comparable to midazolam and propofol in terms of sedation level. In conclusion, DEX provides an additional option in sedation for gastrointestinal endoscopic procedures. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#searchadvanced.

Effect of systemic lidocaine on postoperative quality of recovery, the gastrointestinal function, inflammatory cytokines of lumbar spinal stenosis surgery: a randomized trial

Surgery is one of the most frequent and effective intervention strategies for lumbar spinal stenosis, however, one-third of patients are not satisfied with postoperative outcomes. It is not clear whether perioperative systemic lidocaine could accelerate the early postoperative quality of recovery in patients undergoing lumbar spinal stenosis surgery. 66 patients were enrolled in this trial. Lidocaine or placebo was administered at a loading dose of 1.5 mg/kg for 10 min and then infused at 2.0 mg/kg/hour till the end of surgery. Continued infusion by postoperative patient-controlled intravenous analgesia with a dose of 40 mg/hour. The primary outcome was the quality of recovery. Secondary outcomes included the time of the patient's first flatus, catheter removal time, underground time from the end of the surgery, pain score, levels of inflammatory factors (IL-6, IL-10, TNF-α), postoperative nausea and vomiting (PONV), sufentanil rescues, patients' satisfaction scores, and complications of lidocaine. Eventually, 56 patients were in the final analysis with similar age, Body Mass Index (BMI), duration of surgery and anesthesia, and median QoR-15 score (a development and Psychometric Evaluation of a Postoperative Quality of Recovery Score). The difference in median QoR-15 score in placebo versus lidocaine patients was statistically significant (IQR, 106 (104-108) versus 114 (108.25-119.25), P < 0.001). The Numeric Rating Scale (NRS) score at the 12th hour, median sufentanil rescue consumption, IL-6, tumor necrosis factor-alpha (TNF-α) of patients treatment with lidocaine were lower. Nevertheless, patients given lidocaine had high satisfaction scores. Suggesting that lidocaine enhanced the postoperative quality of recovery, met early postoperative gastrointestinal function recovery, provided superior pain relief, lessened inflammatory cytokines, etc., indicating it may be a useful intervention to aid recovery following lumbar spinal stenosis surgery.

Efficacy and safety of alfentanil plus propofol versus propofol only in painless gastrointestinal endoscopy: A meta-analysis

BACKGROUND

To systematically evaluate the efficacy and safety of alfentanil plus propofol versus propofol only for painless gastrointestinal endoscopy.

METHODS

The Cochrane Library, PubMed, Embase, China Biology Medicine, CNKI, WanFang, and VIP databases were searched to identify randomized controlled trials on alfentanil combined with propofol versus propofol only for painless gastrointestinal endoscopy from the inception of the database to August 2022. The Rev Man 5.4 software was used for statistical analyses.

RESULTS

Thirteen randomized controlled trials involving 1762 patients were identified as eligible for this study. The meta-analysis showed that compared with propofol, alfentanil combined with propofol had a more stable mean arterial pressure [mean difference (MD) = 5.38, 95% confidence interval (CI): 1.97-8.80; P = .002], heart rate (MD = 3.78, 95% CI: 1.30-6.26; P = .003) and pulse oxygen saturation (MD = 1.90, 95% CI: 0.93-2.78; P = .0001); a lower propofol dose (standard mean difference = -2.82, 95% CI: -3.70 to -1.94; P < .00001), lower awakening time (MD = -3.23, 95% CI: -4.01 to -2.45; P < .00001) and lower directional force recovery time (MD = -3.62, 95% CI: -4.22 to -3.03; P < .00001); a lower incidence of nausea and vomiting (relative risk [RR] = 0.32, 95% CI: 0.14-0.71; P = .005), body movement (RR = 0.27, 95% CI: 0.13-0.54; P = .0002), hypotension (RR = 0.23, 95% CI: 0.12-0.46; P < .0001), respiratory depression (RR = 0.37, 95% CI: 0.15-0.89; P = .03) and cough reflex (RR = 0.33, 95% CI: 0.12-0.89; P = .03).

CONCLUSION

This meta-study found that current evidence indicates that alfentanil plus propofol is better than propofol alone for painless gastrointestinal endoscopy and is associated with a lower incidence of adverse reactions. Due to the limited quality and quantity of the included studies, more high-quality studies are needed to validate these above conclusions.

Remimazolam: Non-Clinical and Clinical Profile of a New Sedative/Anesthetic Agent

A program to identify novel intravenous sedatives with a short and predictable duration of action was initiated in the late 1990's by Glaxo Wellcome. The program focussed on the identification of ester-based benzodiazepine derivatives that are rapidly broken down by esterases. Remimazolam was identified as one of the lead compounds. The project at Glaxo was shelved for strategic reasons at the late lead optimization stage. Via the GSK ventures initiative, the program was acquired by the small biotechnology company, TheraSci, and, through successive acquisitions, developed as the besylate salt at CeNeS and PAION. The development of remimazolam besylate has been slow by industry standards, primarily because of the resource limitations of these small companies. It has, however, recently been approved for anesthesia in Japan and South Korea, procedural sedation in the United States, China, and Europe, and for compassionate use in intensive care unit sedation in Belgium. A second development program of remimazolam was later initiated in China, using a slightly different salt form, remimazolam tosylate. This salt form of the compound has also recently been approved for procedural sedation in China. Remimazolam has the pharmacological profile of a classical benzodiazepine, such as midazolam, but is differentiated from other intravenous benzodiazepines by its rapid conversion to an inactive metabolite resulting in a short onset/offset profile. It is differentiated from other intravenous hypnotic agents, such as propofol, by its low liability for cardiovascular depression, respiratory depression, and injection pain. The benzodiazepine antagonist flumazenil can reverse the effects of remimazolam in case of adverse events and further shorten recovery times. The aim of this review is to provide an analysis of, and perspective on, published non-clinical and clinical information on 1) the pharmacology, metabolism, pharmacokinetics, and pharmacodynamic profile of remimazolam, 2) the profile of remimazolam compared with established agents, 3) gaps in the current understanding of remimazolam, 4) the compound's discovery and development process and 5) likely future developments in the clinical use of remimazolam.