Korean Journal of Anesthesiology最新文献

Background: Remimazolam is a novel ultra-short-acting benzodiazepine known for its hemodynamic stability over propofol. However, its hemodynamic effects compared to those of etomidate are not well established. This study aimed to determine whether the use of remimazolam is non-inferior to etomidate with regard to the occurrence of post-induction hypotension in patients undergoing coronary arterial bypass grafting.

Methods: Patients were randomly assigned to either the remimazolam group (6 m/kg/h) or the etomidate group (0.3 mg/kg) for induction of anesthesia. Anesthetic depth was adjusted based on the bispectral index (BIS). Primary outcome was the incidence of post-induction hypotension, defined as a mean arterial pressure (MAP) less than 65 mmHg within 15 min after endotracheal intubation, with a non-inferiority margin of 12%.

Results: A total of 144 patients were finally analyzed. Incidence of post-induction hypotension was 36 / 71 (50.7%) in the remimazolam group and 25 / 73 (34.2%) in the etomidate group, with a rate difference of 16.5% (95% CI, 3.0-32.6) between the two groups that was beyond the prespecified non-inferiority margin of 12.0%. The number of patients who needed vasopressors was similar in the two groups.

Conclusions: In this non-inferiority trial, remimazolam failed to show non-inferiority to etomidate in terms of post-induction hypotension when used as an induction drug for general anesthesia in patients undergoing coronary arterial bypass grafting. However, different doses or infusion techniques of remimazolam must be compared with etomidate in various patient groups to fully assess its hemodynamic non-inferiority during induction of anesthesia.

Background: Remimazolam is a novel short-acting benzodiazepine. This study compared the effects of remimazolam and propofol on cognitive function in adult patients after surgery or other procedures.

Methods: We searched electronic databases, including PubMed, EMBASE, CENTRAL, Web of Science, and SCOPUS, for relevant studies. The primary outcome was the proportion of participants who experienced delirium or impaired cognitive function postoperatively. Secondary outcomes included the incidence of hypotension, bradycardia, and postoperative nausea and vomiting (PONV). We estimated the odds ratios (OR) and mean differences (MD) with 95% CIs using a random-effects model.

Results: In total, 1,295 patients from 11 randomized controlled trials (RCTs) were included. The incidence of postoperative delirium was 8.0% in the remimazolam group and 10.4% in the propofol group that was not significantly different (OR, 0.74; 95% CI [0.39, 1.42]; P = 0.3692; I² = 32%). More favorable cognitive function, as assessed using the Mini-Mental State Examination (MMSE), was observed in the remimazolam group compared to the propofol group (MD: 1.06, 95% CI [0.32, 1.80], P = 0.0050, I² = 89%). Remimazolam lowered the incidence of hypotension (OR: 0.28, 95% CI [0.21, 0.37], P = 0.0000, I² = 0%) compared to propofol.

Conclusions: Remimazolam did not increase the risk of postoperative delirium and maintained cognitive function well, providing hemodynamic stability during surgery compared to propofol.

Background: Delirium in the post-anesthesia care unit (PACU) may be associated with worse outcomes in children with moyamoya disease (MMD). This retrospective study aimed to describe the prevalence of PACU delirium in children with MMD and investigate its risk factors.

Methods: Patients with MMD aged < 15 years who underwent indirect revascularization between January 2014 and October 2023 were included in this study. Delirium was assessed using the Pediatric Anesthesia Emergence Delirium Scale. Potential risk factors for PACU delirium were evaluated using multivariate logistic regression.

Results: PACU delirium occurred in 245 (33%) of the 750 hemispheric procedures performed in 522 patients. Delirium was associated with a higher incidence in patients undergoing the first revascularization (37%) than in those undergoing the second (25%; P = 0.002). Cerebral infarction as the initial presentation (odds ratio [OR] 4.64, first revascularization), high pediatric moyamoya magnetic resonance imaging (MRI) score (OR 2.75, first revascularization; OR 3.50, second revascularization), and high intraoperative mean arterial pressure variability (mmHg/min) (OR 9.17, first revascularization; OR 8.82, second revascularization) were associated with PACU delirium. Conversely, total intravenous anesthesia (TIVA) was associated with a lower incidence of PACU delirium (OR 0.46, first revascularization; OR 0.25, second revascularization).

Conclusions: A significant proportion of patients with MMD developed delirium in the PACU. High intraoperative blood pressure variability and preoperative MRI lesions are independent risk factors for PACU delirium in children with MMD. TIVA may exert a protective effect against PACU delirium. Further studies are required to clarify the causality of these associations.

This review aims to assess the existing studies on propofol, a relatively new intravenous anesthetic, related to its abuse and addictive potential and to explain the neurobiological and neuropharmacological aspects of propofol addiction. Several neurobiological factors related to complex processes in the brain influence propofol abuse and addiction. In this review, we assessed the literature regarding propofol abuse and addiction, including both experimental and clinical studies. We selected articles from animal studies, case reports, clinical trials, meta-analyses, narrative reviews, and systemic reviews to extract all relevant crucial quantitative data with a measure of neurobiological and neuropharmacological aspects. Thus, the main goal of this study was to investigate the current literature and discuss the association between the central nervous system and propofol abuse and addiction in the context of addictive behavior. Current data suggest that propofol has a strong addictive potential and produces prominent addiction in both animals and humans. Thus, medical practitioners should exercise caution with propofol use, and we argue that this drug should be added to the list of controlled substances.

Background: In this study, we aimed to investigate whether opioid-sparing anesthesia (OSA) reduces postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic gynecological surgery.

Methods: Adult patients undergoing elective laparoscopic gynecological surgery were randomly assigned to either the opioid-using anesthesia (OUA) or the OSA groups. In the OUA group, remifentanil was administered as an opioid during general anesthesia. In the OSA group, apart from a single dose of 5 μg/kg of alfentanil for tracheal intubation, no other opioids were used. In both groups, a multimodal intravenous non-opioid analgesic regimen was used preferentially in the post-anesthesia care unit (PACU). The primary outcome was the incidence of PONV, assessed by symptoms until the postoperative day 1.

Results: A total of 120 patients were included in this study. The incidence of nausea in the PACU was significantly lower in the OSA group compared to in the OUA group (31.7% in the OSA group vs. 51.7% in the OUA group, P = 0.026). Pain scores and the incidence of opioid analgesic administration were lower in the OSA group during PACU stay, resulting in a significantly lower number of patients requiring rescue opioid analgesics (3.3% vs. 18.3%, P = 0.008). There were no significant differences in intraoperative vital signs, hemodynamic interventions, or duration of PACU and hospital stay between the two groups.

Conclusions: OSA significantly reduced postoperative nausea, pain scores, and the need for rescue analgesics in the PACU without increasing hemodynamic instability in patients undergoing laparoscopic gynecological surgery.

Background: Preventing intraoperative nausea and vomiting (IONV) is crucial for maternal safety during cesarean section under spinal anesthesia. While midazolam is known to prevent IONV, we hypothesized that remimazolam would be superior due to its minimal hemodynamic effects. We compared the effects of the two drugs on IONV.

Methods: Parturients scheduled for cesarean section were randomly assigned to receive either midazolam or remimazolam. They received midazolam 2 mg or remimazolam 5 mg, with additional doses administered upon request. The primary outcome measure was the incidence of newly developed IONV during sedation. Other outcomes included overall IONV, rescue antiemetic use, shivering, hemodynamic variables, sedation scale scores, and satisfaction scores.

Results: Data from 80 participants were analyzed. Deeper sedation was induced in the remimazolam group (PGroup × Time < 0.001) despite comparable hemodynamic trends between the groups. The incidence of overall IONV was comparable between the two groups (27.5% in the midazolam group vs. 17.5% in the remimazolam group, absolute risk reduction [ARR]: 0.100, 95% CI [-0.082, 0.282], P = 0.284); however, newly developed IONV during sedation was significantly reduced in the remimazolam group (20.0% vs. 5.0%, ARR: 0.150, 95% CI [0.009, 0.291], P = 0.043). The need for rescue antiemetics was also lower in the remimazolam group (15.0% vs. 2.5%, ARR: 0.125, 95% CI [0.004, 0.246], P = 0.048).

Conclusion: Remimazolam significantly reduced the incidence and severity of newly developed IONV compared with midazolam, with minimal impact on hemodynamics, making it a useful sedative option for cesarean section.

Background: The incidence of epistaxis during nasotracheal intubation via the left nostril is more frequent than that during intubation via the right nostril. This study evaluated the effect of the reverse bevel and tip direction of the nasotracheal tube on the incidence of epistaxis during nasotracheal intubation via the left nostril.

Methods: Patients undergoing right-sided maxillofacial surgery requiring left nasotracheal intubation were randomly allocated to the control (tracheal tube in the conventional direction) or reverse (a 180˚ reverse direction, with the tube bevel facing the nasal septum and the leading edge (i.e., the tip) of the bevel pointing away from the nasal septum) groups (n = 37 for both). The primary outcome was the incidence of epistaxis evaluated using videolaryngoscopy.

Results: The incidence of epistaxis in the reverse group was significantly lower than that in the control group (9 [24.3%] vs. 20 [54.1%], P = 0.009; relative risk: 0.45, 95% CI [0.24, 0.85], absolute risk reduction: 29.8%, number needed to treat: 3). The severity of epistaxis was significantly lower in the reverse group (P = 0.002). The first attempt nasal passage (P = 0.027) was significantly higher in the reverse group. Postoperative nasal pain was lower (P < 0.001), and patient satisfaction was higher (P < 0.001) in the reverse group. Nasotracheal tube-related complications did not occur in either group.

Conclusions: The reverse bevel and tip direction of the nasotracheal tube reduced the incidence and severity of epistaxis and increased patient satisfaction among patients undergoing left nasotracheal intubation.