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Scarlata S, Scaduto V, Paglione L, Pascarella G, Strumia A, Bruno F, Antonelli Incalzi R, Carassiti M, Agrò FE, Costa F. Remifentanil Target-controlled Infusion Versus Standard of Care for Conscious Sedation During Ultrasound-guided Transbronchial Needle Aspiration and Biopsy: A Randomized, Prospective, Control Study. J Bronchology Interv Pulmonol 2024; 31:e0989. [PMID: 39262169 DOI: 10.1097/lbr.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 08/05/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in the diagnosis and staging of mediastinal lymph node lesions in lung cancer. Adequate sedation is an important part of the procedure as it provides patient comfort and potentially increases diagnostic yield. The sedation modality varies among centers and includes moderate sedation/conscious sedation, deep sedation, and general anesthesia. The object of this study will be the evaluation of patient's comfort and level of satisfaction with the involved health care providers (bronchoscopist and anesthesiologist) of remifentanil administration in target-controlled infusion (TCI) for conscious sedation in patients undergoing EBUS‑TBNA, with a prospective randomized study design versus the of standard sedation protocol with midazolam and/or fentanest and/or propofol. METHODS This study was carried out at the "Campus Biomedico di Roma" University Hospital between September 2021 and November 2021, with a total number of 30 patients enrolled who met the eligibility criteria, randomly divided into 2 groups: group 1 "REMIFENTANIL TCI" (experimental group) where the patients performed the EBUS-TBNA procedure under conscious sedation with infusion of remifentanil TCI with a target between 3 ng/mL and 6 ng/mL and group 2 "STANDARD" (control group) with patients undergoing conscious sedation with the association of midazolam and/or fentanest and/or propofol in refracted boluses based on clinical needs. Complications, safety, and level of satisfaction of the operator, the anesthesiologist, and the patient were evaluated. RESULTS The results show that sedation with remifentanil in TCI can improve the comfort level of patients, reducing the risks associated with the procedure (lower frequency of oversedations and hypotension), allowing for greater intraprocedural safety. Furthermore, the level of satisfaction of the anesthesiologist and that of the operator appears to be significantly higher in the Remifentanil group. CONCLUSION The execution of a mild to moderate sedation with Remifentanil in TCI in patients undergoing EBUS is safe, tolerated, and allows to obtain greater intraprocedural comfort. Further studies and larger and more representative samples are obviously needed to confirm and strengthen the validity of a remifentanil TCI-based sedation in endoscopic diagnostics.
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Affiliation(s)
- Simone Scarlata
- Internal Medicine Unit
- Department of Medicine and Surgery, Research Unit of Internal Medicine, Fondazione Policlinico Università Campus Biomedico, Roma, Italy
| | - Valentina Scaduto
- Department of Anesthesiology, Intensive Care and Pain Management, Fondazione Policlinico Universitario Campus Bio-Medico
| | - Lucio Paglione
- Department of Anesthesiology, Intensive Care and Pain Management, Fondazione Policlinico Universitario Campus Bio-Medico
| | - Giuseppe Pascarella
- Department of Anesthesiology, Intensive Care and Pain Management, Fondazione Policlinico Universitario Campus Bio-Medico
| | - Alessandro Strumia
- Department of Anesthesiology, Intensive Care and Pain Management, Fondazione Policlinico Universitario Campus Bio-Medico
| | - Federica Bruno
- Department of Anesthesiology, Intensive Care and Pain Management, Fondazione Policlinico Universitario Campus Bio-Medico
| | - Raffaele Antonelli Incalzi
- Internal Medicine Unit
- Department of Medicine and Surgery, Research Unit of Internal Medicine, Fondazione Policlinico Università Campus Biomedico, Roma, Italy
| | - Massimiliano Carassiti
- Department of Medicine and Surgery, Research Unit of Anesthesiology, Intensive Care and Pain Management, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Rome, Italy
| | - Felice Eugenio Agrò
- Department of Medicine and Surgery, Research Unit of Anesthesiology, Intensive Care and Pain Management, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Rome, Italy
| | - Fabio Costa
- Department of Anesthesiology, Intensive Care and Pain Management, Fondazione Policlinico Universitario Campus Bio-Medico
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Al-Husinat L, Jouryyeh B, Rawashdeh A, Alenaizat A, Abushehab M, Amir MW, Al Modanat Z, Battaglini D, Cinnella G. High-Flow Oxygen Therapy in the Perioperative Setting and Procedural Sedation: A Review of Current Evidence. J Clin Med 2023; 12:6685. [PMID: 37892823 PMCID: PMC10607541 DOI: 10.3390/jcm12206685] [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: 08/03/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
High-flow oxygen therapy (HFOT) is a respiratory support system, through which high flows of humidified and heated gas are delivered to hypoxemic patients. Several mechanisms explain how HFOT improves arterial blood gases and enhances patients' comfort. Some mechanisms are well understood, but others are still unclear and under investigation. HFOT is an interesting oxygen-delivery modality in perioperative medicine that has many clinical applications in the intensive care unit (ICU) and the operating room (OR). The purpose of this article was to review the literature for a comprehensive understanding of HFOT in the perioperative period, as well as its uses in procedural sedation. This review will focus on the HFOT definition, its physiological benefits, and their mechanisms, its clinical uses in anesthesia, and when it is contraindicated.
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Affiliation(s)
- Lou’i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (L.A.-H.); (Z.A.M.)
| | - Basil Jouryyeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.); (A.A.)
| | - Ahlam Rawashdeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.); (A.A.)
| | - Abdelrahman Alenaizat
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.); (A.A.)
| | - Mohammad Abushehab
- Anesthesia and Intensive Care Unit, Salmanyeh Hospital, Manama 323, Bahrain;
| | - Mohammad Wasfi Amir
- Department of General Surgery and Anesthesia, Faculty of Medicine, Mutah University, Karak 61710, Jordan;
| | - Zaid Al Modanat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (L.A.-H.); (Z.A.M.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy;
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Hu Q, Liu X, Wen C, Li D, Lei X. Remimazolam: An Updated Review of a New Sedative and Anaesthetic. Drug Des Devel Ther 2022; 16:3957-3974. [PMID: 36411859 PMCID: PMC9675580 DOI: 10.2147/dddt.s384155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/27/2022] [Indexed: 08/16/2023] Open
Abstract
Remimazolam (CNS7056) is a novel benzodiazepine for intravenous sedation; it has an ultra-short duration of action and was recently approved for use in procedural sedation and general anaesthesia. It acts on γ-aminobutyric acid type A receptors and is rapidly converted into an inactive metabolite by tissue esterase enzymes. Remimazolam has been successfully used in endoscopic inspection or surgery and general anaesthesia induction and maintenance with fast and predictable onset and recovery times, high procedure success rates, and minor respiratory and hemodynamic fluctuations and without serious drug-related adverse reactions. If needed, the effects of remimazolam can be reversed by flumazenil, which allows prompt termination of sedation. Although remimazolam has great potential for sedation in patients admitted to intensive care units, future studies are needed to evaluate its efficacy and safety in patients requiring sedation for a long period, and numerous studies are warranted to explore the optimal dose in different application scenarios. The review aimed to provide an introduction to the process of remimazolam synthesis and its current clinical uses and future clinical developments.
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Affiliation(s)
- Qinxue Hu
- Department of Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Xing Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People’s Republic of China
| | - Chengli Wen
- Department of Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Duo Li
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
- Department of Inflammation & Allergic Diseases Research Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
- Infection Control Department, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Xianying Lei
- Department of Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
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Zhang YX, He XX, Chen YP, Yang S. The effectiveness of high-flow nasal cannula during sedated digestive endoscopy: a systematic review and meta-analysis. Eur J Med Res 2022; 27:30. [PMID: 35209948 PMCID: PMC8876126 DOI: 10.1186/s40001-022-00661-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/14/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Studies evaluating the role of high-flow nasal cannula (HFNC) in sedated digestive endoscopy have reported conflicting results. This meta-analysis evaluates the effectiveness of HFNC in patients undergoing digestive endoscopy procedures under sedation. METHODS PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science, were searched from inception to 31 July 2021. Only randomized clinical trials comparing HFNC with standard nasal cannula oxygen (SNC) during sedated digestive endoscopy were included. The incidence of hypoxemia was the primary outcome, and the secondary outcome was the percentage of patients who needed airway interventions. RESULTS Seven studies that enrolled 2998 patients were included. When compared to SNC, HFNC was associated with a significant reduction in hypoxemia incidence (OR 0.24, 95% CI 0.09 to 0.64) and airway intervention requirements (OR 0.15, 95% CI 0.03 to 0.69), with both high heterogeneity (I2 = 81% and 94%). In subgroup analysis, when hypoxemia was defined as pulse oxygen saturation (SpO2) < 90%, low risk of hypoxemia subjects who received HFNC were associated with a significant reduction in hypoxemia incidence (OR 0.02, 95% CI 0.00 to 0.07; heterogeneity I2 = 39%) and airway intervention requirements (OR 0.02, 95% CI 0.01 to 0.04; heterogeneity I2 = 15%). However, in the high risk of hypoxemia subjects, there were no significant differences between the two oxygen administration techniques in both primary (OR 0.81, 95% CI 0.36 to 1.78; heterogeneity I2 = 0%) and secondary outcomes (OR 0.85, 95% CI 0.46 to 1.59; heterogeneity I2 = 0%). CONCLUSIONS Compared to SNC, HFNC not only reduce the incidence of hypoxemia but also reduce the requirements for airway interventions during sedated digestive endoscopy procedures, especially in patients at low risk for hypoxemia. In high risk of hypoxemia patients, there were no significant differences between the two oxygen administration techniques. Trial registration PROSPERO International prospective register of systematic reviews on 28 July 2021, registration no. CRD42021264556.
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Affiliation(s)
- Yu-Xin Zhang
- Department of Gastroenterology, Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, 519000, China
| | - Xing-Xiang He
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, China
| | - Yu-Ping Chen
- Department of Gastroenterology, Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, 519000, China
| | - Shuai Yang
- Department of Emergency Intensive Care Unit, Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), 79 Kangning Road, Xiangzhou District, Zhuhai, 519000, China.
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Chen W, Chen S, Huang Y. Induction and maintenance of procedural sedation in adults: focus on remimazolam injection. Expert Rev Clin Pharmacol 2021; 14:411-426. [PMID: 33686920 DOI: 10.1080/17512433.2021.1901575] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Procedural sedation (PS) is a humane way to help patients get through painful medical procedures by the administration of sedative drugs combined with analgesics. However, each of the currently used medications has certain shortcomings, urging the search for a new drug. Remimazolam, a novel benzodiazepine, is an ultra-short-acting hypnotic agent invented out of the 'soft drug' development.Areas covered: This presented review provides an overview of the drugs used in clinical practice for the induction and maintenance of procedural sedation in adults, focusing on the newly investigated benzodiazepine remimazolam. Literature search was conducted using the MEDLINE and ClinicalTrial.gov databases from January 2007 to December 2020.Expert opinion: Based on the reported clinical trials so far, remimazolam has demonstrated its effectiveness and safety with promising properties including rapid onset, short duration of action, predictable and consistent recovery profile, metabolism almost unaffected by liver or renal function, with non or minimal cardiorespiratory depression, and availability with a reversal drug. With marketing approval received recently, remimazolam is expected to have a place in the practice for procedural sedation in the near future if its efficacy and safety are further confirmed by more clinical trials and post-market analyses.
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Affiliation(s)
- Weiyun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Shaohui Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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High-Flow Nasal Cannula and Mandibular Advancement Bite Block Decrease Hypoxic Events during Sedative Esophagogastroduodenoscopy: A Randomized Clinical Trial. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4206795. [PMID: 31380421 PMCID: PMC6662466 DOI: 10.1155/2019/4206795] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/21/2019] [Accepted: 07/04/2019] [Indexed: 01/02/2023]
Abstract
During sedated endoscopic examinations, upper airway obstruction occurs. Nasal breathing often shifts to oral breathing during open mouth esophagogastroduodenoscopy (EGD). High-flow nasal cannula (HFNC) which delivers humidified 100% oxygen at 30 L min−1 may prevent hypoxemia. A mandibular advancement (MA) bite block with oxygen inlet directed to both mouth and nose may prevent airway obstruction during sedated EGD. The purpose of this study was to evaluate the efficacy of these airway devices versus standard management. One hundred and eighty-nine patients were assessed for eligibility. One hundred and fifty-three were enrolled. This study randomly assigned eligible patients to three arms: the standard bite block and standard nasal cannula, HFNC, and MA bite block groups. EGD was performed after anaesthetic induction. The primary endpoint was the oxygen desaturation area under curve at 90% (AUCDesat). The secondary endpoints were percentage of patients with hypoxic, upper airway obstruction, and apnoeic and rescue events. One hundred and fifty-three patients were enrolled. AUCdesat was significantly lower for HFNC and MA bite blocks versus the standard management (p= 0.019). The HFNC reduced hypoxic events by 18% despite similar airway obstruction and apnoeic events as standard group. The MA bite block reduced hypoxic events by 12% and airway obstructions by 32%. The HFNC and MA groups both showed a 16% and 14% reduction in the number of patients who received rescue intervention, respectively, compared to the standard group. The HFNC and MA bite block may both reduce degree and duration of hypoxemia. HFNC may decrease hypoxemic events while maintaining nasal patency is crucial during sedative EGD. The MA bite block may prevent airway obstruction and decrease the need for rescue intervention.
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