Infectious Disease Risk Associated with Contaminated Propofol Anesthesia, 1989-2014(1)

Fospropofol disodium versus propofol for long-term sedation during invasive mechanical ventilation: A pilot randomized clinical trial

STUDY OBJECTIVE

Fospropofol disodium is a propofol prodrug that is water-soluble and has a reduced risk of bacterial contamination and hypertriglyceridemia compared with propofol. Prior to implementing a large randomized trial, we investigated the feasibility, initial efficacy, and safety of fospropofol disodium compared with propofol in long-term mild-to-moderate sedation in intensive care units (ICUs).

DESIGN

Single-centered, prospective, unblind, randomized, parallel-group clinical trial.

SETTING

The general ICU of university-affiliated teaching hospital.

PATIENTS

Adult patients (n = 60) expected to have mechanical ventilation for >24 h were enrolled and randomly assigned to the fospropofol or propofol group.

INTERVENTIONS

The fospropofol group received continuous fospropofol disodium infusions and the propofol group received continuous propofol infusions. The sedation goal was a score of -3 to 0 on the Richmond Agitation and Sedation Scale (RASS).

MEASUREMENTS

The primary outcome was the percentage of time spent in the target sedation range without rescue sedation. Safety outcomes were based on adverse events. Blood samples were collected to measure formate concentration in plasma.

MAIN RESULTS

The median dose was 4.33 (IQR, 3.08-4.94) mg/kg/h in the fospropofol group and 1.96 (IQR, 1.44-2.94) mg/kg/h in the propofol group. The median percentage of time spent in the target RASS range without rescue sedation was identical in both groups, with 83.33% (IQR, 74.43%-100.00%) in the fospropofol group and 83.33% (IQR, 77.45%-100.00%) in the propofol group (p = 0.887). At least one adverse event was identifed in 23 (76.7%) fospropofol patients and 27 (90.0%) propofol patients. The most common adverse events were tachycardia and hypotension. No paresthesia, catheter-related bloodstream infection or propofol infusion syndrome in both groups was reported. Three patients in the fospropofol group had mild hypertriglyceridemia, and nine patients in propofol group had hypertriglyceridemia (mild in eight patients and moderate in one patient) (10% versus 30%, p = 0.104). The formate concentration in plasma was very low, and no significant difference was identified at any time point between the two groups.

CONCLUSIONS

Fospropofol disodium appears to be a feasible, effective and safe sedative for patients receiving invasive mechanical ventilation with long-term sedation.

Lethal Gram-negative sepsis in healthy pigs during anaesthesia with contaminated propofol

Two healthy Landrace pigs anaesthetized with propofol suffered rapid onset of fatal sepsis. Clinical signs included severe arterial hypotension, loss of peripheral oxygenation, low end-tidal CO2, clinical onset of pulmonary oedema and cardiac dysfunction. Gross and histopathological examination revealed loss of vascular integrity with severe lung oedema and congestion, haemorrhages in several organs and fluid leakage into body cavities. Large numbers of Gram-negative bacteria, primarily Klebsiella sp., were present in the anaesthetic infusion containing propofol and were also cultured from internal organs of both pigs. The propofol was likely contaminated by bacteria after inappropriate handling and storage in the operating room. This report illustrates the potential for severe nosocomial infection when applying propofol in animals and humans and may serve as a reminder of the importance of strict aseptic practice in general, and specifically in the handling of this anaesthetic agent.

Association between first-week propofol administration and long-term outcomes of critically ill mechanically ventilated patients: A retrospective cohort study

BACKGROUND & AIM

Propofol is commonly used in ICUs, but its long-term effects have not been thoroughly studied. In vitro studies suggest it may harm mitochondrial function, potentially affecting clinical outcomes. This study aimed to investigate the association between substantial propofol sedation and clinical outcomes in critically ill patients.

METHODS

We conducted a single-centre cohort study of critically ill, mechanically ventilated (≥7 days) adults to compare patients who received a substantial dose of propofol (cumulative >500 mg) during the first week of ICU admission with those who did not. The primary outcome was the association between substantial propofol administration and 6-month mortality, adjusted for relevant covariates. Subanalyses were performed for administration in the early (day 1-3) and late (day 4-7) acute phases of critical illness due to the metabolic changes in this period. Secondary outcomes included tracheostomy need and duration, length of ICU and hospital stay (LOS), discharge destinations, ICU, hospital, and 3-month mortality.

RESULTS

A total of 839 patients were enrolled, with 73.7 % receiving substantial propofol administration (substantial propofol dose group). Six-month all-cause mortality was 32.4 %. After adjusting for relevant variables, we found no statistically significant difference in 6-month mortality between both groups. There were also no significant differences in secondary outcomes.

CONCLUSION

Our study suggests that substantial propofol administration during the first week of ICU stay in the least sick critically ill, mechanically ventilated adult patients is safe, with no significant associations found with 6-month mortality, ICU or hospital LOS, differences in discharge destinations or need for tracheostomy.

Long-term sedation with remimazolam besylate versus propofol in critically ill patients during invasive mechanical ventilation: a study protocol for a multicenter randomized non-inferior trial

Background: Remimazolam besylate is a novel ultra-short-acting benzodiazepine that can potentially be a safe and effective sedative in intensive care units. This study aims to assess whether remimazolam besylate is not inferior to propofol in maintaining mild-to-moderate sedation in critically ill patients receiving long-term mechanical ventilation. Methods and analysis: This is a multicenter, randomized, single-blind, propofol-controlled, non-inferiority study. Eligible patients are randomly assigned to receive remimazolam besylate or propofol in a 1:1 ratio to maintain a Richmond Agitation-Sedation Scale score between -3 and 0. When patients are under-sedated, rescue sedation of dexmedetomidine is added. The primary outcome is the percentage of time in the target sedation range. The secondary outcomes are hours free from the invasive ventilator in 7 days, successful extubation in 7 days, and weaning time, the length of intensive care unit stay, the length of hospital stay, and mortality in 28 days. Modified intention-to-treat and safety analysis is performed. Clinical trial registration number: https://clinicaltrials.gov/ct2/show/NCT05555667.

[Sepsis outbreak associated with use of contaminated propofol: A new case series and literature review]

INTRODUCTION

Propofol is the most commonly used hypnotic agent for the induction and maintenance of general anesthesia. Due to its lipid-based composition, propofol requires a strict handling protocol to avoid an increased risk of extrinsic contamination.

METHODS

On September 09, 2021, 05 patients with post-anaesthetic Enterobacter cloacae infections were identified in the pediatric exploration department of the Hassan II University Hospital of Fez in Morocco. We describe the investigation into this outbreak. All patient medical records were reviewed to determine patient characteristics and potential risk factors. For the literature review, we identified relevant articles by searching PubMed, Medline, Embase and Science Direct.

RESULTS

Our study included five patients, 80% were boys. The average age was 4.6 years (1-7 years), with no medical history. All five patients underwent exploratory procedures. Immediately after the procedures, all 5 patients presented with chills, tachycardia and fever in the same order of admission. They were all admitted to hospital and blood samples were taken. Blood cultures were positive for E. cloacae. All patients had elevated levels of C-reactive protein (CRP) and an elevated white blood cell count. Bacteriological investigation revealed that the infection was caused by extrinsic contamination of the intravenous anesthetic propofol by E. cloacae.

CONCLUSION

Fatal infections due to contaminated drugs, including propofol, have been reported worldwide. Propofol is a potential source of infections due to its lipophilic nature which promotes microbial growth. This probably remains an underestimated problem that deserves awareness for early recognition.

Propofol and survival: an updated meta-analysis of randomized clinical trials

BACKGROUND

Propofol is one of the most widely used hypnotic agents in the world. Nonetheless, propofol might have detrimental effects on clinically relevant outcomes, possibly due to inhibition of other interventions' organ protective properties. We performed a systematic review and meta-analysis of randomized controlled trials to evaluate if propofol reduced survival compared to any other hypnotic agent in any clinical setting.

METHODS

We searched eligible studies in PubMed, Google Scholar, and the Cochrane Register of Clinical Trials. The following inclusion criteria were used: random treatment allocation and comparison between propofol and any comparator in any clinical setting. The primary outcome was mortality at the longest follow-up available. We conducted a fixed-effects meta-analysis for the risk ratio (RR). Using this RR and 95% confidence interval, we estimated the probability of any harm (RR > 1) through Bayesian statistics. We registered this systematic review and meta-analysis in PROSPERO International Prospective Register of Systematic Reviews (CRD42022323143).

RESULTS

We identified 252 randomized trials comprising 30,757 patients. Mortality was higher in the propofol group than in the comparator group (760/14,754 [5.2%] vs. 682/16,003 [4.3%]; RR = 1.10; 95% confidence interval, 1.01-1.20; p = 0.03; I² = 0%; number needed to harm = 235), corresponding to a 98.4% probability of any increase in mortality. A statistically significant mortality increase in the propofol group was confirmed in subgroups of cardiac surgery, adult patients, volatile agent as comparator, large studies, and studies with low mortality in the comparator arm.

CONCLUSIONS

Propofol may reduce survival in perioperative and critically ill patients. This needs careful assessment of the risk versus benefit of propofol compared to other agents while planning for large, pragmatic multicentric randomized controlled trials to provide a definitive answer.

A Nontrivial Analysis of Patient Safety Risk from Parenteral Drug- and Medical Device-Borne Endotoxin

BACKGROUND

A thorough and systematic analysis of potential endotoxin-related safety issues from parenteral drugs and devices is important to ensure appropriate current Good Manufacturing Practices, compendial requirements, standards and regulatory guidance. Lately, the US Food and Drug Administration has been expecting pharmaceutical firms to apply an arbitrary safety factor to compendial compliant drug specifications for endotoxin, potentially causing manufacturing challenges, supply issues and additional unwarranted costs.

OBJECTIVE

The aim of this study was to evaluate data from three disparate sources over an extended period of time, from 2008 to 2021, to determine if there exists an industry-wide risk to patients from parenteral drugs and devices, thereby evaluating if changes to current Good Manufacturing Practices or compendial requirements are indeed warranted. Food and Drug Administration data from current Good Manufacturing Practices non-compliance observations, product recalls and the FDA Adverse Event Reporting System were used as the three sources of data.

METHODS

Parenteral products were separated into drugs and devices, potential endotoxin-related patient safety issues were characterised in terms of the available non-compliance information, the type and number of product recalls, and the type and number of potential adverse events. Descriptive statistics in Microsoft Excel 2019 and Pivot tables were used for the analysis and presentation of the data.

RESULTS

From 2011 to 2021, a total of 188 endotoxin-related current Good Manufacturing Practices compliance observations were recorded, 70% and 30% were associated with laboratory and manufacturing origins, respectively. Finished drug product testing accounted for 56% of these. In contrast, 95% of all endotoxin-related product recalls were associated solely with medical devices. Over the years 2008-2021, approximately 1.4% of all adverse events (23,663,780) were recorded with some reference to pyrexia (fever); however, there are sparse data categorically attributing this to the administration of parenteral drugs or devices or combinations of these possessing high levels of endotoxin.

CONCLUSIONS

Analysis of data concerning drug- and device-borne endotoxin obtained from FDA data from current Good Manufacturing Practices non-compliance observations, product recalls and the FDA Adverse Event Reporting System demonstrated the absence of industry-wide issues with endotoxin contamination. Based upon these data, changes to current Good Manufacturing Practices and the compendial methodology of setting endotoxin specifications (and hence the compendial methodology of testing for endotoxins) are unwarranted.

Comparative growth dynamics of bacterial and fungal contaminants in bupivacaine liposomal injectable suspension, bupivacaine 0.5%, and propofol

OBJECTIVE

To determine whether bupivacaine liposomal injectable suspension (BLIS) supports microbial growth when artificially inoculated and to evaluate liposomal stability in the face of this extrinsic contamination as evidenced by changes in free bupivacaine concentrations.

STUDY DESIGN

A randomized, prospective in vitro study in which three vials of each BLIS, bupivacaine 0.5%, and propofol were individually inoculated with known concentrations of Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans (n = 36) to quantify bacterial and fungal growth was conducted. Over 120 hours, aliquots from contaminated vials were withdrawn, plated, and incubated to determine microbial concentrations. High-pressure liquid chromatography (HPLC) was used to evaluate free bupivacaine concentrations over time in BLIS. Data were analyzed using a mixed effects model with multiple comparisons.

SAMPLE POPULATION

Twelve vials of each BLIS, bupivacaine 0.5%, and propofol.

RESULTS

BLIS did not support significant growth of Staphylococcus aureus or Candida albicans at any time. BLIS supported significant growth of Escherichia coli and Pseudomonas aeruginosa beginning at the 24 hour time point. Bupivacaine 0.5% did not support significant growth of any organisms. Propofol supported significant growth of all organisms. Free bupivacaine concentrations changed minimally over time.

CONCLUSION

Bacterial and fungal contaminant growth in artificially inoculated BLIS is organism dependent. BLIS supports significant growth of Escherichia coli and Pseudomonas aeruginosa. Extra-label handling of BLIS should only be undertaken with caution and with adherence to strict aseptic technique.

Review of remimazolam and sedatives in the intensive care unit

Remimazolam is a novel intravenous ultra-short acting benzodiazepine that has the potential of being a safe and effective new sedative for use in intensive care unit (ICU) settings. Because remimazolam metabolizes rapidly by being hydrolyzed to an inactive metabolite (CNS 7054) through non-specific tissue esterase activity, specific dosing adjustment for older adults and for patients with renal or hepatic impairment patients (except for those with severe hepatic impairment) is not required. In addition, research has shown that remimazolam may be reversed by administration of flumazenil, as its half time was sufficiently short compared to flumazenil. It shows a lower incidence of cardiorespiratory depression, less injection pain, and no fatal complications such as propofol infusion syndrome and malignant hyperthermia of inhalational anesthetics. Future studies to study the suitability of remimazolam for managing the sedation of ICU patients who need sedation for a long time over several days is required.

Outbreak of Sepsis Following Surgery: Utilizing 16S RNA Sequencing To Detect the Source of Infection

Background

Nosocomial infections are a significant health concern. Following surgery, infections are most commonly associated with the surgical site, yet there are other potential sources for infections after surgical interventions. Identification of the source of infections can be very challenging.

Methodology

An outbreak of postoperative infections following surgery led to intensive care unit (ICU) admission of patients immediately after the surgical procedure. The blood cultures of two patients were positive for Citrobacter freundii. The only connection between all cases was the anesthesiologist. An epidemiological inquiry could not definitively identify the source of the outbreak. Therefore, we utilized an RNA sequencing technique to evaluate the microbiome of the anesthesiologist and compared the results to bacteria cultured from the bloodstream of the two patients.

Results

The anesthesiologist’s microbiome contained amplicons that were identical to those of the bacteria in the patient’s bloodstream. Because Citrobacter freundii is an uncommon source of bloodstream infections, and in the normal human microbiome, the results establish the source of a cluster of infections to the anesthesiologist.

Conclusions

In cases of nosocomial infections, when conventional microbiological techniques do not clearly establish the source of the infection, using 16S RNA sequencing should be considered.

Propofol toxicity in the developing mouse heart mitochondria

BACKGROUND

Propofol infusion syndrome (PRIS) is a potentially lethal consequence of long-term propofol administration. Children are vulnerable and cardiac involvement is often prominent and associated with mortality. We aimed to determine the mechanism of propofol toxicity in newborn mice, hypothesizing that propofol would induce discrete defects within immature cardiac mitochondria.

METHODS

Newborn murine cardiac mitochondria were exposed to propofol or intralipid in vitro. Non-exposed mitochondria served as controls. Mitochondrial respiration and membrane potential (ΔΨ) were measured and respiratory chain complex kinetics were determined.

RESULTS

Propofol and intralipid exerted biological activity in isolated mitochondria. Although intralipid effects were a potential confounder, we found that propofol induced a dose-dependent increase in proton leak and caused a defect in substrate oxidation at coenzyme Q (CoQ). These impairments prevented propofol-exposed cardiomyocyte mitochondria from generating an adequate ΔΨ. The addition of the quinone analog, CoQ₀, blocked propofol-induced leak and increased Complex II+III activity.

CONCLUSIONS

Propofol uncoupled immature cardiomyocyte mitochondria by inducing excessive CoQ-sensitive leak and interfered with electron transport at CoQ. The findings provide new insight into the mechanisms of propofol toxicity in the developing heart and may help explain why children are vulnerable to developing PRIS.

IMPACT

Propofol uncouples immature cardiomyocyte mitochondria by inducing excessive coenzyme Q (CoQ)-sensitive proton leak. Propofol also interferes with electron transport at the level of CoQ. These defects provide new insight into propofol toxicity in the developing heart.

[An analysis of medication errors in patients admitted to surgery rooms and post-anesthetic recovery at a high-complexity hospital in Bogota, Colombia]

Medication errors represent one of the main causes of incidents and adverse events during the perioperative period. Therefore, this study analyzes errors before, during, and after the administration of general anesthesia for abdominal surgery at a high-complexity hospital in Bogota, Colombia. A descriptive cross-sectional study was conducted with 390 patients between January and September 2019. Of the 3,677 medication administrations, some type of error was made in 60% of cases, mostly in emergency surgeries. The pharmacological group with the most errors was general anesthetics, with 32%. All identified errors constituted situations with harm potential, indicating the need to promote the standardization of activities involving the use of medications and a culture of healthcare safety in order to avoid adverse events.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

Investigation of Variables Associated with Surgical Site Infection following the Management of Canine Cranial Cruciate Ligament Rupture with a Lateral Fabellotibial Suture

OBJECTIVE

 This study investigated variables associated with surgical site infection (SSI) in dogs with cranial cruciate ligament rupture managed with stifle joint examination and lateral fabellotibial suture stabilization.

STUDY DESIGN

 A retrospective study of dogs that had stifle arthroscopy, stifle arthrotomy, or a combination of both, followed by lateral fabellotibial suture stabilization for cranial cruciate ligament rupture. All cases had a minimum follow-up of 90 days. Lameness grades were recorded preoperatively, and at 6-week and final follow-up.

RESULTS

 One hundred fifty procedures in 130 dogs met the inclusion criteria. Overall, SSI rate was 17.3% and removal of the lateral fabellotibial suture was performed in 53% of SSI. Multivariable analysis showed significant association between SSI and bodyweight (p = 0.013), and induction using propofol (p = 0.029). Multilevel ordinal logistic regression analysis showed a greater proportion of dogs had a higher lameness grade at 6-week (p = 0.021) and final follow-up (p = 0.002) assessments in the infected compared with non-infected dogs.

CONCLUSION

 Our study demonstrated a higher SSI incidence than previously reported in dogs undergoing a lateral fabellotibial suture for cranial cruciate ligament rupture. Bodyweight and induction with propofol were identified as significant risk factors for postoperative SSI. Owners could be advised of an increased SSI risk in larger dogs and consideration should be given to selection of induction agent. Dogs that develop an SSI have a worse lameness grade at 6-week and final follow-up.

Serratia marcescens sepsis outbreak caused by contaminated propofol

We presented a sepsis outbreak caused by Serratia marcescens from contaminated propofol to raise awareness. Three patients had sepsis syndrome after chest surgery. Isolation of S marcescens from patients' respiratory and blood samples alerted us to a possible outbreak. Four syringes filled with propofol and 1 saline solution yielded S marcescens. Nine of 10 isolates from samples of patients and environment genotyped by pulsed-field gel electrophoresis were the same. Disobeying aseptic injection rules of propofol is still causing outbreaks.

Suspected periprosthetic joint infection after total knee arthroplasty under propofol versus sevoflurane anesthesia: a retrospective cohort study

PURPOSE

Periprosthetic joint infection is a serious complication of total knee arthroplasty. Though there are many factors that might increase its risk, the use of propofol for maintaining general anesthesia could theoretically increase the incidence of infection because of its lipid component that supports bacterial growth. Nevertheless, the relationship between anesthetic maintenance agents and the occurrence of periprosthetic joint infection remains uncertain. The purpose of this study was to compare the incidence of suspected early-onset periprosthetic joint infection between patients undergoing total knee arthroplasty under propofol vs sevoflurane anesthesia.

METHODS

We conducted a retrospective cohort study of patients in the national inpatient Diagnosis Procedure Combination database in Japan who underwent total knee arthroplasty. Suspected periprosthetic joint infection was surrogately defined as the need for arthrocentesis or debridement within 30 days of surgery. Propensity score matching was performed between patients who received either propofol or sevoflurane for anesthetic maintenance to determine the proportion of those with infection.

RESULTS

Eligible patients (n = 21,899) were categorized into either the propofol (n = 7,439) or sevoflurane (n = 14,460) groups. In the 5,140 propensity-matched patient pairs, there was no significant difference in the proportion of arthrocentesis or debridement [1.3% propofol vs 1.7% sevoflurane; respectively (relative risk, 0.76; 95% CI, 0.55 to 1.04; P = 0.10)] between the groups. The mean (SD) length of stay in the propofol group was significantly longer than in the sevoflurane group [32.5 (18.4) days vs 31.4 (14.4) days, respectively; mean difference, 1.1; 95% CI, 0.5 to 1.8; P < 0.001].

CONCLUSION

Propensity score analysis suggested no significant association between the choice of anesthetic maintenance agent and the occurrence of suspected early-onset periprosthetic joint infection in patients undergoing total knee arthroplasty.

Burkholderia stabilis outbreak associated with contaminated commercially-available washing gloves, Switzerland, May 2015 to August 2016

We describe an outbreak of Burkholderia stabilis associated with contaminated washing gloves, a commercially available Class I medical device. Triggered by an increase in Burkholderia cepacia complex (BCC) bacteremias and the detection of BCC in unopened packages of washing gloves, an ad hoc national outbreak committee comprising representatives of a public health organisation, a regulatory agency, and an expert association convened and commissioned an outbreak investigation. The investigation included retrospective case finding across Switzerland and whole genome sequencing (WGS) of isolates from cases and gloves. The investigation revealed that BCC were detected in clinical samples of 46 cases aged 17 to 91 years (33% females) from nine institutions between May 2015 and August 2016. Twenty-two isolates from case patients and 16 from washing gloves underwent WGS. All available outbreak isolates clustered within a span of < 19 differing alleles, while 13 unrelated clinical isolates differed by > 1,500 alleles. This BCC outbreak was rapidly identified, communicated, investigated and halted by an ad hoc collaboration of multiple stakeholders. WGS served as useful tool for confirming the source of the outbreak. This outbreak also highlights current regulatory limitations regarding Class I medical devices and the usefulness of a nationally coordinated outbreak response.

The Role of GABA Receptor Agonists in Anesthesia and Sedation

GABA (γ-aminobutyric acid) receptors, of which there are two types, are involved in inhibitory synapses within the central nervous system. The GABA_A receptor (GABAAR) has a central role in modern anesthesia and sedation practice, which is evident from the high proportion of agents that target the GABAAR. Many GABAAR agonists are used in anesthesia practice and sedation, including propofol, etomidate, methohexital, thiopental, isoflurane, sevoflurane, and desflurane. There are advantages and disadvantages to each GABAAR agonist currently in clinical use. With increasing knowledge regarding the pharmacology of GABAAR agonists, however, newer sedative agents have been developed which employ 'soft pharmacology', a term used to describe the pharmacology of agents whereby their chemical configuration allows rapid metabolism into inactive metabolites after the desired therapeutic effect(s) has occurred. These newer 'soft' GABAAR agonists may well approach ideal sedative agents, as they can offer well-controlled, titratable activity and ultrashort action. This review provides an overview of the role that GABAAR agonists currently play in sedation and anesthesia, in addition to discussing the future role of novel GABAAR agonists in anesthesia and sedation.