Effect of sevoflurane on CD4+CD25+FOXP3+ regulatory T cells in patients with gastric cancer undergoing radical surgery.

In this study, the proportion of CD4+CD25+FOXP3+ regulatory T (Treg) cells in CD4+ T cells in the peripheral blood of gastric cancer patients before anesthesia induction (T1), after surgery (T2) and the first day after surgery (T3) was studied to explore the effect of sevoflurane and propofol anesthesia on the prognosis of gastric cancer patients. Forty patients with advanced gastric cancer were recruited and randomly divided into the sevoflurane group (S group) and the propofol group (T group). Flow cytometry was used to detect the proportion of CD4+CD25+FOXP3+ Treg cells in CD4+ T cells in the peripheral blood of patients with T1, T2 and T3, respectively. Compared with stage ⅡB, the proportion of CD4+CD25+FOXP3+ Treg cells in T1, T2 and T3 of stage ⅢA and stage ⅢB patients was increased. Compared with the T group, the expression of CD4+CD25+FOXP3+ Treg cells in the peripheral blood of T2 and T3 in the S group was decreased. The results showed that the expression of CD4+CD25+FOXP3+ Treg cells might be related to the TNM stage of gastric cancer and sevoflurane could alleviate the inhibition of postoperative immune function more than propofol. Sevoflurane effectively reduced the expression level of CD4+CD25+FOXP3+ Treg cells in peripheral blood of T2 and T3 of patients with gastric cancer, providing the theoretical basis for the selection of surgical anesthetics for patients with gastric cancer.

Effect of esketamine on inflammatory factors in opioid-free anesthesia based on quadratus lumborum block: A randomized trial.

BACKGROUND: As strong analgesics, opioids provide the analgesic component of general anesthesia, but they have bidirectional effects on the immune system, promoting the production of pro-inflammatory factors. The idea of opioid-free anesthesia is to replace the analgesic effect of opioids in the treatment of acute pain with comparably effective drugs that do not affect the immune system and thereby decrease the production of inflammatory factors. Therefore, this study aims to observe the effect of opioid-free esketamine anesthesia based on quadratus lumborum block on inflammatory factors in patients undergoing lower abdominal or pelvic surgery. METHODS: A total of 122 patients who underwent lower abdominal or pelvic surgery in our hospital from March 2021 to June 2022 were selected and divided into the esketamine (E) group (n = 62) and control (C) group (n = 60) according to the random number table method. According to the surgical field, the 2 groups underwent unilateral/bilateral quadratus lumborum block in the supine position under ultrasound guidance. In addition, both groups received a target controlled infusion of propofol 3 to 3.5 µg/mL and intravenous rocuronium 0.8 mg/kg. Group E was given opioid-free anesthesia, group C was given opioid-based anesthesia. A 3 to 5 laryngeal mask was inserted according to body weight, and rocuronium 0.5 mg/kg was added intermittently. The levels of interleukin-6 (IL-6), interleukin-8 (IL-8), C-reactive protein (CRP), procalcitonin, tumor necrosis factor-α (TNF-α), numeric rating scales, dosage of propofol, dexmedetomidine and rocuronium, as well as the numeric rating scales score and analgesic complications were monitored in the 2 groups. RESULTS: There was no significant differences in general outcomes between the 2 groups (P > .05). The blood pressure in group E was higher than in group C at T1 (P < .05). The levels of IL-6, TNF-α, CRP and IL-8 in group E were significantly lower than in group C at T1, T2, T3, and T4 (P < .05). The levels of IL-6, TNF-α, procalcitonin, CRP and IL-8 in the 2 groups at T1, T2, T3, and T4 were significantly higher than at T0 (P < .05). CONCLUSION: Opioid-free esketamine anesthesia based on quadratus lumborum block achieved perfect postoperative analgesia with little effect on inflammatory factors in patients undergoing lower abdominal or pelvic surgery.

Awake surgery for glioma resection during pregnancy: a systematic review.

Brain tumors are rarely present during pregnancy. However, they can severely impact the fetus and mother's well-being due to a complex interaction of disease and physiological factors. Moreover, awake surgery for gliomas has been scarcely reported during this life stage, and the nuances and techniques merit further investigation. Herein, we performed a systematic review of the literature about awake surgery for glioma resection during pregnancy. A total of six patients with a median age of 30.5 years (interquartile range: 40-27) were analyzed. Awake surgery was performed in the third trimester in 50% of patients (median time: 24.5 weeks) without reported intraoperative complications. Conscious sedation was achieved by remifentanil and propofol infusion in 67% of cases, and intraoperative fetal heart monitoring was utilized in 83% of cases. Most studies revealed good clinical maternal-fetal outcomes at follow-up; however, long-term safety effects remain undetermined and warrant further research. In conclusion, awake surgery for glioma resection under a multidisciplinary approach can be a reasonable treatment option for select patients during pregnancy.

Effect of Dexmedetomidine and Two Different Doses of Esketamine Combined Infusion on the Quality of Recovery in Patients Undergoing Modified Radical Mastectomy for Breast Cancer - A Randomised Controlled Study.

Purpose: This study evaluated the effect of a combined infusion of dexmedetomidine and esketamine on the quality of recovery in patients undergoing modified radical mastectomy. Methods: A total of 135 patients were randomly divided into three groups: dexmedetomidine group (group D) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion), dexmedetomidine plus low-dose esketamine group (group DE1) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion) and esketamine (0.5 mg/kg loading, 2 µg/kg/min infusion), dexmedetomidine plus high-dose esketamine group (group DE2) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion) and esketamine (0.5 mg/kg loading, 4 µg/kg/min infusion). The primary outcome was the overall quality of recovery-15 (QoR-15) scores at 1 day after surgery. The secondary endpoints were total QoR-15 scores at 3 days after surgery, propofol and remifentanil requirement, awaking and extubation time, postoperative visual analogue scale (VAS) pain scores, rescue analgesic, nausea and vomiting, bradycardia, excessive sedation, nightmares, and agitation. Results: The overall QoR-15 scores were much higher in groups DE1 and DE2 than in groups D 1 and D 3 days after surgery (P < 0.05). VAS pain scores at 6, 12, 24 h postoperatively, propofol and remifentanil requirements were significantly lower in groups DE1 and DE2 than in group D (P < 0.05). Compared with group D, awaking time, extubation time, and post-anesthesia care unit (PACU) stay were significantly prolonged in groups DE1 and DE2 (P < 0.05) and were much longer in group DE2 than in group DE1 (P < 0.05). The proportion of postoperative rescue analgesics and bradycardia was higher and the incidence of excessive sedation was lower in group D than in groups DE1 and DE2 (P < 0.05). Conclusion: Dexmedetomidine plus esketamine partly improved postoperative recovery quality and decreased the incidence of bradycardia but prolonged awaking time, extubation time, and PACU stay, especially dexmedetomidine plus 4 µg/kg/min esketamine.

The study of different dosages of remazolam combined with sufentanil and propofol on painless gastroscopy: A randomized controlled trial.

BACKGROUND: Gastroscopy is one of the most commonly used diagnostic modalities for upper gastrointestinal disorders. Remazolam besylate, a new type of ultrashort-acting benzodiazepine drug, has been less studied in gastroscopy. In this study, we studied the efficacy and safety of remazolam combined with propofol for painless gastroscopy. METHODS: This is a single-center, randomized controlled clinical trial. Hundred patients undergoing painless gastroscopy were included in this study and randomly divided into 2 groups (n = 50 per group): the remazolam 3 mg group (R3 group) and the remazolam 6 mg group (R6 group). Sufentanil, remazolam, and propofol are used to anesthetize the patients, and then, the effects of different dosages of remazolam on these patients are compared and analyzed. The patient's general condition, vital signs at different times, the dosage of propofol (mg) and additional times, complications, duration of gastroscopy (minute), awakening time (minute), residence time in the resuscitation room (minute), and adverse reactions were recorded. RESULTS: R3 group systolic blood pressure and diastolic blood pressure are more stable (P < .05); The number of additional propofol in R6 group was less (P < .05). The incidence of hypotension was lower in R3 group, as well as the time of awakening and staying in the resuscitation room were shorter (P < .05). CONCLUSION: Remazolam 3mg combined with sufentanil and propofol have less effect on hemodynamics in painless gastroscopy, and the patients have shorter awakening time.

Effect of ciprofol on swallowing function in patients undergoing painless gastrointestinal endoscopy.

BACKGROUND: Gastroscopy is one of the most commonly used diagnostic modalities for upper gastrointestinal disorders. This study compared the effect of ciprofol and propofol on swallowing function during painless gastroenteroscopy. METHODS: This was a single-center, placebo-controlled randomized trial. Three hundred sixty-eight patients undergoing painless gastroscopy were included in this study and randomly divided into 2 groups: the propofol group (PRO group, n = 183) and the ciprofol group (CIP group, n = 185). Sufentanil, ciprofol, and propofol are used to anesthetize the patients, and the effects of different solutions on these patients are compared and analyzed. The patient's general condition, vocal cord adduction reflex, dysphagia severity score, penetration and aspiration scale score, vital signs at different times, complications, recovery time (minutes), residence time in the resuscitation room (minutes), and adverse reactions were recorded. RESULTS: During the examination, the incidence of severe swallowing dysfunction in CIP group was lower than that in PRO group (P < .05). The BP in CIP group was higher than that in PRO Group (P < .05). The HR of CIP group was lower than that of PRO Group (P < .05). SpO2 in CIP group was higher than that in PRO Group (P < .05). The recovery time of CIP group was longer than that of PRO Group, and the postanesthesia care unit stay time of PRO group was longer than that of CIP group(P < .05). The incidence of respiratory depression, hypotension and cough in CIP group was lower than that in PRO Group (P < .05). The incidence of injection pain in CIP group was lower than that in PRO Group (P < .05). CONCLUSION: Compared with propofol, ciprofol has less inhibition on swallowing function, less impact on hemodynamics, less respiratory depression, and less injection pain, which is more suitable for painless gastroscopy.

The efficacy of non-anesthesiologist-administered propofol sedation with a target-controlled infusion system during double-balloon endoscopic retrograde cholangiopancreatography.

BACKGROUND: The sedation method used during double-balloon endoscopic retrograde cholangiopancreatography (DB-ERCP) differs among countries and/or facilities, and there is no established method. This study aimed to evaluate the efficacy of non-anesthesiologist-administered propofol (NAAP) sedation using a target-controlled infusion (TCI) system during DB-ERCP. METHODS: This retrospective study was conducted between May 2017 and December 2020 at an academic center. One hundred and fifty-six consecutive patients who underwent DB-ERCP were sedated by gastroenterologists using diazepam (n = 77) or propofol with a TCI system (n = 79), depending on the period. The primary endpoint was a comparison of poor sedation rates between the two groups. Poor sedation was defined as a condition requiring the use of other sedative agents or discontinuation of the procedure. Secondary endpoints were sedation-related adverse events and risk factors for poor sedation. RESULTS: Poor sedation occurred significantly more often in the diazepam sedation group (diazepam sedation, n = 12 [16%] vs. propofol sedation, n = 1 [1%]; P = 0.001). Vigorous body movements (3 or 4) (diazepam sedation, n = 40 [52%] vs. propofol sedation, n = 28 [35%]; P = 0.038) and hypoxemia (< 85%) (diazepam sedation, n = 7 [9%] vs. propofol sedation, n = 1 [1%]; P = 0.027) occurred significantly more often in the diazepam sedation group. In the multivariate analysis, age < 70 years old (OR, 10.26; 95% CI, 1.57-66.98; P = 0.015), BMI ≥ 25 kg/m2 (OR, 11.96; 95% CI, 1.67-85.69; P = 0.014), and propofol sedation (OR, 0.06; 95% CI, 0.01-0.58; P = 0.015) were associated factors for poor sedation. CONCLUSIONS: NAAP sedation with the TCI system during DB-ERCP was safer and more effective than diazepam sedation.

Ti3C2Tx-rGO-chitosan-based microcatheter sensor for real-time continuous monitoring of propofol: toward improved anesthetic management.

We are aiming to develop an electrochemical microcatheter sensor for the detection and real-time continuous monitoring of propofol (PPF), which is an anesthetic drug majorly used during medical treatment. This proposed microcatheter-based sensing strategy meets the challenge of real-time periodic and continuous monitoring of propofol by using d-Ti3C2Tx-rGO-chi-modified carbon paste microcatheter sensor transducer. The sensing methodology relies on voltammetry and chronoamperometry transduction methods. The reusable microcatheter sensor was fabricated by embedding the three electrodes into a few millimeters-wide Teflon tube. The nanocomposite was characterized using advanced analytical instruments such as XRD, FE-SEM, EDX, Raman spectroscopy, and XPS. Further, electrode interfacial properties were characterized with voltammetry and electrochemical impedance spectroscopy. The electroanalytical performance of the modified microcatheter sensor was tested for the detection of PPF in phosphate buffer by using chronoamperometry with a wide linear range of 5 to 110 µM (at an applied potential of 0.3 V vs. Ag/AgCl). The sensor's practical potency was confirmed in human serum with a dynamic linear range of 10 to 130 µM. The sensor exhibited a good limit of detection values in phosphate buffer (2 µM) and natural human plasma (4 µM). The new sensor displays different dimensions of information while displaying high sensitivity, selectivity, and long-term stability. The outstanding analytical performance of the developed sensor holds considerable promise for the continuous monitoring of propofol, its effective management, and optimization of the doses in the patient's body.

A synopsis of multitarget therapeutic effects of anesthetics on depression.

Depression is a profound mental disorder that dampens the mood and undermines volition, which exhibited an increased incidence over the years. Although drug-based interventions remain the primary approach for depression treatment, the available medications still can't satisfy the patients. In recent years, the newly discovered therapeutic targets such as N-methyl-D-aspartate (NMDA) receptor, α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) receptor, and tyrosine kinase B (TrkB) have brought new breakthroughs in the development of antidepressant drugs. Moreover, it has come to light that certain anesthetics possess pharmacological mechanisms intricately linked to the aforementioned therapeutic targets for depression. At present, numerous preclinical and clinical studies have explored the therapeutic effects of anesthetic drugs such as ketamine, isoflurane, N2O, and propofol, on depression. These investigations suggested that these drugs can swiftly ameliorate patients' depression symptoms and engender long-term effects. In this paper, we provide a comprehensive review of the research progress and potential molecular mechanisms of various anesthetic drugs for depression treatment. By shedding light on this subject, we aim to facilitate the development and clinical implementation of new antidepressant drugs based on anesthetic medications.

Effects of Remimazolam and Propofol on Emergence Agitation in Elderly Patients Undergoing Hip Replacement: A Clinical, Randomized, Controlled Study.

Purpose: The aim of this study was to compare the effects of remimazolam and propofol on emergence agitation (EA) in elderly patients undergoing hip replacement. Methods: A total of 60 elderly patients undergoing hip replacement were recruited for this prospective, single-center, clinical, randomized, controlled study from February to April 2023. They were randomly assigned to two groups: the remimazolam group (group R) and the propofol group (group P). In group R, remimazolam was administered intravenously during the induction and maintenance of anesthesia, In group P, propofol was used during the induction and maintenance of anesthesia. The incidence of EA was recorded as the primary indicator. Secondary indicators included heart rate (HR) and mean arterial pressure (MAP) values at the following moments: 5 min prior to anesthetic induction (T0), 1 min following induction (T1), 5 min after the laryngeal mask was inserted (T2), the beginning of surgery (T3), the moment the laryngeal mask was removed (T4), and the overall incidence of postoperative adverse events (bleeding or splitting of the surgical incision, removal of the intravenous infusion needle, falling off the bed, hypoxemia, and hypertension). Results: The incidence of EA was significantly lower in group R than in group P (10% vs 33%, P < 0.05). At T1, T2, and T3, the HR and MAP values of group R were higher than those of group P (P < 0.05). The overall incidence of postoperative adverse events was significantly lower in group R than in group P (P < 0.05). Conclusion: Remimazolam further reduced the incidence of emergence agitation when compared to propofol during geriatric hip replacement. Moreover, it has a minor hemodynamic effect and lower the incidence of postoperative adverse events.

General purpose models for intravenous anesthetics, the next generation for target-controlled infusion and total intravenous anesthesia?

PURPOSE OF REVIEW: There are various pharmacokinetic-dynamic models available, which describe the time course of drug concentration and effect and which can be incorporated into target-controlled infusion (TCI) systems. For anesthesia and sedation, most of these models are derived from narrow patient populations, which restricts applicability for the overall population, including (small) children, elderly, and obese patients. This forces clinicians to select specific models for specific populations. RECENT FINDINGS: Recently, general purpose models have been developed for propofol and remifentanil using data from multiple studies and broad, diverse patient groups. General-purpose models might reduce the risks associated with extrapolation, incorrect usage, and unfamiliarity with a specific TCI-model, as they offer less restrictive boundaries (i.e., the patient "doesn't fit in the selected model") compared with the earlier, simpler models. Extrapolation of a model can lead to delayed recovery or inadequate anesthesia. If multiple models for the same drug are implemented in the pump, it is possible to select the wrong model for that specific case; this can be overcome with one general purpose model implemented in the pump. SUMMARY: This article examines the usability of these general-purpose models in relation to the more traditional models.

Dexmedetomidine vs. propofol sedation reduces the duration of mechanical ventilation after cardiac surgery - a randomized controlled trial.

OBJECTIVE: The aim of our study was to compare the clinical effects of sedation with dexmedetomidine vs. propofol in patients undergoing cardiac surgery and analyze their effects on the duration of mechanical ventilation (MV), length of stay in the intensive care unit (ICU), and total hospital stay. PATIENTS AND METHODS: The study included 120 patients who were randomized in a 1:1 ratio into two groups of 60 patients. The first group was sedated with continuous dexmedetomidine in doses 0.2-0.7 mcg/kg/h. The second group was sedated with propofol in doses 1-2 mg/kg/h. RESULTS: Patients sedated with dexmedetomidine required 2.2 hours less time on MV (p<0.001). There was a positive correlation between the duration of MV and the ICU length of stay (r=0.368; p<0.001), as well as between the duration of MV and the total hospital stay (r=0.204; p=0.025). Delirium occurred in the postoperative period in 25% of patients sedated with propofol, while in the dexmedetomidine group it was only 11.7% (p=0.059). Patients who developed delirium had a significantly longer duration of MV (12.6±5.4 vs. 9.3±2.5 hours, p=0.010). CONCLUSIONS: Postoperative sedation with dexmedetomidine, compared to propofol, reduces the duration of MV, but does not influence the length of stay in the ICU and length of hospitalization after open heart surgery.

Effects of remimazolam combined with sufentanil on hemodynamics during anesthetic induction in elderly patients with mild hypertension undergoing orthopedic surgery of the lower limbs: a randomized controlled trial.

BACKGROUND: This randomized controlled trial was performed to observe the effect of remimazolam with sufentanil on hemodynamics during anesthetic induction in elderly patients with mild hypertension undergoing orthopedic surgery of the lower limbs. METHODS: Sixty elderly patients were randomly assigned to undergo general anesthesia with intravenous injection of either remimazolam besylate (25 mg/vial, batch number 10T11011; Yichang Humanwell Pharmaceutical Co., Ltd., Yichang, China) at 0.2 mg/kg (Group R, n = 30) or propofol at 1.5 mg/kg (Group P, n = 30). Both injections were completed within 15 to 20 s. If the bispectral index value did not reach 40 to 60, then 0.05 mg/kg of remimazolam was added in Group P and 1 mg/kg of propofol was added in Group R. When the BIS value reached 40 to 60, sufentanil was administered at 0.3 to 0.5 µg/kg and cisatracurium was administered at 0.15 to 0.2 mg/kg in both groups. Three minutes later, tracheal intubation and controlled ventilation were performed to maintain the end-tidal carbon dioxide partial pressure at 4.5 to 5.0 kPa. The mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), continuous cardiac index (CI), systemic vascular resistance (SVR), and pulse oxygen saturation were recorded before induction (T0), when the eyelash reflex disappeared (T1), immediately after endotracheal intubation (T2), 1 min after endotracheal intubation (T3), and 5 min after endotracheal intubation (T4). The disappearance time of the eyelash reflex, injection pain, hypotension, bradycardia, hiccupping, nausea and vomiting, and other adverse events were observed. RESULTS: The MAP, HR, CO, and CI at T1, T2, T3, and T4 were significantly higher in Group R than P, while SVR was significantly lower in Group R than P (P < 0.05). In Group P, the MAP, HR, CO, and CI were significantly lower and the SVR was significantly higher at T1, T2, T3, and T4 than at T0 (P < 0.05). Adverse events occurred in 8 (20%) patients in Group R and 22 (73%) in Group P. The total incidence of adverse events was significantly lower in Group R than P (P < 0 0.001). CONCLUSION: Remimazolam combined with sufentanil for general anesthesia induction has the advantages of small hemodynamic fluctuations, stable circulation, and few adverse reactions, making it suitable for elderly patients with mild hypertension. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2300069224, 10/03/2023).

The art of chasing numbers in titration of anaesthetic dose.

There is no difference in between-patient variability of concentrations when comparing propofol and sevoflurane titrated to a bispectral index of 40-60. There is about a 300% variation in hypnotic concentration between the bottom 5% and top 5% of the population. Anaesthesia titration cannot be based solely on measured or estimated drug concentrations.

A preclinical study on online monitoring of exhaled ciprofol concentration by the ultraviolet time-of-flight spectrometer and prediction of anesthesia depth in beagles.

BACKGROUND: Exhaled air has been demonstrated as a reliable medium for monitoring propofol concentration. However, online monitoring of exhaled ciprofol have not been reported. METHODS: Thirty-six beagles undergoing mechanical ventilation were divided into 6 groups, including bolus injection of low (Group BL, n = 6), medium (Group BM, n = 6), and high dose of ciprofol (Group BH, n = 6) groups; as well as 1 h continuous infusion of low (Group IL, n = 6), medium (Group IM, n = 6), and high dose of ciprofol (Group IH, n = 6) groups. The ciprofol concentration in exhaled air (CE) was determined by the ultraviolet time-of-flight mass spectrometer (UV-TOFMS). The correlations of CE and plasma concentration (Cp), CE and the bispectral index (BIS) were explored. Additionally, the pharmacokinetics (PK) models of CE and Cp, the pharmacodynamics (PD) models of CE and BIS were also established. RESULTS: Online monitoring of exhaled ciprofol can be achieved with the UV-TOFMS instrument. The CE of ciprofol in beagles was found at parts per billion by volume (ppbv) level. The linear correlation of CE and Cp was weak in bolus injection groups (R2 = 0.01) nonetheless moderate in continuous infusion groups (R2 = 0.53). The i.v. bolus PK model of CE and Cp can be fitted with the non-compartment models. Additionally, the the PD models of CE and BIS can be well fitted with the inhibitory sigmoid Emax model with the estimate values of IC50 = 0.05 ± 0.01 ppbv, γ = 4.74 ± 1.51, E0 = 81.40 ± 3.75, Imax = 16.35 ± 4.27 in bolus injection groups; and IC50 = 0.05 ± 0.01 ppbv, γ = 6.92 ± 1.30, E0 = 83.08 ± 1.62, Imax = 12.58 ± 1.65 in continuous infusion groups. CONCLUSIONS: Online monitoring of exhaled ciprofol concentration in beagles can be achieved with the UV-TOFMS instrument. Good correlations can be observed between exhaled ciprofol concentration and its cerebral effects reflected by the BIS value, demonstrating the potential of exhaled ciprofol monitoring for titrating depth of anesthesia in future clinical setting.

Prospective, randomized, double-blind, double-dummy, active-controlled, phase 3 clinical trial comparing the safety and efficacy of intranasal dexmedetomidine to oral midazolam as premedication for propofol sedation in pediatric patients undergoing magnetic resonance imaging: the MIDEX MRI trial.

BACKGROUND: Children under 6 years who need magnetic resonance imaging usually require sedation to obtain best quality images, but the optimal sedation protocol remains to be determined. In 2018, we showed a 22% interruption in image acquisition during magnetic resonance imaging when performing a propofol-based sedation using a bolus approach. As non-pharmacological premedication is often insufficient to reduce the anxiety of children related to parental separation, pharmacological premedication may be useful to facilitate the induction of anesthesia. In our institution, effective premedication is obtained oral intake of midazolam, though its administration relies on patients' compliance and could also lead to paradoxical reaction. Dexmedetomidine has a safe profile in the pediatric population and can therefore represent an interesting alternative. The primary objective of this trial is to demonstrate the superiority of intranasal dexmedetomidine compared to oral midazolam as premedication in reducing the occurrence of any event requiring temporary or definitive interruption of the examination to allow anesthesiologist intervention in children undergoing magnetic resonance imaging under propofol sedation. METHODS: In this single-center, prospective, randomized, double-blind, double-dummy, active comparator-controlled, superiority trial, we planned to include 250 patients, aged 6 months to 6 years, undergoing a scheduled magnetic resonance imaging requiring the presence of an anesthesiologist. After informed consent, the patients will be randomized to receive either oral midazolam or intranasal dexmedetomidine as premedication. The data will be analyzed in intention to treat, using Kolmogorov-Smirnov Z, chi-square, Wilcoxon, and Mann-Whitney U tests. A P-value < 0.05 will be considered statistically significant. DISCUSSION: The MIDEX MRI study will assess the efficacy of intranasal dexmedetomidine compared to oral midazolam to improve the quality of a propofol-based sedation prior to magnetic resonance imaging, without negative repercussion on the postoperative period. TRIAL REGISTRATION: ClinicalTrial.gov NCT05192629 . Registered on 14 January 2022. Protocol version 2.1.

Intravenous Lidocaine Decreased the Median Effective Concentration of Sufentanil for Tracheal Intubation in Obese Patients.

Purpose: Sufentanil has been widely used to inhibit the hemodynamic responses caused by tracheal intubation. Using intravenous lidocaine may reduce the dose of sufentanil and better maintain the hemodynamics. This study aimed to determine the effects of intravenous lidocaine on the median effective concentration (EC50) of sufentanil for endotracheal intubation in obese patients. Patients and Methods: This is a randomized, double-blind, up-and-down sequential allocation study. Fifty obese patients undergoing bariatric surgery were randomly allocated in a 1:1 ratio into the lidocaine group and the saline group. Anesthesia was induced using a target-controlled infusion of propofol and sufentanil. The effect-site concentration (Ce) of propofol was 3.5 µg/mL. The Ce of sufentanil for the first patient was 0.4 ng/mL, and the sufentanil dose for the next patient was determined according to the responses of the previous patient, using Dixon's up-and-down sequential method with an interval of 0.05 ng/mL. When the target concentration of propofol and sufentanil was reached, lidocaine 1.5 mg/kg or the same volume of normal saline was infused over 3 min. Tracheal intubation was performed 3 min after the end of the lidocaine or normal saline infusion. Probit regression was used to calculate the EC50 and 95% confidence interval (CI) of sufentanil. Results: Thirty-eight patients completed this study. The EC50 of sufentanil was 0.36 ng/mL (95% CI: 0.31-0.41 ng/mL) in the lidocaine group, which was significantly lower than 0.50 ng/mL (95% CI: 0.43-0.62 ng/mL) in the saline group. In addition, compared with saline group, the dosage of sufentanil in lidocaine group decreased significantly during the test. The hemodynamics of the two groups were stable during the study period. Conclusion: Intravenous lidocaine 1.5 mg/kg decreased the EC50 of sufentanil required for tracheal intubation in obese patients undergoing bariatric surgery.

The safety and efficacy of remimazolam tosylate combined with propofol in upper gastrointestinal endoscopy: A multicenter, randomized clinical trial.

INTRODUCTION: Hypotension is the most common adverse event under propofol-mediated sedation and is possible to cause varying degrees of damage to patients. Whereas remimazolam has a poorer sedative effect than propofol. AIM: The aim of this study was to explore the advantages of the combination of remimazolam tosylate and propofol. METHODS: 304 patients were divided into the remimazolam tosylate group (RT group), the propofol group (P group), and the remimazolam tosylate plus propofol group(R+T group). The primary outcome was the incidence of hypotension. Secondary outcomes included the results of sedation and recovery. The safety results mainly include the incidence of Hypotension, adverse respiratory events, postoperative nausea and vomiting, hiccup, cough, body movement and bradycardia. RESULTS: The incidence of hypotension was 56.7% in the P group, 12.6% in the RT group, and 31.3% in the R+P group, three groups of pairwise comparisons showed statistical differences, with P< 0.001. The incidence of body movement was significantly higher in the RT group (26.1%) than in the P group (10.3%) and the R+P group (12.5%), P = 0.004. The endoscopist satisfaction was higher in the P (3.87±0.44) and R+P (3.95±0.22)groups than in the RT(3.53±0.84) group. The incidence of adverse events, in descending order, was P group, RT group, and R+P group (93.8%vs.61.3%vs.42.7%). CONCLUSION: Co-administration had fewer adverse events than propofol monotherapy, also had a better sedative effect and higher endoscopist satisfaction than remimazolam monotherapy. TRIAL REGISTRATION: Clinical trial registration number: NCT05429086.

Comparison of nasotracheal versus orotracheal intubation for sedation, assisted spontaneous breathing, mobilization, and outcome in critically ill patients: an exploratory retrospective analysis.

Nasotracheal intubation (NTI) may be used for long term ventilation in critically ill patients. Although tracheostomy is often favored, NTI may exhibit potential benefits. Compared to orotracheal intubation (OTI), patients receiving NTI may require less sedation and thus be more alert and with less episodes of depression of respiratory drive. We aimed to study the association of NTI versus OTI with sedation, assisted breathing, mobilization, and outcome in an exploratory analysis. Retrospective data on patients intubated in the intensive care unit (ICU) and ventilated for > 48 h were retrieved from electronic records for up to ten days after intubation. Outcome measures were a Richmond Agitation and Sedation Scale (RASS) of 0 or - 1, sedatives, vasopressors, assisted breathing, mobilization on the ICU mobility scale (ICU-MS), and outcome. From January 2018 to December 2020, 988 patients received OTI and 221 NTI. On day 1-3, a RASS of 0 or - 1 was attained in OTI for 4.0 ± 6.1 h/d versus 9.4 ± 8.4 h/d in NTI, p < 0.001. Propofol, sufentanil, and norepinephrine were required less frequently in NTI and doses were lower. The NTI group showed a higher proportion of spontaneous breathing from day 1 to 7 (day 1-6: p < 0.001, day 7: p = 0.002). ICU-MS scores were higher in the NTI group (d1-d9: p < 0.001, d10: p = 0.012). OTI was an independent predictor for mortality (odds ratio 1.602, 95% confidence interval 1.132-2.268, p = 0.008). No difference in the rate of tracheostomy was found. NTI was associated with less sedation, more spontaneous breathing, and a higher degree of mobilization during physiotherapy. OTI was identified as an independent predictor for mortality. Due to these findings a new prospective evaluation of NTI versus OTI should be conducted to study risks and benefits in current critical care medicine.

Efficacy and safety of alfentanil plus propofol versus propofol only in painless gastrointestinal endoscopy: A meta-analysis.

BACKGROUND: To systematically evaluate the efficacy and safety of alfentanil plus propofol versus propofol only for painless gastrointestinal endoscopy. METHODS: The Cochrane Library, PubMed, Embase, China Biology Medicine, CNKI, WanFang, and VIP databases were searched to identify randomized controlled trials on alfentanil combined with propofol versus propofol only for painless gastrointestinal endoscopy from the inception of the database to August 2022. The Rev Man 5.4 software was used for statistical analyses. RESULTS: Thirteen randomized controlled trials involving 1762 patients were identified as eligible for this study. The meta-analysis showed that compared with propofol, alfentanil combined with propofol had a more stable mean arterial pressure [mean difference (MD) = 5.38, 95% confidence interval (CI): 1.97-8.80; P = .002], heart rate (MD = 3.78, 95% CI: 1.30-6.26; P = .003) and pulse oxygen saturation (MD = 1.90, 95% CI: 0.93-2.78; P = .0001); a lower propofol dose (standard mean difference = -2.82, 95% CI: -3.70 to -1.94; P < .00001), lower awakening time (MD = -3.23, 95% CI: -4.01 to -2.45; P < .00001) and lower directional force recovery time (MD = -3.62, 95% CI: -4.22 to -3.03; P < .00001); a lower incidence of nausea and vomiting (relative risk [RR] = 0.32, 95% CI: 0.14-0.71; P = .005), body movement (RR = 0.27, 95% CI: 0.13-0.54; P = .0002), hypotension (RR = 0.23, 95% CI: 0.12-0.46; P < .0001), respiratory depression (RR = 0.37, 95% CI: 0.15-0.89; P = .03) and cough reflex (RR = 0.33, 95% CI: 0.12-0.89; P = .03). CONCLUSION: This meta-study found that current evidence indicates that alfentanil plus propofol is better than propofol alone for painless gastrointestinal endoscopy and is associated with a lower incidence of adverse reactions. Due to the limited quality and quantity of the included studies, more high-quality studies are needed to validate these above conclusions.