Comparison of 2 effect-site concentrations of remifentanil with midazolam during percutaneous transluminal balloon angioplasty under monitored anesthesia care

Abstract

Background:Until now, target-controlled infusion of remifentanil with midazolam in percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas has not been described. Here, we investigate 2 effect-site concentrations of remifentanil with intermittent bolus midazolam for percutaneous transluminal balloon angioplasty under monitored anesthesia care.Methods:A prospective, randomized controlled trial including patients who received a percutaneous transluminal balloon angioplasty between March 2019 and March 2021 was conducted. Group 1 and Group 2 were, respectively, administered an initial effect-site concentration of remifentanil of 1.0 and 2.0 ng/mL by a target-controlled infusion pump with Minto model. In both groups, maintenance of the effect-site concentration of remifentanil was adjusted upward and downward by 0.5 ng/mL with intermittent bolus midazolam to keep the Observer's Assessment of Alertness/Sedation scale between 2 and 4, mean arterial pressure and heart rate at baseline levels ± 30%, and patient comfort (remaining moveless). The primary outcome was to determine the appropriate effect-site concentration of remifentanil for the procedure in terms of patient comfort (remaining moveless), hemodynamic conditions, and adverse events. Secondary endpoints included the total dosage of anesthetics and total times of target-controlled infusion pump adjustments.Results:A total of 40 patients in Group 1 and 40 patients in Group 2 were eligible for analysis. Most parameters were insignificantly different between 2 groups, except Group 1 having higher peripheral oxygen saturation, while local anesthetic injection compared with Group 2. In addition, Group 1 patients had less apnea with desaturation (peripheral oxygen saturation < 90%; 0 vs 6, P = .034), less remifentanil consumption (189.65 ± 69.7 vs 243.8 ± 76.1 μg, P = .001), but more intraoperative movements affecting the procedure (14 vs 4; P = .016), total times of target-controlled infusion pump adjustment [2 (1-4) vs 1 (1–2), P < .001] compared with Group 2.Conclusion:In percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas, target-controlled infusion with remifentanil Minto model target 2.0 ng/mL with 3 to 4 mg midazolam use provided appropriate hemodynamic conditions, sufficient sedation and analgesia, and acceptable apnea with desaturation.

Comparison of 2 effect-site concentrations of remifentanil with midazolam during transrectal ultrasound-guided prostate biopsy under procedural analgesia and sedation: A randomized controlled study

“…Here, we first reported that REMI Ce of 2.0 µg/mL by TCI pump with 3 to 4 mg midazolam and intrarectal lidocaine gel use provided adequate analgesia and sedation, appropriate hemodynamic conditions, acceptable adverse events (apnea with desaturation; SpO 2 88%-89%), and better surgeon satisfaction in TRUS-guided prostate biopsy under PAS as our previous research in percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas. [10] Anesthesia for TRUS-guided prostate biopsy should be quick in onset of action, have an easily reversible effect, and result in minimal adverse effects while allowing the procedure to be performed on an outpatient basis. The Urological Society of Australia and New Zealand prostate biopsy survey in 2013 showed that 57% of urologists used PAS or general anesthesia, 28% periprostatic nerve block (PNB), and 4% no analgesic agent.…”

“…Here, we first reported that REMI Ce of 2.0 µg/mL by TCI pump with 3 to 4 mg midazolam and intrarectal lidocaine gel use provided adequate analgesia and sedation, appropriate hemodynamic conditions, acceptable adverse events (apnea with desaturation; SpO 2 88%–89%), and better surgeon satisfaction in TRUS-guided prostate biopsy under PAS as our previous research in percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas. [10]…”

“…However, in our country, most patients prefer moderate sedation rather than light sedation, and 3 to 4 mg of midazolam with continuous infusion of REMI is feasible and safe for patients during PAS. [10] In addition, the use of intrarectal lidocaine gel might only diminish the sensation of pain while probe insertion, but not during insertion of needles. [30] Moreover, only one anesthesiologist or urologist is based on our study design.…”

“…During anesthesia maintenance, the REMI Ce was adjusted upward or downward by 0.5 ng/mL to make patient remaining moveless as adequate analgesia, moderate to deep sedation with intermittent bolus midazolam 1 to 1.5 mg per time (the maximal midazolam dose was no more than 5 mg in the 2 groups) to maintain the Observer's Assessment of Alertness/Sedation (OAA/S) scores of 2 to 4, and stable hemodynamics with mean arterial pressure (MAP) and heart rate (HR) within baseline levels ± 30%. [10] In addition, when apnea without desaturation (SpO 2 ≥ 90%) occurred, we conducted jaw elevation to keep airway open. Whereas positive-pressure mask ventilation (with 100% oxygen at 6 L/min) and decreasing REMI Ce were conducted, while apnea with desaturation (SpO 2 < 90%) occurred.…”

“…In our previous study, we showed that TCI with REMI Ce of 2.0 ng/mL and 3 to 4 mg midazolam use provided appropriate hemodynamic and respiratory conditions, and sufficient analgesia and sedation under PAS in percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas. [10] Thus, this study investigated 2 effect-site concentration (Ce) of REMI with midazolam for TRUS-guided prostate biopsy under PAS.…”