Abstract
BackgroundRemimazolam, a novel benzodiazepine, has been reported to cause less hypotension than propofol during induction of anesthesia. Therefore, remimazolam might be a valuable option in elderly patients with severe aortic stenosis who are considered to be the most vulnerable to hemodynamic instability. We aimed to evaluate the feasibility and hemodynamic effects of remimazolam as an induction agent in elderly patients with severe aortic stenosis.MethodsThis prospective, open-label, single-arm, observational pilot study was conducted in a university hospital between November 2020 and April 2021. We included 20 patients aged 65 years or older scheduled for transcatheter or surgical aortic valve replacement for severe aortic stenosis under general anesthesia. Patients were administered intravenous remimazolam infusion at 6 mg/kg/h combined with 0.25 μg/kg/min of remifentanil infusion. The primary outcome was the vasopressor dosage between the induction of anesthesia and the completion of tracheal intubation. The secondary outcomes included hemodynamic changes, bispectral index changes, and the time from the start of remimazolam infusion to loss of consciousness. We also recorded awareness during anesthesia induction and serious adverse events related to death, life-threatening events, prolonged hospitalizations, and disability due to permanent damage.ResultsTwenty patients aged 84 [79–86] (median [interquartile range]) with American Society of Anesthesiologists physical status 4 were analyzed. Ephedrine 0 [0–4] mg and phenylephrine 0.1 [0–0.1] mg were administered to 14/20 patients (3 doses in 1 patient, 2 doses in 4 patients, and one dose in 9 patients). Loss of consciousness was achieved at 80 [69–86] s after the remimazolam infusion was started. The mean arterial pressure decreased gradually after loss of consciousness but recovered immediately after tracheal intubation. The bispectral index values gradually decreased and reached < 60 at 120 s after loss of consciousness. Neither awareness during induction of anesthesia nor serious adverse events, such as severe bradycardia (< 40 bpm), life-threatening arrhythmia, myocardial ischemia, or anaphylactic reactions were observed.ConclusionsRemimazolam could be used as an induction agent with timely bolus vasopressors in elderly patients with severe aortic stenosis.Trial registrationUMIN Clinical Trials Registry, identifier UMIN000042318.
Highlights
Remimazolam, a novel benzodiazepine, has been reported to cause less hypotension than propofol during induction of anesthesia
loss of consciousness (LoC) was achieved at 80 [69–86] s, and tracheal intubation was completed at 322 [292–346] s after the remimazolam infusion was started at 6 mg/kg/h, with a total dose of 0.13 [0.12–0.14] mg/kg
We found that anesthesia induction using a combination of remimazolam and remifentanil was possible in elderly patients with severe Aortic stenosis (AS) with a timely bolus administration of ephedrine and phenylephrine
Summary
Remimazolam, a novel benzodiazepine, has been reported to cause less hypotension than propofol during induction of anesthesia. Remimazolam might be a valuable option in elderly patients with severe aortic stenosis who are considered to be the most vulnerable to hemodynamic instability. We aimed to evaluate the feasibility and hemodynamic effects of remimazolam as an induction agent in elderly patients with severe aortic stenosis. Advances in perioperative care and surgical techniques have reduced the mortality of patients with severe AS undergoing general anesthesia [2]. The primary goal for the hemodynamic management of patients with severe AS is to prevent hypotension. Older age and a higher American Society of Anesthesiologists physical status (ASA-PS) are associated with a greater risk of hypotension after anesthesia induction [3, 4]. Careful hemodynamic management is crucial during anesthesia induction, especially for patients with severe AS, who are typically elderly and have a higher ASA-PS
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