Sedation, analgesia, and monitoring

Efficacy and Safety of Different Doses of Remimazolam Tosilate Applied in Upper Gastrointestinal Endoscopy: A Prospective Randomized Controlled Double-Blind Trial

Background

Remimazolam is a novel benzodiazepine narcotic. When used for gastrointestinal endoscopy or bronchoscopy, it provides adequate sedation and rapid recovery. However, studies on the optimal initial loading dose of remimazolam remain inadequate. Therefore, we conducted a randomized controlled clinical trial to investigate the efficacy and safety of different doses of remimazolam applied in upper gastrointestinal endoscopy.

Methods

A total of 218 patients scheduled for upper gastrointestinal endoscopy were included in our trial and divided into experimental and control groups: the experimental groups were the remimazolam groups (R1 of 0.2 mg/kg, R2 of 0.3 mg/kg, and R3 of 0.4 mg/kg), and the control group was the propofol group. Following a single injection of trial drugs during the induction period, operational requirements were evaluated based on MOAA/S scores. When the sedation was successfully achieved, safety was evaluated based on the incidence of various intraoperative and postoperative adverse events.

Results

The success rates of intraoperative sedation were 82% in group R1, 98% in group R2, 96% in group R3, and 100% in group P. The incidence of hypotension was lower in the remimazolam groups than in the propofol group (16%), 4% in group R1, 6% in group R2, and 6% in group R3. The incidence of postoperative vertigo was significantly higher, and sedation recovery time was prolonged in high-concentration remimazolam group.

Conclusion

Satisfactory efficacy can be obtained with higher concentrations of remimazolam tosilate in patients undergoing upper gastrointestinal endoscopy with ASA grade I or II. However, as the dose is progressively increased, the incidence of adverse reactions by remimazolam tosilate are also significantly increased, such as vertigo and prolonged sedation recovery time.

Trial Registration

The trial was registered prior to enrollment at the Chinese Clinical Trial Registry (ChiCTR 2000032067).

Efficacy and Safety of Remimazolam for Procedural Sedation: A Meta-Analysis of Randomized Controlled Trials With Trial Sequential Analysis

Background: Remimazolam is a new ultrashort-acting benzodiazepine. Remimazolam has been approved for procedural sedation by the US Food and Drug Administration in 2020. However, prior trials and the participants they enrolled were limited.

Aim: In this meta-analysis, we investigated the effectiveness and adverse events (AEs) of remimazolam during procedural sedation.

Materials and Methods: The study protocol was registered (doi: 10.37766/inplasy2020.8.0043), and six databases were searched. We performed meta-analysis, trial sequential analysis (TSA), and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for judging the certainty of evidence (CoE).

Results: A total of five randomized controlled trials with 1,248 participants were included. Compared with the use of midazolam, the utilization of remimazolam resulted in an increase in procedure success rate [odds ratio (OR) = 9.01, 95% confidence interval (CI): 2.35–34.57], a reduction in the application of rescue medication (OR = 13.58, 95% CI: 3.46–53.28), a decrease in time to recovery [minutes, weighted mean difference (WMD) = −5.70, 95% CI: −8.68 to −2.72], and a better cognitive recovery of Hopkins Verbal Learning Test-Revised (WMD = 5.22, 95% CI: 2.88–7.55). No difference was found in completion of procedure (OR = 1.68, 95% CI: 0.72–3.90) with inconclusive in TSA. Despite no difference of total AEs (OR = 0.60, 95% CI: 0.24–1.50), more detailed analysis of AEs remained inconclusive in TSA. The GRADE assessment demonstrated low to very low CoE.

Conclusion: Our analysis suggested that remimazolam may be a better choice for procedural sedation than midazolam. Nevertheless, further studies are warranted to conclusively establish its safety.

Nonoperating Room Anesthesia: Anesthesia in the Gastrointestinal Suite

Exponential growth in endoscopy suite procedures due to technological advances requires teamwork between anesthesiologists, endoscopists, nursing teams, and technical and support staff. The current standard of care for moderate sedation includes a combination of anxiolytic drugs and analgesic drugs and sometimes are not adequate to ensure patient safety, efficiency, and comfort. The use of anesthesia services can improve safety, recovery, turnovers, and efficiency. The article discusses comprehensive preoperative evaluation, optimization of comorbidities, and intraoperative airway management strategies to deliver safe and efficient anesthesia, given the need to share the airway and allow the use of carbon dioxide in the gastrointestinal suite.

The effect of magnesium sulphate on postoperative analgesia requirements in gynecological surgeries

Objective:

Recent studies have shown the positive effect of magnesium sulphate (MgSO4) on pain reduction and postoperative analgesic requirements in patients undergoing surgery. We assessed the effect of MgSO4 on intra-operative and postoperative analgesic requirements in patients undergoing lower abdominal gynecological laparotomy.

Materials and Methods:

This randomized clinical trial was conducted on 30 female patients at Rasool-e-Akram (referral and academic) hospital in Tehran from August 2012 to March 2013. The patients who were candidates for gynecologic surgeries (hysterectomy and/or myomectomy) were randomized into study (n=15) and control (n=15) groups. Same anesthetic technique was used in all patients. Besides induction of the anesthesia in the study group, we administered MgSO4 50 mg/kg/hr intravenously (IV) for analgesic purposes as a bolus dose and then 8 mg/kg IV as maintenance dose. Control group received the same anesthetic agents and the same amount of isotonic saline instead of MgSO4. Analgesic consumption was measured in both groups postoperatively within 24 hours. The visual analog scale (VAS) was used for the evaluation of postoperative pain in both groups.

Results:

There was a decrease in analgesic consumption and pain in the group receiving MgSO4, in comparison to control group. Pain severity assessment, 24 hours post operatively showed similar results in both groups. There was a statistically significant difference in prescribed dose of pethidine between study and control groups (p=<0.0001).

Conclusion:

Intra-operative MgSO4 is effective in postoperative pain control following lower abdominal laparotomy. Further studies with larger sample sizes and longer follow-up should be performed to obtain more information about safety and to determine whether doses of MgSO4 can provide postoperative analgesic benefits.