Search Results (45)

Background/Objectives: Total intravenous anesthesia (TIVA) typically combines propofol and remifentanil. Remifentanil exerts minimal influence on motor evoked potential (MEP), whereas propofol partially reduces MEP amplitude. Remimazolam, a novel agent, is a component of TIVA. However, evidence of remimazolam on MEP is limited. We aimed to compare the effects of propofol and remimazolam, combined with remifentanil, on relative MEP depression. Methods: Using a crossover design, 18 patients undergoing spine surgery were randomly assigned to receive either propofol or remimazolam as the first agent. In the propofol first sequence, anesthesia was induced and maintained with propofol, which was then switched to remimazolam 60 min after surgery. In the remimazolam first sequence, remimazolam was used first and then switched to propofol. The primary outcomes measured were the MEP amplitude and latency. Results: MEP amplitude and latency during propofol and remimazolam infusions were as follows: amplitude (mean (SD); 635.3 (399.1) vs. 738.4 (480.4) μV, p = 0.047) and latency (median [IQR]; 22.4 [20.3–24.6] vs. 21.4 [19.6–23.5] ms, p = 0.070), indicating propofol caused greater depression in amplitude than remimazolam. However, an incident of severe body movement disrupting surgery occurred under remimazolam anesthesia in a young, healthy male patient, although bispectral index remained below 60. This suggests that remimazolam, at hypnotic levels similar to propofol, may result in reduced akinesia in major surgeries, such as spinal surgery, when neuromuscular blockade is not employed. Conclusions: Remimazolam demonstrated comparable or superior effects to propofol on MEP latency and amplitude when combined with remifentanil during spinal surgery, rendering it a potential alternative to propofol for MEP monitoring. Full article

Background and Objectives: Deep brain stimulation (DBS) requires sedation strategies that enable rapid and reliable awakening during intraoperative electrophysiological testing. Although propofol and dexmedetomidine are commonly used, their lack of pharmacological antagonists might delay recovery. In this retrospective case series, we assessed the effects of using remimazolam, a short-acting benzodiazepine that is reversible with flumazenil. No existing research has determined whether this may represent a clinically advantageous alternative. Materials and Methods: Six patients who underwent DBS surgery with monitored anesthetic care between May and August 2024 were included. Two patients received dexmedetomidine and propofol combined, whereas four received remimazolam for initial sedation. The time from sedation discontinuation to intraoperative electrophysiological examination, postoperative hospital stays, and perioperative complications were evaluated. Results: Patients who received remimazolam had shorter awakening intervals (median 17 min) compared to those who received dexmedetomidine and propofol (median 50 min), with a large effect size difference (Cliff’s delta −1.00). In all cases of remimazolam, patients were administered flumazenil to facilitate awakening, and transient hypertension requiring nicardipine was observed in some patients. Among the patients who underwent unilateral DBS, those who received remimazolam had shorter postoperative hospital stays (5–7 days) than the patient who received dexmedetomidine and propofol (9 days). No patient had complications. Conclusions: This small retrospective case series indicated that remimazolam, when reversed with flumazenil, was associated with rapid awakening compared with dexmedetomidine and propofol in patients undergoing DBS surgery. However, these findings require validation in larger prospective studies due to the small sample size. Full article

Perioperative neurocognitive disorder (PND) is a concern following anesthesia, particularly in individuals at risk for Alzheimer’s disease (AD). This study compared the cognitive and pathological effects of propofol and remimazolam in a mouse model with AD following surgery. Five-month-old male ApoE4-KI mice underwent abdominal surgery under either propofol (170 mg/kg) or remimazolam (85 mg/kg) anesthesia. Cognitive function was assessed using the Morris water maze and Y-maze, and neuronal apoptosis and amyloid-beta (Aβ) deposition in the CA3 and dentate gyrus (DG) of the hippocampus were evaluated preoperatively and at 2, 4, and 7 days postoperatively. Both groups showed similar postoperative cognitive functions, with increased relative escape latency at day 2 and decreased relative spontaneous alternation at days 4 and 7. However, the neuropathological analysis revealed that propofol-induced significantly more neuronal death in the CA3 (days 4 and 7) and DG (days 2, 4, and 7), and greater Aβ accumulation in the CA3 (days 2 and 4) and DG (days 2 and 7) compared to remimazolam (p < 0.05). Propofol was associated with more pronounced neuropathologic changes in the hippocampus compared to remimazolam. These findings suggest remimazolam may be a safer anesthetic for patients at risk for neurodegenerative disorders, as it is associated with less severe hippocampal pathology, which is characteristic of AD. Full article

Background and Objectives: Postoperative delirium (POD) is a common complication in elderly patients undergoing major surgery, associated with systemic inflammation and potentially influenced by anesthetic techniques. This study investigated whether remimazolam-based total intravenous anesthesia (R-TIVA) reduces the level of systemic inflammatory biomarkers and the incidence of POD more compared to inhalational anesthesia (IA) or balanced anesthesia (BA) in patients aged ≥ 65 years undergoing major non-neurosurgical, non-cardiac surgery. Materials and Methods: This retrospective cohort study analyzed the medical records of 340 patients categorized by anesthesia type: R-TIVA (n = 111), IA (n = 117), or BA (n = 112). Propensity score matching (PSM) created POD (n = 104) and No POD (n = 106) cohorts. Systemic inflammatory biomarkers—the systemic immune–inflammation index (SII), the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP)—were measured pre- and postoperatively. POD was identified by clinical symptoms or the postoperative use of antipsychotics/sedatives. Results: The incidence of POD did not significantly differ among the R-TIVA, IA, and BA groups. However, the postoperative SII, NLR, PLR, and CRP levels were significantly lower in the R-TIVA group compared to those in the IA group (p < 0.05). Both the preoperative (r_pb = 0.72, p < 0.01) and postoperative (r_pb = 0.58, p < 0.01) NLRs were strongly correlated with POD. Higher NLR values predicted the incidence of POD, with odds ratios of 1.71 for preoperative and 1.32 for postoperative measurements. Conclusions: While R-TIVA did not significantly reduce the incidence of POD compared to that of IA or BA, it was associated with reduced levels of postoperative inflammatory biomarkers. The preoperative and postoperative NLRs emerged as strong predictors of POD, suggesting their potential utility in guiding prophylactic strategies for older surgical patients. These findings underscore the interplay between anesthesia type, systemic inflammation, and delirium risk. Full article

Background and Objectives: The Analgesia Nociception Index (ANI), a surrogate marker derived from heart rate variability (HRV) analysis, has been validated for assessing the balance between antinociception and nociception during propofol anesthesia. The ANI continuously monitors this balance, with values above 50 indicating optimal analgesia. By adjusting analgesic administration based on ANI values, anesthesiologists can provide more personalized intraoperative pain control. Remimazolam, a novel benzodiazepine anesthetic lacking intrinsic analgesic properties, exhibits distinct HRV patterns compared to propofol. Considering these differences, the validity of the ANI during remimazolam anesthesia remains uncertain. We evaluated the validity of the ANI by assessing its ability to detect nociceptive stimuli during remimazolam anesthesia. Materials and Methods: In total, 28 patients were administered general anesthesia using remimazolam and remifentanil. We evaluated changes in the ANI before and after tetanic stimulation. In addition, we investigated the association between hemodynamic responses during surgical incisions and changes in the ANI. Results: Tetanic stimulation resulted in a significant (p < 0.001) reduction in the ANI, from 62.0 (interquartile range [IQR] 50.5–76.0) to 44.0 (IQR 37.0–55.5). Of the 13 patients who experienced hemodynamic responses during surgical incision, the ANI significantly decreased from 63.2 ± 13.6 to 36.9 ± 13.8 following noxious surgical stimulation (p < 0.001). Conclusions: The ANI reflects the dynamic equilibrium between antinociception and nociception during remimazolam-based general anesthesia. Full article

Background and Objectives: This meta-analysis compares the safety and efficacy of remimazolam and dexmedetomidine for sedation during regional anesthesia, focusing on respiratory and hemodynamic outcomes. Materials and Methods: A systematic search of CENTRAL, Embase, PubMed, Scopus, and Web of Science up to November 2024 identified randomized controlled trials (RCTs) comparing remimazolam with dexmedetomidine. Outcomes included respiratory depression (primary outcome), bradycardia, hypotension, hypertension, respiratory and heart rates, mean arterial pressure, sedation onset time, emergence time, and postoperative nausea and vomiting (PONV). Effect sizes were calculated as relative risks (RRs) or mean differences (MDs) using random-effects models. Results: Five RCTs involving 439 participants were included. Remimazolam did not significantly increase respiratory depression risk compared to dexmedetomidine (RR: 1.36, 95% CI [0.39, 4.71], p = 0.6305, I² = 44%). Bradycardia incidence was lower with remimazolam (RR: 0.15, 95% CI [0.06, 0.39], p = 0.0001, I² = 0%). Remimazolam showed faster sedation onset (MD: −6.04 min, 95% CI [−6.99, −5.09], p = 0.0000, I² = 68%). Both drugs demonstrated similar occurrences of hypotension and hypertension, respiratory rates, mean arterial pressures, emergence times, and incidences of PONV. Conclusions: Remimazolam offers comparable safety and efficacy to dexmedetomidine, with advantages such as lower bradycardia risk and faster sedation onset. These findings support remimazolam as a viable sedative option during regional anesthesia, although further large-scale studies are warranted to confirm these results and optimize sedation practices. Full article

Background and Objectives: Patients with type 2 diabetes are at a higher risk of postoperative complications, such as infections, delayed wound healing, and increased mortality compared to non-diabetic patients. Materials and Methods: This prospective randomized study aims to compare the effects of two anesthetics, remimazolam and propofol, on blood glucose levels and immune function in diabetic patients undergoing surgery. Seventy-four diabetic patients undergoing general anesthesia were randomly assigned to receive either remimazolam or propofol. Plasma blood glucose levels, anti-inflammatory markers, and insulin levels were measured during the perioperative period. Results: No statistically significant differences were observed between the remimazolam and propofol groups in terms of neutrophil-to-lymphocyte ratio, anti-inflammatory markers, or glucose levels during the perioperative period (p value > 0.05). Conclusions: These results suggest that there is no difference between propofol and remimazolam in immune function deterioration that occurs due to surgical stress. This study is limited by its small sample size, and in future, larger trials could be conducted to find differences in the effects of blood sugar levels and serum inflammatory markers between the two groups. Full article

Background/Objectives: Remimazolam, a short-acting benzodiazepine, promotes quick and consistent recovery from anesthesia. However, flumazenil’s rapid antagonistic effects on benzodiazepines during the emergence from anesthesia are thought to increase the risk of postoperative nausea and vomiting (PONV). This study aimed to compare the rate of PONV in monitored anesthesia care (MAC) with remimazolam versus conventional MAC with dexmedetomidine. Methods: This single-center retrospective study included all cases with transcatheter aortic valve replacements (TAVR) performed using MAC at our institution between January 2019 and April 2023. The patients were divided into remimazolam and dexmedetomidine–propofol groups based on the anesthetic method used. We used propensity score matching at a 1:1 ratio to account for the patient backgrounds. The primary outcome measure was the rate of PONV within 48 h. Secondary outcome measures included the severity of PONV and the number of antiemetics administered. Results: This study included 177 subjects. Following propensity score matching, 61 patients were allocated to each group. The incidence of PONV within 48 h after surgery was 4.92% in the remimazolam group and 3.28% in the dexmedetomidine–propofol group, with no significant difference between the two groups (p = 0.817). There was no significant difference between the two groups in terms of the secondary outcomes, including the severity of PONV (p = 0.190) and the use of antiemetics (p = 0.690). Conclusions: In TAVR with MAC and remimazolam, the incidence of PONV within 48 h was comparable to that of dexmedetomidine. Full article

Background and Objectives: Appropriate sedation and anesthesia are crucial for ensuring comfortable endoscopic procedures. Propofol is one of the most often used sedatives. However, its safety and adverse effects restrict its usage. Remimazolam is a relatively new intravenous benzodiazepine that offers many benefits. Our analysis aims to evaluate the effectiveness and safety of remimazolam during short endoscopic procedures. Materials and Methods: We conducted a comprehensive search of the PubMed, Web of Science, ClinicalTrials.gov, and Turning Research Into Practice databases up to 31 December 2023, for randomized controlled trials published in English. Statistical analyses were performed using Cochrane Review Manager 5.4.1 and Stata Software/MP. Results: The success rate of sedation with remimazolam was slightly lower than that with propofol (RR: 0.99, 95% CI: 0.98~1.00; p = 0.004; I² = 42%). As for anesthetic effect-related outcomes, remimazolam did not show advantages in onset time (MD = 12.72, 95% CI: 6.53~18.90, p < 0.001, I² = 94%), recovery time (MD = 0.86, 95% CI: −0.55~2.27, p = 0.23, I² = 98%), or intraoperative body movement (RR: 1.18, 95% CI: 0.60~2.32, p = 0.62, I² = 87%). However, compared to propofol, remimazolam significantly reduced the incidence of several adverse events, including injection pain (RR: 0.07, 95% CI: 0.03~0.14, p < 0.001, I² = 69%), intraoperative hypotension (RR: 0.38, 95% CI: 0.31~0.47, p < 0.001, I² = 65%), bradycardia (RR: 0.25, 95% CI: 0.15~0.45, p < 0.001, I² = 0%), and respiratory depression (RR: 0.34, 95% CI: 0.25~0.46, p < 0.001, I² = 50%). The incidence of postoperative nausea and vomiting (PONV) was slightly higher with remimazolam (RD: 0.01, 95% CI: 0.00~0.03, p = 0.04, I² = 33%). Conclusions: Remimazolam is a promising sedative for short endoscopic procedures due to its superior safety profile despite a slightly lower sedation success rate compared to propofol. Full article

Background/Objectives: Transurethral resection of bladder tumor (TURBT) is commonly performed in elderly patients and often requires repeated procedures. A high proportion of non-procedural time in TURBT affects operating room utilization, highlighting the need for a safe and efficient anesthesia method. This study aimed to compare remimazolam-based monitored anesthesia care (MAC) guided by analgesia nociception index (ANI) monitoring to inhalation-based general anesthesia (GA) for TURBT, focusing on induction and emergence time (IAET). Methods: Forty-six patients who underwent TURBT were randomly assigned into either the MAC group or GA group. The primary outcome was the IAET. The secondary outcomes included hospital and anesthesia charges, safety (intraoperative hypotension and desaturation), and feasibility (surgeon and patient satisfaction) of both anesthetic methods. Results: The MAC group demonstrated a significantly shorter IAET (14 vs. 25 min, p < 0.001) and lower anesthesia cost (USD 152 vs. USD 195, p < 0.001). The MAC group showed better hemodynamic stability with a lower incidence of hypotension (29% vs. 73%, p = 0.004). Seven patients (33%) in the MAC group experienced intraoperative desaturation; all patients recovered without complications through the jaw-thrust maneuver. Patient satisfaction was equally high in both groups, and surgeon satisfaction, though slightly lower with MAC (71% vs. 100% rating “excellent”, p = 0.009), remained acceptable. Conclusions: Remimazolam-based MAC, guided by ANI monitoring, offers significant advantages including shorter IAET, reduced costs, and improved safety for TURBT, particularly in patients with small tumors. These findings support MAC as a promising alternative to GA for TURBT, as it enhances perioperative outcomes and operating room efficiency. Full article

Background and Objectives: Postoperative delirium (POD) is a transient but significant complication in geriatric patients following hip or femur surgery. POD occurs in 19–65% of patients after hip surgeries, with notable risks associated with augmented morbidity, mortality, and prolonged hospitalization. The perioperative administration of benzodiazepines, particularly midazolam, is associated with an increased incidence of POD. Remimazolam, a novel ultra-short-acting benzodiazepine, has potential benefits, such as hemodynamic stability and ease of reversal, but its effect on POD occurrence remains unclear. Materials and Methods: This retrospective study investigated patients who were aged 65 years old and older who underwent hip or femur surgery. Following the application of exclusion criteria, 502 patients were grouped according to whether anesthesia was maintained with remimazolam (R group) or sevoflurane (S group). Data regarding patients’ baseline characteristics, anesthetic details, and postoperative outcomes, including the incidence of POD, were gathered and analyzed. Propensity score matching and logistic regression were conducted to identify factors associated with POD and compare outcomes between the two groups. Results: Among the 502 patients, POD was observed in 161 (32%). The POD incidence was not statistically significantly different between the groups (p = 1.000). A multivariable logistic regression analysis indicated that remimazolam was not a determinant of POD (p = 0.860), whereas being male and polypharmacy were (p = 0.022; p = 0.047). Initial disparities in age and comorbid conditions between the groups were rectified through matching, demonstrating that remimazolam had a similar POD risk to sevoflurane. Conclusions: This study showed that remimazolam did not exacerbate the risk of POD in elderly patients undergoing hip or femur surgery. Remimazolam is a reliable anesthetic option for this vulnerable demographic. Also, this study’s results indicated that polypharmacy and being male are POD risk factors, suggesting that meticulous perioperative medication management may help alleviate the risk of POD. Full article

Background: Patients undergoing endoscopic submucosal dissection under monitored anesthesia care (MAC) with remimazolam may develop respiratory distress during the procedure. In these cases, low doses of flumazenil improved respiratory distress without completely reversing sedation, which is a novel phenomenon. This study aimed to explore the ED90 of flumazenil to selectively improve respiratory distress in patients with MAC treated with remimazolam. Methods: Flumazenil dose determination followed a biased-coin up-and-down design. Starting with a dose of 5 mcg, if respiratory distress improved, the biased-coin method was used to give the same dose in the next patient with a probability of 8/9, and a decreased dose of 5 mcg in the next patient with a probability of 1/9. Any improvement in respiratory distress within 30 s of flumazenil administration was recorded. After the procedure, patients were asked whether they had any memory recall during the procedure. Centered isotonic regression was used to determine the ED90 of flumazenil. Results: Sixty patients were included in the study. The estimated ED90 was 76.72 mcg (95% CI: 68.07–102.62). Memory recall occurred in two of thirteen patients (15%) near the ED90 dose range (75 mcg and 80 mcg). None of the patients developed major postoperative complications (bleeding, perforation, or aspiration) within the 2-day postoperative period. Conclusions: This study determined that the ED90 of flumazenil for effectively alleviating respiratory distress in patients undergoing MAC with remimazolam was 76.7 mcg, without reversing consciousness. These findings provide valuable guidance for the care of patients undergoing sedation. Full article

Objective: To compare the efficacy and safety of remimazolam with propofol in general anesthesia in adult patients. Methods: A systematic search in Pubmed, Scopus, Web of Science, and Embase was performed. Patients undergoing complex surgery who were critically ill or non-critically ill were included. The risk of bias (RoB) 2.0 tool was applied. Random-effects models using the inverse variance method were applied for all meta-analyses. Results: Nine randomized controlled trials were included (patients taking remimazolam, n = 678; propofol, n = 454). Remimazolam compared to propofol is likely to produce a large decrease in intraoperative hypotension (RR 0.62, 95% CI 0.50 to 0.76, I2 = 63%, n = 9, CoE moderate certainty), incidence of respiratory depression (RR 0.28, 95% CI 0.09 to 0. 82, I2 = 0%, n = 3; CoE moderate certainty), injection site pain (RR 0.14, 95% CI 0.02 to 0.94, I2 = 21%, n = 4; CoE moderate certainty), and may produce little or no difference in bradycardia (RR 0.61, 95% CI 0.36 to 1.06, I2 = 0%, n = 4; CoE moderate certainty). Conclusions: In patients undergoing complex surgery who are critically ill or non-critically ill, remimazolam, compared with propofol, is likely to produce a large decrease in intraoperative hypotension, incidence of respiratory depression, and injection site pain, but little or no difference in bradycardia is possible. Full article

The field of interventional pulmonology has grown immensely and is increasingly recognized as a subspecialty. The new procedures introduced in the last decade pose unique challenges, and anesthesiologists need to readapt to their specific demands. In this review, we extensively discuss the pathophysiology, technical aspects, preprocedural preparation, anesthetic management, and postprocedural challenges of many new procedures such as navigational bronchoscopy, endobronchial valve deployment, and bronchial thermoplasty. Majority of these procedures are performed under general anesthesia with an endotracheal tube. Total intravenous anesthesia with rocuronium as a muscle relaxant seems to be the standard US practice. The easy availability and proven safety and efficacy of sugammadex as a reversal agent of rocuronium has decreased the need for high-dose remifentanil as an agent to avoid muscle relaxants. Additional research is available with regard to the utility of nebulized lidocaine and is discussed. Finally, two newer drugs administered for conscious sedation (typically without the need of an anesthesiologist) are likely to gain popularity in the future. Remimazolam is a new short-acting benzodiazepine with a relatively faster offset of clinical effects. Dexmedetomidine, a selective adrenergic agonist, is increasingly employed in bronchoscopy as a sedative during bronchoscopic procedures. Full article

Objectives: Laparoscopic gynecological surgeries are commonly performed under general anesthesia and can induce cardiovascular depression and hypotension, requiring vasopressor support. Remimazolam, a novel ultra-short-acting benzodiazepine, is used to treat minimal cardiovascular depression. This study compared the hemodynamic effects of remimazolam and sevoflurane anesthesia in patients undergoing laparoscopic gynecological surgery. Methods: A retrospective analysis was conducted on 474 patients who underwent laparoscopic gynecological surgery at Korea University Anam Hospital between September 2021 and December 2022. The patients were categorized into two groups based on the anesthetic agent used: remimazolam or sevoflurane. Hemodynamic parameters, vasopressor use, and intraoperative variables were compared between anesthetic agents. Propensity score matching was applied to account for potential confounders, and logistic regression was utilized to assess the relationship between anesthesia type and outcomes. Results: Remimazolam anesthesia was linked to a significantly lower incidence of vasopressor use compared to sevoflurane-based anesthesia (3.7% vs. 19.5%, p < 0.0001). The odds of requiring vasopressor support were significantly lower during the post-induction and maintenance phases in the remimazolam group. Furthermore, hemodynamic stability, particularly systolic and mean arterial pressures, was better maintained with remimazolam than sevoflurane. Conclusions: Remimazolam provides superior hemodynamic stability and reduces the need for vasopressor support during laparoscopic gynecological surgery compared with sevoflurane. Full article