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Acta Anaesthesiologica Scandinavica Apr 2024Remimazolam, a novel benzodiazepine, shows promise as an alternative to traditional sedatives and hypnotic agents in procedural sedation and general anaesthesia. While... (Review)
Review
BACKGROUND
Remimazolam, a novel benzodiazepine, shows promise as an alternative to traditional sedatives and hypnotic agents in procedural sedation and general anaesthesia. While preliminary research indicates potential advantages over conventional agents, such as faster onset, predictable duration, and improved safety profile, the extent and quality of existing evidence remain unclear. This scoping review aims to investigate the current clinical role of remimazolam and provide a broad and comprehensive overview.
METHODS
The proposed review will adhere to the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Reviews. A comprehensive search will be conducted across major peer-reviewed databases and grey literature will be sought. All studies involving individuals undergoing procedural sedation or general anaesthesia with remimazolam will be eligible. Data extraction will encompass trial and participant characteristics, intervention details, reported outcomes, comparative efficacy versus midazolam and propofol, patient and operator experience and economic costs.
RESULTS
We will provide a descriptive summary supplemented by statistics, figures and tables where applicable.
CONCLUSION
The outlined scoping review aims to assess the clinical use of remimazolam in procedural sedation and as the hypnotic component of general anaesthesia. The review will map the current body of evidence of remimazolam and identify knowledge gaps, contributing to understanding its clinical implications and guiding future research efforts in procedural sedation and general anaesthesia.
PubMed: 38561232
DOI: 10.1111/aas.14421 -
Critical Care and Resuscitation :... Dec 2022We aimed to investigate the use of sedation in patients with severe traumatic brain injury (TBI), focusing on the choice of sedative agent, dose, duration, and their...
We aimed to investigate the use of sedation in patients with severe traumatic brain injury (TBI), focusing on the choice of sedative agent, dose, duration, and their association with clinical outcomes. Multinational, multicentre, retrospective observational study. 14 trauma centres in Europe, Australia and the United Kingdom. A total of 262 adult patients with severe TBI and intracranial pressure monitoring. We described how sedative agents were used in this population. The primary outcome was 60-day mortality according to the use of different sedative agents. Secondary outcomes included intensive care unit and hospital length of stay, and the Extended Glasgow Outcome Scale at hospital discharge. Propofol and midazolam were the most commonly used sedatives. Propofol was more common than midazolam as first line therapy (35.4% 25.6% respectively). Patients treated with propofol had similar Acute Physiology and Chronic Health Evaluation (APACHE) II and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) scores to patients treated with midazolam, but lower Injury Severity Score (ISS) (median, 26 [IQR, 22-38] 34 [IQR, 26-44]; = 0.001). The use of propofol was more common in heavier patients, and midazolam use was strongly associated with opioid co-administration (OR, 12.9; 95% CI, 3.47-47.95; < 0.001). Sixty-day mortality and hospital mortality were predicted by a higher IMPACT score ( < 0.001) and a higher ISS ( < 0.001), but, after adjustment, were not related to the choice of sedative agent. Propofol was used more often than midazolam, and large doses were common for both sedatives. The first choice was highly variable, was affected by injury severity, and was not independently associated with 60-day mortality.
PubMed: 38047010
DOI: 10.51893/2022.4.OA2 -
European Journal of Anaesthesiology Sep 2023Peripheral regional anaesthesia is frequently used for upper extremity surgery. To prolong the duration of analgesia, adjuvants can be added to single-injection local... (Meta-Analysis)
Meta-Analysis
The effect of adjuvants added to local anaesthetics for single-injection upper extremity peripheral regional anaesthesia: A systematic review with network meta-analysis of randomised trials.
BACKGROUND
Peripheral regional anaesthesia is frequently used for upper extremity surgery. To prolong the duration of analgesia, adjuvants can be added to single-injection local anaesthetics. Despite attempts to compare several adjuvants in pairwise meta-analyses, a comprehensive comparison is still missing.
OBJECTIVE
The objective of this network meta-analysis was to determine the effectiveness of adjuvants in upper extremity peripheral nerve blocks.
DESIGN
A systematic review of randomised controlled trials with network meta-analyses.
DATA SOURCES
A literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023.
ELIGIBILITY CRITERIA
Randomised trials comparing different adjuvants injected perineurally in peripheral upper extremity nerve blocks were eligible. Frequentist network meta-analysis was conducted using a random effects model with physiological saline as the comparator. The primary endpoint was the ratio of means (ROM) of the duration of analgesia.
RESULTS
The review included 242 randomised controlled trials with a total of 17 391 patients. Twenty-eight adjuvants were compared in the largest networks. Most network estimations consisted of a high proportion of direct evidence. Fourteen adjuvants increased the duration of analgesia significantly by the following factors, ROM [95% confidence interval (CI)]: dexamethasone 1.95 (1.79 to 2.13), buprenorphine 1.83 (1.51 to 2.24), butorphanol 1.84 (1.41 to 2.39), potassium chloride 1.89 (1.15 to 3.11), dexmedetomidine 1.70 (1.59 to 1.81), sufentanil 1.70 (1.27 to 2.29), ketorolac 1.68 (1.24 to 2.27), midazolam 1.55 (1.24 to 1.94), tramadol 1.52 (1.32 to 1.75), nalbuphine 1.50 (1.30 to 1.72), morphine 1.43 (1.09 to 1.88), magnesium sulfate 1.42 (1.20 to 1.67), clonidine 1.36 (1.24 to 1.50) and fentanyl 1.23 (1.08 to 1.40). Inconsistency in network meta-analysis was substantial. Overall side effect rates were low with all adjuvants.
CONCLUSION
The best interventions to prolong the duration of analgesia were dexamethasone, followed by dexmedetomidine, opioids, electrolytes, ketorolac and midazolam. There are general concerns about the quality of underlying studies and the risk of publication bias.
TRIAL REGISTRATION
PROSPERO 2018 CRD42018115722.
Topics: Humans; Anesthetics, Local; Network Meta-Analysis; Midazolam; Dexmedetomidine; Ketorolac; Anesthesia, Conduction; Pain; Upper Extremity; Dexamethasone; Randomized Controlled Trials as Topic
PubMed: 37337656
DOI: 10.1097/EJA.0000000000001860 -
Advanced Emergency Nursing JournalThis article reviews the results of a randomized controlled trial, "Rapid Agitation Control with Ketamine in the Emergency Department: A Blinded, Randomized Controlled... (Review)
Review
This article reviews the results of a randomized controlled trial, "Rapid Agitation Control with Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial" by D. Barbic et al. (2021), comparing time to sedation, level of sedation, and adverse outcomes between intramuscular ketamine versus intramuscular midazolam and haloperidol among acutely agitated patients presenting to the emergency department (ED). The findings are discussed in the context of practice change for patient stabilization within the ED. Emergency department nurse practitioners must employ continuing education and remain current with clinical practices and treatment options to ensure that patients receive optimal safe care. Although the use of midazolam and haloperidol has historically been the first-line treatment for the acutely agitated patient, use of ketamine shows promise in providing a safe alternative for expedited patient stabilization for acutely agitated patients presenting to the ED.
Topics: Humans; Ketamine; Midazolam; Haloperidol; Psychomotor Agitation; Advanced Practice Nursing; Emergency Service, Hospital; Randomized Controlled Trials as Topic
PubMed: 37885076
DOI: 10.1097/TME.0000000000000479 -
Experimental Animals Aug 2023Chicken embryos (CE) are an experimental model used as an important life science research tool worldwide, and then, adequate anesthetic protocols must be adopted to...
Chicken embryos (CE) are an experimental model used as an important life science research tool worldwide, and then, adequate anesthetic protocols must be adopted to avoid the unjustifiable suffering of animals. Thus, our objective was to evaluate different anesthetic protocols in CEs using an easy inoculation route, the shell membrane (SM). We adopted the heart rate by pulse and the CE movements as a parameter of pain by assessing the vase in the chorioallantoic membrane (CAM) through the shell by a sensor of a multiparametric monitor. CEs were distributed into the following groups: (i) association of ketamine (5 mg/CE), midazolam (0.05 mg/CE) and morphine (0.15 mg/CE); (ii) ketamine (5 mg/CE) and xylazine (0.125 mg/CE); (iii) xylazine (0.0125 mg/CE) and morphine (0.15 mg/CE). The stress method used to test the anesthetic potential of the drugs was high temperature stimulation, keeping the CEs 10 cm from the fire of a Bussen nozzle for 30 s. In this experimental model, associations between different drugs decreased the pulse and the movement, indicating possible sedation. After treatment, the CE's submitted to the stress method had the heart rate and movements kept low in the groups ketamine-midazolam-morphine and ketamine-xylazine, while the non-drug-treated group increased heart rate. In a group treated with xylazine-morphine, the heart rate did not decrease, but the movement decreased after the stimulus. As the best results were the combinations of ketamine-midazolam-morphine and ketamine-xylazine, we recommend these associations for use in embryos in the final third of embryonic development in experimental protocols and euthanasia.
Topics: Chick Embryo; Animals; Midazolam; Ketamine; Xylazine; Chickens; Anesthesia; Anesthetics; Morphine Derivatives
PubMed: 36642540
DOI: 10.1538/expanim.22-0133 -
Journal of Neurosurgical Anesthesiology Jan 2024Remimazolam is a novel ultrashort-acting benzodiazepine that produces sedation by acting as a positive allosteric modulator of the gamma-amino butyric acid-A receptor.... (Review)
Review
Remimazolam is a novel ultrashort-acting benzodiazepine that produces sedation by acting as a positive allosteric modulator of the gamma-amino butyric acid-A receptor. Its high water solubility and metabolism via tissue esterases allow for a rapid onset of sedation/anesthesia and prompt arousal despite prolonged use. In addition, the effects of remimazolam can be reversed with flumazenil. This narrative review discusses the role of remimazolam in patients undergoing neurosurgical and neuroradiological procedures, specifically its role during awake craniotomies and compatibility with neuromonitoring. Considerations for remimazolam use in patients with neurological diseases are also highlighted. In addition, the impact of remimazolam on postoperative excitation, risk for postoperative delirium, and delayed neurocognitive recovery are discussed. Although there seems to be a clinical promise for remimazolam based on limited case studies and our own institutional experience of its use, further clinical investigation is warranted to understand the potential impact of remimazolam on surgical and neurological outcomes.
Topics: Humans; Midazolam; Hypnotics and Sedatives; Neurosurgery; Double-Blind Method; Benzodiazepines; Nervous System Diseases
PubMed: 37264540
DOI: 10.1097/ANA.0000000000000917 -
BMJ Supportive & Palliative Care Dec 2023Seizures occur in around 13% of patients with cancer and can be distressing for family members to witness. In those unable to manage regular antiepileptic medications,...
Seizures occur in around 13% of patients with cancer and can be distressing for family members to witness. In those unable to manage regular antiepileptic medications, midazolam can be administered subcutaneously using a syringe driver, but this may cause sedation. Brivaracetam is a newer drug licensed as an adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalisation and for restricted use in those with refractory epilepsy. It is associated with fewer behavioural or psychiatric side effects than levetiracetam, has a very low incidence of drug interactions and the maximal dose can be accommodated in a single syringe driver. We present three cases from 2019 to 2020 where subcutaneous brivaracetam has been successfully used in a Specialist Inpatient Palliative Care setting to manage seizures. Brivaracetam dosing is 1:1 conversion from oral:subcutaneous, with syringe driver doses ranging from 150 mg to 300 mg/24 hours being successfully used, with no adverse effects observed.
Topics: Humans; Palliative Medicine; Seizures; Pyrrolidinones; Anticonvulsants; Treatment Outcome
PubMed: 34257063
DOI: 10.1136/bmjspcare-2021-003228 -
Current Opinion in Anaesthesiology Oct 2023Successful awake intubation hinges upon adequate airway anesthesia and sedation for patient comfort. This review will summarize relevant anatomy and regional anesthesia... (Review)
Review
PURPOSE OF REVIEW
Successful awake intubation hinges upon adequate airway anesthesia and sedation for patient comfort. This review will summarize relevant anatomy and regional anesthesia techniques to achieve airway anesthesia, and compare various airway anesthesia and sedation regimens.
RECENT FINDINGS
Overall, nerve blocks consistently provided superior airway anesthesia, shorter time to intubation, higher patient comfort, and higher postintubation patient satisfaction. Additionally, ultrasound guidance can further provide benefit by reducing the amount of local anesthetic administered, leading to denser blockade, and proving invaluable in challenging clinical situations. Regarding sedation methods, numerous studies supported the use of dexmedetomidine, with or without the addition of supplemental sedation, such as midazolam, ketamine, or opioids.
SUMMARY
Emerging evidence has indicated that nerve blocks for airway anesthesia may be superior to other methods of topicalization. Additionally, dexmedetomidine can be useful, both as monotherapy and with supplemental sedatives, to safely provide anxiolysis for the patient and increase success. However, it is crucial to note that the method of airway anesthesia and sedation regimen should be adapted to each patient and clinical situation, and knowledge of multiple techniques and sedation regimens can best equip anesthesiologists to do so.
Topics: Humans; Dexmedetomidine; Hypnotics and Sedatives; Intubation, Intratracheal; Midazolam; Anesthesia, Local
PubMed: 37314139
DOI: 10.1097/ACO.0000000000001273 -
Journal of Yeungnam Medical Science Nov 2023Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a clinical entity characterized by classic neuropathic pain,...
Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a clinical entity characterized by classic neuropathic pain, autonomic involvement, motor symptoms, and trophic changes in the skin, nails, and hair. Although various therapeutic modalities are used to control CRPS-related pain, severe pain due to CRPS often persists and progresses to the chronic phase. In this study, we constructed an algorithm for multimodal medication therapy for CRPS based on the established pathology of CRPS. Oral steroid pulse therapy is recommended for initial pain management in patients with CRPS. Oral steroid therapy can reduce peripheral and central neuroinflammation, contributing to the development of neuropathic pain during the acute and chronic phases. If steroid pulse therapy offers poor relief or is ineffective, treatment to control central sensitization in the chronic phase should be initiated. If pain persists despite all drug adjustments, ketamine with midazolam 2 mg before and after ketamine injection can be administered intravenously to inhibit the N-methyl D-aspartate receptor. If this treatment fails to achieve sufficient efficacy, intravenous lidocaine can be administered for 2 weeks. We hope that our proposed drug treatment algorithm to control CRPS pain will help clinicians appropriately treat patients with CRPS. Further clinical studies assessing patients with CRPS are warranted to establish this treatment algorithm in clinical practice.
PubMed: 37434359
DOI: 10.12701/jyms.2023.00360 -
Cureus Nov 2023Introduction Minor dental and oral surgical procedures have been made comfortable with the rise in the use of daycare sedatives. Of these sedatives, midazolam is deemed...
Introduction Minor dental and oral surgical procedures have been made comfortable with the rise in the use of daycare sedatives. Of these sedatives, midazolam is deemed a common sedative used for minor oral surgical procedures. Newer and safer sedatives such as dexmedetomidine have certain properties that may prove more efficient in oral surgical procedures. Third molar surgery is one of the most common minor oral surgical procedures performed in dentistry. Thus, this study aims to compare the efficacy of midazolam and dexmedetomidine as sedative agents in third molar surgery. Materials and methods Sixty young adult patients free from other comorbidities were included in the study with ages ranging between 18 and 50 years. The samples were matched for the difficulty of impacted teeth and randomly distributed among the groups. Groups were administered the respective sedative drugs midazolam and dexmedetomidine and their effects were observed through the Observer's Assessment of Alertness/Sedation scale. The intraoperative vitals and sedation effects were checked every 15 minutes. Statistical analysis was done using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States). Independent samples t-test and analysis of variance were the statistical tests employed to analyze the obtained data with p<0.05 considered as statistically significant. Results The depth of sedation has been both subjectively and objectively assessed and had no significant difference among the groups. The intra-operative heart rate assessment proved a more efficient reduction of pulse rate in the dexmedetomidine group as compared with the midazolam group. However, it was not statistically significant (p=0.121). The mean diastolic blood pressure showed a statistically significant difference between the groups with dexmedetomidine having lower blood diastolic pressure compared to midazolam (p=0.004). Quick arousal was witnessed in the dexmedetomidine group. Conclusion It can be concluded from the study that both dexmedetomidine and midazolam were equally effective as sedative agents for third molar surgery. However, the nature of cardio-protection, anti-sialagogue, and analgesic properties of dexmedetomidine can prove helpful, especially in minor oral surgical procedures like third molar surgery and it is recommended.
PubMed: 38156170
DOI: 10.7759/cureus.49477