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Journal of Clinical Medicine Nov 2023(1) Purpose: to systematically evaluate the recovery following sedation and anesthesia with remimazolam combined with flumazenil in comparison to propofol. (2) Methods:... (Review)
Review
(1) Purpose: to systematically evaluate the recovery following sedation and anesthesia with remimazolam combined with flumazenil in comparison to propofol. (2) Methods: Electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, were systematically searched from their inception up to 22 October 2023. Included in this analysis were randomized controlled trials (RCT) that compared remimazolam-flumazenil with propofol for the recovery from sedation and anesthesia in adults. The risk of bias was assessed using the Cochrane risk of bias tool. Pooled risk ratios (RR) or mean differences (MD) along with their corresponding 95% confidence intervals (CI) were calculated using either fixed-effects or random-effects models, and the results were visualized in forest plots. (3) Results: Nine RCTs involving 745 patients who underwent general anesthesia in three different countries were included. Compared to propofol, the remimazolam-flumazenil combination shortened the emergence time (MD = -4.34 min, 95% CI = [-6.88, -1.81], = 0.0008, low certainty), extubation time (MD = -4.26 min, 95% CI = [-6.81, -1.7], = 0.0011, low certainty), and the post-anesthesia care unit (PACU) stay (MD = -4.42 min, 95% CI = [-7.45, -1.38], = 0.0044, low certainty), while reducing the incidence of respiratory depression (RR = 0.2, 95% CI = [0.04, 0.89], = 0.03, high certainty) after general anesthesia. However, this combination was associated with a higher incidence of re-sedation (RR = 4.15, 95% CI = [1.31, 13.13], = 0.01, moderate certainty). (4) Conclusions: Based on the existing evidence, the combination of remimazolam and flumazenil accelerates recovery from general anesthesia and lowers the risk of respiratory depression compared to propofol. However, it is important to consider the higher risk of re-sedation when using this combination in clinical practice. Due to limitations in the quality of the evidence, it is advisable to interpret the results of meta-analyses with caution.
PubMed: 38068368
DOI: 10.3390/jcm12237316 -
Pain Physician Nov 2023Remimazolam is a novel ultrashort-effect benzodiazepine. In 2020, the US Food and Drug Administration approved it for procedural sedation. Remimazolam is beneficial for... (Meta-Analysis)
Meta-Analysis
Hemodynamic Influences of Remimazolam Versus Propofol During the Induction Period of General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
BACKGROUND
Remimazolam is a novel ultrashort-effect benzodiazepine. In 2020, the US Food and Drug Administration approved it for procedural sedation. Remimazolam is beneficial for consistent sedation and quick recovery in painless gastrointestinal endoscopy. Propofol is one of the most commonly used intravenous anesthetics in clinical practice. Recently, only a few studies have compared propofol with remimazolam for general anesthesia induction.
OBJECTIVES
The purpose of our systematic review and meta-analysis was to compare the hemodynamic effects of remimazolam and propofol during the induction of general anesthesia.
STUDY DESIGN
Systematic review and meta-analysis of randomized, controlled trials.
METHODS
The authors retrieved the PubMed, Embase, Cochrane Library, and Web of Science databases for studies published through September 30, 2022, which reported relevant prospective randomized controlled trials (RCTs) comparing remimazolam with propofol for general anesthesia. The primary outcome was hemodynamic changes, including the absolute value of fluctuation of mean arterial pressure (delta MAP) and heart rate delta HR). The secondary outcomes were the following 2 indicators: the occurrence of total adverse events and the quality of recovery from general anesthesia at 24 hours postsurgery. RevMan 5.4.1 (The Nordic Cochrane Centre for The Cochrane Collaboration) and trial sequential analysis were used to execute the statistical analyses. The different domains of bias were judged by the Cochrane risk of the bias assessment tool.
RESULTS
The authors identified 189 papers in PubMed, Embase, Cochrane Library, and Web of Science. Eight articles with 964 patients were selected. The included studies had moderate quality. For primary outcomes, the lower delta HR (mean difference [MD] = -4.99; 95% CI, -7.97 to -2.00; I² = 41.6%; P = 0.001] and delta MAP (MD = -5.91; 95% CI. -8.57 to -3.24; I² = 0%; P < 0.0001) represent more stable hemodynamic characteristics in the remimazolam group. Regarding secondary outcomes, a considerably lower incidence of total adverse events was noted in the remimazolam group than that for the propofol group (odds ratio [OR] = 0.40; 95% CI, 0.28 to 0.58; I² = 63%; P < 0.00001). In comparison to the propofol group, remimazolam achieved an advantage score of quality of recovery -15 in 24 hours postsurgery (MD = 5.31, 95% CI, 1.51 to 9.12; I² = 87%; P = 0.006).
LIMITATION
Firstly, there are only a handful of published RCTs on the administration of remimazolam in general anesthesia. In addition, due to patient privacy, we could not extract individual patient data, therefore we could not combine and assess any variations in patient characteristics.
CONCLUSION
Evidence suggests that remimazolam has a lower hemodynamic effect during general anesthesia and fewer perioperative adverse effects after general anesthesia than propofol; however, which agent is superior regarding quality benefit in postoperative recovery based on the studies included here remains inconclusive. Additional RCTs with updated meta-analyses to enlarge the sample size and properly analyze the benefit-to-risk ratio to patients are needed to determine the evidence for such a relatively new medicine.
Topics: Humans; Propofol; Randomized Controlled Trials as Topic; Anesthesia, General; Benzodiazepines; Hemodynamics
PubMed: 37976477
DOI: No ID Found -
Advanced Pharmaceutical Bulletin Feb 2019Ketamine-propofol combination (ketofol) is being used to provide a safe and effective procedural sedation (PS) in emergency department (ED) and may theoretically have... (Review)
Review
Ketamine-propofol combination (ketofol) is being used to provide a safe and effective procedural sedation (PS) in emergency department (ED) and may theoretically have beneficial effects since using lower doses of each drug may result in a reduction of the adverse events of both agents while maintaining optimal conditions for performing procedures. This systematic review was conducted to evaluate the efficacy, advantages and disadvantages of these two drugs for PS. The PRISMA statement was used for this systematic review. We searched the databases of PubMed, Scopus, ProQuest, Medline (Ovid) from 1990 to August 2017 for randomized clinical trials (RCTs) in which the study population aged ≥18 and was referred to ED. Full-texts of the studies performed in adults that were published in English were reviewed for inclusion. Both authors independently evaluated all studies. Five articles were eligible for the meta-analysis based on their common outcomes. The total number of subjects was 1250, of which 635 were treated with propofol and 615 were treated with ketofol. Although two of the five studies showed a better quality of sedation with ketofol, the other three did not find any significant difference between propofol and ketofol. This systematic review found a lower incidence of respiratory adverse effects in ketofol group than propofol group. Ketamine/propofol mixture (ketofol) has less respiratory adverse effects than propofol alone in ED procedural sedation.
PubMed: 31011553
DOI: 10.15171/apb.2019.002 -
BMC Anesthesiology Jun 2023Patients who undergo gastrointestinal endoscopy often require propofol-based sedation combined with analgesics. At present, the efficacy and safety of esketamine as an... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patients who undergo gastrointestinal endoscopy often require propofol-based sedation combined with analgesics. At present, the efficacy and safety of esketamine as an adjunct to propofol for sedation during endoscopic procedures in patients remains controversial. Moreover, there is no universal agreement regarding the appropriate dose of esketamine supplementation. This study aimed to assess the efficacy and safety of esketamine as an adjunct to propofol for sedation during endoscopic procedures in patients.
METHODS
Seven electronic databases and three clinical trial registry platforms were searched and the deadline was February 2023. Randomized controlled trials (RCTs) evaluating the efficacy of esketamine for sedation were included by two reviewers. Data from the eligible studies were combined to calculate the pooled risk ratio or standardized mean difference.
RESULTS
Eighteen studies with 1962 esketamine participants were included in the analysis. As an adjunct to propofol, the administration of esketamine reduced the recovery time compared to normal saline (NS). However, there was no significant difference between the opioids group and ketamine group. For propofol dosage, the administration of esketamine required a lower propofol dosage compared to the NS group and opioids group].For complications, the esketamine group had fewer complications compared to the NS group and opioid group in patients, but there were no significant differences between the esketamine group and ketamine group. Notably, the coadministration of esketamine was associated with a higher risk of visual disturbance compared to the NS group. In addition, we used subgroup analysis to investigate whether 0.2-0.5 mg/kg esketamine was effective and tolerable for patients.
CONCLUSION
Esketamine as an adjunct to propofol, is an appropriate effective alternative for sedation in participants undergoing gastrointestinal endoscopy. However, considering the possibility of its psychotomimetic effects, esketamine should be used with caution.
Topics: Humans; Ketamine; Analgesics, Opioid; Propofol; Endoscopy, Gastrointestinal; Saline Solution
PubMed: 37312027
DOI: 10.1186/s12871-023-02167-0 -
Anesthesiology Research and Practice 2020To evaluate the effectiveness of an admixture of ketamine and propofol on peri-induction hemodynamics during airway manipulation, we searched electronic databases of... (Review)
Review
To evaluate the effectiveness of an admixture of ketamine and propofol on peri-induction hemodynamics during airway manipulation, we searched electronic databases of randomized controlled trials from January 1, 2000, to October 17, 2018. Trial screening, selection, and data extraction were done independently by two reviewers with outcomes pooled across included trials using the random-effects model. We included 10 randomized trials (722 patients, mean age of 53.99 years, 39.96% female). American Society of Anesthesiologists physical status was reported in 9 trials with classes I and II representing the majority. Ketamine/propofol admixture was associated with a nonsignificant increase in heart rate (weighted mean difference, 3.36 beats per minute (95% CI, -0.88, 7.60), = 88.6%), a statistically significant increase in systolic blood pressure (weighted mean difference, 9.67 mmHg (95% CI, 1.48, 17.86), = 87.2%), a nonsignificant increase in diastolic blood pressure (weighted mean difference, 2.18 mmHg (95% CI, -2.82, 7.19), = 73.1%), and a nonsignificant increase in mean arterial pressure (weighted mean difference, 3.28 mmHg (95% CI, -0.94, 7.49), = 69.9%) compared to other agents. The risk of bias was high and the certainty of evidence was low. In conclusion, among patients undergoing airway manipulation and needing sedation, the use of a ketamine/propofol admixture may be associated with better hemodynamics compared to nonketamine/propofol sedation. This trial is registered with CRD42019125725.
PubMed: 32454816
DOI: 10.1155/2020/9637412 -
BMC Anesthesiology Jul 2023The number of non-intubated general anesthesia outside the operating room is growing as the increasing demand for comfort treatment. Non-intubated general anesthesia... (Meta-Analysis)
Meta-Analysis
Analysis of the efficacy of subclinical doses of esketamine in combination with propofol in non-intubated general anesthesia procedures - a systematic review and meta-analysis.
BACKGROUND
The number of non-intubated general anesthesia outside the operating room is growing as the increasing demand for comfort treatment. Non-intubated general anesthesia outside the operating room requires rapid onset of anesthesia, smoothness, quick recovery, and few postoperative complications. Traditional anesthetic regimens (propofol alone or propofol and opioids/dezocine/midazolam, etc.) have severe respiratory and circulatory depression and many systemic adverse effects. In this paper, we compare the effectiveness and safety of propofol and subclinical doses of esketamine with other traditional regimens applied to non-intubated general anesthesia through a systematic review and meta-analysis.
METHODS
We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and Sinomed databases for the period from January 2000 to October 2022. We rigorously screened the literature according to predefined inclusion and exclusion criteria, while risk assessment of the studies was performed using The Cochrane Collaboration's tool, and statistical analysis of the data was performed using RevMan 5.4 software. The main outcome indicators we evaluated were the various hemodynamic parameters and incidence of various adverse effects between the experimental and control groups after induction of anesthesia.
RESULTS
After a rigorous screening process, a total of 14 papers were included in the final meta-analysis. After risk bias assessment, three of the papers were judged as low risk and the others were judged as having moderate to high risk. Forest plots were drawn for a total of 16 indicators. Meta-analysis showed statistically significant differences in HR' WMD 3.27 (0.66, 5.87), MAP' WMD 9.68 (6.13, 13.24), SBP' WMD 5.42 (2.11, 8.73), DBP' WMD 4.02 (1.15, 6.88), propofol dose' SMD -1.39 (-2.45, -0.33), hypotension' RR 0.30 (0.20, 0.45), bradycardia' RR 0.33 (0.14, 0.77), hypoxemia or apnea' RR 0.45 (0.23, 0.89), injection pain' RR 0.28 (0.13, 0.60), intraoperative choking' RR 0.62 (0.50, 0.77), intraoperative body movements' RR 0.48 (0.29, 0.81) and overall incidence of adverse reactions' RR 0.52 (0.39, 0.70).The indicators that were not statistically different were time to wake up' WMD - 0.55 (-1.29, 0.19), nausea and vomiting 0.84' RR (0.43, 1.67), headache and dizziness' RR 1.57 (0.98, 2.50) and neuropsychiatric reaction' RR 1.05 (0.28, 3.93). The funnel plot showed that the vast majority of studies fell within the funnel interval, but the symmetry was relatively poor.
CONCLUSION
In non-intubated general anesthesia, the combination of subclinical doses of esketamine and propofol did reduce circulatory and respiratory depression, injection pain, and other adverse effects, while the incidence of esketamine's own side effects such as neuropsychiatric reactions did not increase, and the combination of the two did not cause the occurrence of new and more serious adverse reactions, and the combination of the two was safe and effective.
TRIAL REGISTRATION
PROSPREO registration number: CRD 42022368966.
Topics: Humans; Propofol; Ketamine; Anesthesia, General; Pain; Drug-Related Side Effects and Adverse Reactions
PubMed: 37479982
DOI: 10.1186/s12871-023-02135-8 -
International Journal of Surgery... Mar 2018We performed a systematic review of various anaesthetic medications for endoscopic retrograde cholangiopancreatography (ERCP) and aimed to make a comprehensive... (Meta-Analysis)
Meta-Analysis Review
AIMS
We performed a systematic review of various anaesthetic medications for endoscopic retrograde cholangiopancreatography (ERCP) and aimed to make a comprehensive comparison based on a network meta-analysis.
METHODS
We searched globally recognized electronic databases, including PubMed, Cochrane Central and EMBASE, to retrieve relevant randomized controlled trials (RCTs) of anaesthetic medications for ERCP. Network meta-analysis was conducted by evaluating the procedure time, adverse effects and drug requirements. The cumulative probability P value was utilized to rank the medications under examination.
RESULTS
Seventeen RCTs that examined 1877 patients were included in this research. Under good convergence and efficiency, data analysis was performed using a consistency model. For the comparison of procedure times, we found that a combination of dexmedetomidine and ketamine (P = 0.19) or propofol plus pethidine (P = 0.18) seemed to be the two best medications for reducing procedure time. Additionally, midazolam combined with dexmedetomidine plus pethidine seemed to be the safest application for ERCP (P = 0.36). Propofol plus alfentanil also exhibited a good safety value (P = 0.28). For evaluation of drug requirements, the whole network connection could not be established; thus, comparisons in two subgroups were conducted. The results showed that midazolam combined with dexmedetomidine plus pethidine (P = 0.41) and propofol plus refentanil (P = 0.94) were superior to others in decreasing drug requirements.
CONCLUSIONS
Based on the objective results and our conclusions, we deemed that a combination of midazolam and dexmedetomidine was recommended, and propofol plus opioids also revealed great clinical value. However, we are still expecting more clinical research in the future.
Topics: Alfentanil; Analgesics, Opioid; Anesthetics; Cholangiopancreatography, Endoscopic Retrograde; Dexmedetomidine; Drug Therapy, Combination; Humans; Ketamine; Meperidine; Midazolam; Network Meta-Analysis; Operative Time; Propofol; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 29367034
DOI: 10.1016/j.ijsu.2018.01.018 -
Disease Markers 2022Hysteroscopy is a minimally invasive gynecologic technique that is widely practiced in outpatient procedures. The choice of anesthesia is a key factor for the surgical... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Hysteroscopy is a minimally invasive gynecologic technique that is widely practiced in outpatient procedures. The choice of anesthesia is a key factor for the surgical outcome and postoperative recovery. This study was conducted to assess the effects of different anesthetic modalities based on dexmedetomidine in outpatient hysteroscopic surgery anesthesia.
METHODS
We did a systematic review and network meta-analysis of outpatient hysteroscopic surgery anesthesia. We searched Pubmed, Embase, and Cochrane-Library from database inception to December 31, 2021. Duplicate literature was excluded and screened separately for initial screening at three tiers: article title, abstract, and full text before deciding whether to include in this study against the above criteria. Results after analysis of categorical variables were expressed as ORR Ratio (95% CI) and continuous variables were expressed as Mean Difference (95% CI). Data collation and analyses were performed using the gemtc package in the R language.
RESULTS
Four trials were finally included with data for 301 participants, three anesthetic drugs, and five anesthetic modalities. A fixed-effects model was used for the different anesthesia modalities without significant heterogeneity (all I2<20%) in the analysis of adverse events (AEs), the incidence of respiratory depression, operative time, and time in the post-anesthesia care unit (PACU). Remimazolam tosylate was associated with a lower incidence of AEs versus dexmedetomidine, and significant differences between dexmedetomidine and propofol were absent. Propofol and various doses of remimazolam tosylate resulted in a lower incidence of respiratory depression versus dexmedetomidine, with an absence of differences between propofol and dexmedetomidine. The operative time for different anesthetic modalities was, in descending order, dexmedetomidine < remimazolam tosylate (0.60 mg/kg/h <0.48 mg/kg/h) < propofol < remimazolam tosylate (1.00 mg/kg/h), despite the absence of intergroup differences. Propofol was associated with a longer time in PACU versus dexmedetomidine and remimazolam tosylate (1.00 mg/kg/h); those of dexmedetomidine and remimazolam tosylate (1.00 mg/kg/h) were similar. The time in PACU for different anesthetic modalities, in descending order, was dexmedetomidine < remimazolam tosylate (1.00 mg/kg/h) < propofol. Propofol was associated with a longer time in PACU versus dexmedetomidine and remimazolam tosylate.
CONCLUSION
In outpatient hysteroscopic surgery anesthesia, dexmedetomidine was associated with a higher incidence of AEs and respiratory depression and a shorter operative time and time in PACU versus remimazolam tosylate and propofol. Remimazolam tosylate showed safety benefits with a similar duration of PACU stay versus dexmedetomidine. Therefore, the choice of anesthetic drugs in outpatient surgery requires consideration of the patient's conditions and preferences.
Topics: Ambulatory Surgical Procedures; Anesthetics; Dexmedetomidine; Female; Humans; Hysteroscopy; Network Meta-Analysis; Outpatients; Pregnancy; Propofol; Respiratory Insufficiency
PubMed: 36188426
DOI: 10.1155/2022/2408685 -
BMC Neurology Apr 2019Several studies have compared the efficacy and safety of propofol and barbiturates in the treatment of refractory status epilepticus (RSE). This study aims to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Several studies have compared the efficacy and safety of propofol and barbiturates in the treatment of refractory status epilepticus (RSE). This study aims to quantitatively assess the advantages and disadvantages of propofol and barbiturates in controlling RSE.
METHODS
We searched for studies with relevant data from the PubMed, Embase, Ovid, Cochrane Library, Springer Link, Web of Science, and China National Knowledge Infrastructure databases. By calculating odds ratios and standardized mean differences with 95% confidence intervals, we assessed the disease control rate (DCR), case fatality rate (CFR), average control time (ACT), average tracheal intubation placement time (ATIPT), and incidence of hypotension between propofol and barbiturates in treating RSE.
RESULTS
Seven studies with 261 patients were included in this analysis. Meta-analysis revealed that the DCR of propofol was higher than that of barbiturates (p < 0.001) and that the CFR (p = 0.382) between the two treatment did not significantly differ in controlling RSE. Propofol shortened the ACT (p < 0.001) of RSE and reduced the ATIPT (p < 0.001) of patients with RSE more extensively than did barbiturates and did not increase the incidence of hypotension (p = 0.737).
CONCLUSIONS
In comparison with barbiturates, propofol can control RSE and shorten ATIPT in a more efficient and timely manner. Moreover, the drug does not increase the incidence of hypotension and CFR.
Topics: Anticonvulsants; Barbiturates; China; Humans; Male; Odds Ratio; Propofol; Status Epilepticus
PubMed: 30954065
DOI: 10.1186/s12883-019-1281-y -
Cureus Jul 2022Procedural sedation and analgesia (PSA) is a treatment approach involving treating patients with agents with dissociative, sedative, or analgesic properties to suppress... (Review)
Review
An Analytical Comparison Between Ketamine Alone and a Combination of Ketamine and Propofol (Ketofol) for Procedural Sedation and Analgesia From an Emergency Perspective: A Systematic Review and Meta-Analysis.
Procedural sedation and analgesia (PSA) is a treatment approach involving treating patients with agents with dissociative, sedative, or analgesic properties to suppress their consciousness to variable levels. Ketamine and propofol have been used historically for PSA. Because they each have their demerits, it was postulated that combining both drugs (ketofol) would result in a mixture with additive properties and lessen or eliminate the demerits attributed to each drug. The primary objective of this systematic review and meta-analysis is to compare ketamine alone and a combination of ketamine and propofol (ketofol) for procedural sedation and analgesia from an emergency perspective. A systematic search was conducted on published studies from the databases of Scopus, ScienceDirect, PubMed, Google Scholar, APA PsycInfo, and the Cochrane Central Register of Controlled Trial (CENTRAL) until July 2022. The articles that were published on the online databases were authored between January 2007 and 2018. The selected papers were scanned and examined to check whether they met the eligibility criteria for the study. The search produced six articles that were included in the systematic review and meta-analysis. All six articles that passed the eligibility criteria were viable for the analysis. All the trials focused on the effectiveness of ketofol versus ketamine for PSA from an emergency perspective. Ketofol was found to be safe and more effective in comparison to ketamine for PTA.
PubMed: 36042988
DOI: 10.7759/cureus.27318