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Post by katevaughn on Sept 29, 2016 15:11:57 GMT -5
This month's journal club is presented by Fara Clarke. The article is especially pertinent because it details a drug currently on trial at our institution. Below are the questions to be encompassed within your response. 1. In which patient populations would remimazolam be most beneficial? 2. Considering your own practice, what are some major benefits and drawbacks you can foresee when it comes to using remimazolam in routine cases? (please be specific about which types of cases and patient populations) Enjoy!! Click here for the link to the article.
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Post by faresha on Oct 2, 2016 12:26:13 GMT -5
1. First, I do not think this drug is beneficial in any population if it is not administered by a trained anesthesia provider. I had the experience of watching a team- none anesthesia providers- administer this drug. So, my answer only pertains to the administration of this drug by anesthesia providers. Take for instance this statement from the article, "...although some investigators reported mild hypoxemia resolved using a chin lift maneuver."
Remimazolam would be most beneficial, if at all, in the endoscopy ASA I patient population; and cardiac cripple patients with BMI <30, no sleep apnea, and scheduled for a quick (<1 hour) MAC (+/_ regional anesthesia) case.
2. I think the benefit of remimazolam in the endoscopy ASA I patient population is that it allows the provider to select a drug with a quicker recovery time. A drawback is that a large amount of the drug may be required over time to maintain the patient at a therapeutic sedation level which may increase the overall cost of the drug. Included in this this drawback is that the drug steady-state needs to be maintained to keep the patient sedated.
A benefit of the drug in the cardiac cripple patient is that less is more! This drug seems ideal for this patient population especially in a quick endoscopy case or any quick case where MAC is appropriate. The drawback is similar to above- the need to maintain sedation over a period of time may increase the overall cost of this drug.
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Post by krechti1 on Oct 3, 2016 9:47:34 GMT -5
1. I believe remimazolam would be beneficial in most patient populations. Due to its rapid onset and metabolization, it would be a good adjunct to most deep sedation cases. I think remimazolam would be most beneficial in cardiac and/or critically ill patients. Since it has been shown that patients maintained on remimazolam required less vasopressors than on a propofol infusion, it seems to have a positive cardiac profile. In addition, it would be beneficial for patients with renal or liver insufficiency or failure, since it does not rely on the kidneys or liver for metabolism.
2. One of the major drawbacks to using current BDZ's is the long duration of sedation, especially in the setting of outpatient procedures where the goal is to decrease length of stay in PACU and discharge patients home as efficiently as possible. Therefore, since remimazolam is metabolized quickly, this would be a major benefit. The major drawback would be the cost. It seems like it would be a nice adjunct for almost any case, but especially deep sedation cases where the patient is spontaneously ventilating (most endoscopy procedures). But depending on the cost of the drug, the benefits may not justify the cost. Possibly, depending on the cost, it would be reserved for use on critically ill cardiac patients, or patients with multiple organ failure undergoing endoscopy procedures.
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Post by AugustineEmmanuel on Oct 9, 2016 10:17:18 GMT -5
Good choice of article since I've heard multiple nurses and proceduralists talk about being part of a Remimazolam trial. From the data presented in the article (which does't present the best statistical evidence) it appears that Remimazolam would be beneficial to patients with unstable hemodynamics, patients with morbid obesity, known severe sleep apnea or in proceeds that require "sedation". The article or the authors of the article talk about propofol causes more "cardiac arrest and death" as compared to Remimazolam. From our practice we know that most proceduralists don't want sedation, they want a "room air general". So the data there I'm sure is skewed and biased. In terms of my clinical the major drawbacks I see are cost. Assuming a patient is not severely unstable or in a trauma situation I think that I can get the same outcomes in terms of safety, efficacy and recovery times with propofol or other drugs that we currently use. I do think that Remimazolam does have a place in the GI setting for colonoscopies and endoscopies where a quick turn around is the key. Just a side note: from a financial stand point I think the increased use of Remimazolam for "nursing sedation" would mean less revenues for anesthesia providers and decreased presence of anesthesia providers in GI centers. I'd hard pass that idea from a safety and financial stand point.
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kty67
New Member
Posts: 22
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Post by kty67 on Oct 10, 2016 13:20:16 GMT -5
I agree with above statements that it would be great drug for quick outpatient cases and eye surgeries. Many times I feel bed for my patients not give them Midazolam if they are outpatient or elderly. Remimazolam would be great to substitute Midazolam. Also it can be additive to induction drug for cardiac unstable patients. Also I think dental offices can use it for extensive dental procedures or just for anxious patients.
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Post by belinda on Oct 20, 2016 14:09:01 GMT -5
1. Remimazolam may have its place in our armamentarium of anesthetics for those procedures mentioned, probably most specifically for endo procedures requiring sedation for critically ill/cardiac cripple patients that may not tolerate high dose Propofol anesthetics respiratorily or hemodynamically.
2. This drug as well as all other anesthetics should be given only by trained anesthesia professionals unless the patient is intubated in the ICU as the protocol is now for use of Propofol for sedation in the ICU's.
"Although unsafely, some non-anesthesiologist colleagues use sedative drugs for procedures inside and outside of the operating room, a practice that has been recently debated [3-5]."
In the end, the use of this drug in our facility will be determined by cost as well as necessity.
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Post by mscotth2 on Oct 27, 2016 11:12:16 GMT -5
1. I think this could be helpful in infant eye cases or EUAs as it is suggested that it can be used nasally or orally in this population.
2. Benefits include ease of administration, rapid onset and metabolism leading to (potentially) faster discharges from the PACU. A drawback? becoming accustomed to using a new medication!
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Post by Shannon on Oct 27, 2016 14:14:54 GMT -5
Hi Everyone,
I agree with the above sentiments.
I would just like to add that it may also be used in other outpatient facilities as well such as dental, fertilization, plastics, etc.
I agree with Faresha in that this medication should ONLY be used by trained and certified anesthesia providers.
Thank you for the article choice.
Shannon
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