Safety and efficacy of non-anesthesiologist administration of propofol sedation during esophagogastroduodenoscopy in the intensive care unit

Application effects of remimazolam and propofol on elderly patients undergoing hip replacement

Objective

To explore the anesthetic and analgesic effects of remimazolam and propofol in elderly patients undergoing hip replacement and their effects on respiratory and circulatory systems, stress and cognitive function.

Methods

Sixty elderly patients undergoing elective hip replacement in the hospital were selected as the research subjects, and they were divided into the remimazolam group and the propofol group according to the admission sequence of patients. The remimazolam group was anesthetized with remimazolam, and the propofol group was anesthetized with propofol. The anesthesia-related indicators, perioperative pain degree [Visual Analogue Scale (VAS)], circulatory indicators [heart rate, mean arterial pressure (MAP)] before anesthesia (T₀), immediately before laryngeal mask insertion (T₁), at 5 min after laryngeal mask insertion (T₂), at 30 min after laryngeal mask insertion (T₃) and at 5 min after laryngeal mask removal (T₄), stress response indicators (plasma epinephrine, norepinephrine, cortisol) before anesthesia induction and at 24 h and 72 h after surgery, cognitive function [Mini-Mental State Examination (MMSE)] and adverse reactions were compared between the two groups.

Results

Among the 60 enrolled patients, only 1 case was excluded due to withdrawal, thus 30 cases in the remimazolam group and 29 cases in the propofol group were included. There were statistically significant differences in the heart rate, MAP, plasma epinephrine, norepinephrine, cortisol and VAS score in the two groups from the aspects of interaction effect and time-point effect (P < 0.05). The heart rate and MAP at T₁, T₂ and T₃ in the two groups were significantly decreased compared with those at T₀, but the heart rate and MAP in the remimazolam group at T₁, T₂ and T₃ were significantly higher than those in the propofol group (P < 0.05). There were no statistical differences in the anesthesia time, awakening time and extubation time between the remimazolam group and the propofol group (P > 0.05). The levels of plasma epinephrine, norepinephrine and cortisol in the two groups were significantly higher at 24 h and 72 h after surgery than those before anesthesia induction, and the above levels were significantly lower in the remimazolam group than those in the propofol group (P < 0.05). The VAS scores at each time point in the two groups were significantly reduced compared to before surgery, but there was no statistically significant difference between the two groups after surgery (P > 0.05). The MMSE scores of the two groups were significantly lower at 1 d and 3 d after surgery compared with those before anesthesia induction, but the score in the remimazolam group was significantly higher than that in the propofol group (P < 0.05). In addition, the incidence rates of adverse reactions were significantly lower in the remimazolam group compared to the propofol group (P < 0.05).

Conclusion

Compared with propofol, remimazolam can achieve equivalent anesthetic and analgesic effects in elderly patients undergoing hip replacement. However, the latter one can significantly relieve respiratory and circulatory suppression, stress response and cognitive dysfunction, with good safety.

Trial registration

This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 31/12/2021 with the registration number ChiCTR2100055039.

Fluid administration during routine colonoscopy is not clinically significant: a randomized controlled trial

BACKGROUND

Retrospective studies have questioned the benefits of intravenous (IV) fluids during routine colonoscopies given they are performed on well patients who experience limited fluid loss, consume clear fluids up until 2 h prior and low IV volumes typically infused. This trial aims to assess the impact of IV fluid on hypotension and electrolyte changes amongst patients undergoing colonoscopy.

METHODS

Participants undergoing colonoscopies were randomized (single blinded) to IV fluid or no IV fluid. Primary outcomes were equivalence of intraoperative hypotensive episodes (>20% drop in systolic blood pressure (SBP)) and changes in serum electrolytes post procedure. Secondary outcomes included patient reported outcome measures (PROMs).

RESULTS

Of the 470 participants enrolled, 84/235 (35.7%) from the IV fluids group and 88/230 (38.3%) from the no IV fluids group experienced a hypotensive event (difference in prevalence -2.5, 95% CI -11.3, 6.3). Fourteen participants in each group required clinical intervention to provide haemodynamic support (difference in prevalence -0.1, 95% CI -4.4, 4.2). Postoperative electrolytes changes and PROMs were similar for both groups.

CONCLUSION

Whilst definitive recommendations for IV fluid use during routine colonoscopy are not possible as this trial was underpowered to show equivalence between the groups for hypotensive events, there was no clinically meaningful difference between the groups. These findings provide important data for meta-synthesis and for planning future work.

Efficacy and Safety of Pediatric Procedural Sedation Outside the Operating Room

Background

The volume of pediatric Procedural Sedation and Analgesia (PSA) outside the operating room has been increasing. This high clinical demand leads non-anesthesiologists, especially pediatric intensivists, pediatricians, and emergency physicians, to take a role in performing procedural sedation. Our department has established the PSA service by pediatric intensivists since 2015.

Objectives

We aimed to assess the efficacy and safety of PSA outside the operating room conducted by pediatric intensivists and identify risk factors for severe adverse events.

Methods

This was a retrospective descriptive study conducted from January 2015 to July 2019. Children aged less than 20 years who underwent procedural sedation were included. We collected demographic data, sedative and analgesic medications, American Society of Anesthesiologists (ASA) Physical Status Classification, indications for sedation, the success of procedural sedation, and any adverse events.

Results

Altogether, 395 patients with 561 procedural sedation cases were included. The median age was 55 months (range: 15 to 119 months), and 58.5% (231/395) were male. The rate of successful procedures under PSA was 99.3%. Serious Adverse Events (SAE) occurred in 2.7%. Patients who received more than three sedative medications had higher SAE than patients who received fewer medications (adjusted for age, location of sedation, type of procedure, and ASA classification) (odds ratio: 8.043; 95% CI: 2.472 - 26.173, P = 0.001).

Conclusions

Our data suggest that children who undergo procedural sedation outside the operating room conducted by pediatric intensivists are safe and effectively treated. Receiving more than three sedative medications is the independent risk factor associated with serious adverse events.