Unexpected tachycardia and hypertension during anesthetic induction with remimazolam in cardiac surgery: a case report

Sato, Tomoe; Ohno, Sho; Maeda, Makishi; Sawashita, Yasuaki; Hirata, Naoyuki; Yamakage, Michiaki

doi:10.1186/s40981-021-00462-8

Cited by 8 publications

(4 citation statements)

References 4 publications

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“…Remimazolam anesthesia has been associated with unexpected increases in HR during GA, presumably from its effects on sympathetic superiority [ 30 ]. However, an analysis of HRV before and after the induction of GA showed no change in the ANS with remimazolam [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

Comparative Analysis of the Hemodynamic Effects of Remimazolam and Propofol During General Anesthesia: A Retrospective Study

Tsukimoto,

Kitaura,

Yamamoto

et al. 2024

Cureus

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Purpose: Hypotension is common during anesthesia induction. However, minimal hemodynamic effects of remimazolam anesthesia have been reported. We hypothesized that remimazolam would have weaker hemodynamic effects than would propofol. To test this, we simultaneously evaluated the hemodynamics using the estimated continuous cardiac output (esCCO) system and heart rate variability (HRV) during anesthesia induction. Methods: This was a single-center, observational, retrospective study of patients undergoing dental surgery under general anesthesia between 2020 and 2022. Seventy patients were divided into two groups: remimazolam (R group; n=34) and propofol (P group; n=36). The information obtained from the anesthesia records, patient information, esCCO system parameters, and HRV were integrated and analyzed. The percentages of various parameters were set to 100% for the pre-induction phase as the baseline. Results: The %MAP (noninvasive mean arterial blood pressure) decreased over a narrower range in the R compared to the P group (-17.8% (-26.3%, -11.9%) vs. -22.6% (-32.9%, -17.0%); P=0.039). The %HR (heart rate) increased significantly in the R group and decreased in the P group (+10.7% (+6.5%, +18.6%) vs. -6.5% (-14.5%, +8.4%); P<0.01). The %SV esCCO (stroke volume calculated using the esCCO system) decreased significantly in both groups, but the R group showed a smaller difference compared to the P group (- 5.1% (-7.7%, -2.1%) vs. -10.0% (-13.8%, -5.6%); P<0.01). The rates of change in %LF nu (normalized unit of low frequency) and %HF nu (normalized unit of high frequency) were lower for the R than for the P group, although the difference was not significant (+6.8% (-14.5%, 32.4%) vs. +9.2% (-7.2%, +59.7%), P=0.30; +7.9% (-51.0%, +66.9%) vs. +22.8% (-26.1%, +61.6%), P=0.57). Conclusion: Remimazolam demonstrated a lower MAP reduction rate than propofol. A compensatory increase in HR occurred with a decrease in stroke volume. However, the HR increase was not attributable to the autonomic nervous system.

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Section: Discussionmentioning

confidence: 99%

Comparative Analysis of the Hemodynamic Effects of Remimazolam and Propofol During General Anesthesia: A Retrospective Study

Tsukimoto,

Kitaura,

Yamamoto

et al. 2024

Cureus

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“…While the loss of consciousness was faster after propofol versus remimazolam induction (46 versus 66 s), blood pressure was significantly lower after propofol induction. 103 Japan VATS Anaesthesia 1 100% Anaphylaxis Hong 9 Korea Arthroscopy Anaesthesia 1 0% Horikoshi 10 Japan Laparoscopy Anaesthesia 1 100% Delayed emergence Huang 11 China LMA insertion Anaesthesia NA 0% Hwang 12 Korea Teratoma resection Anaesthesia 2 0% Kawasaki 13 Japan Liver transplantation Anaesthesia 1 0% Kida 14 Japan CABG Anaesthesia 1 100% Tolerance Kim 107 Korea All kinds Anaesthesia 5 100% Anaphylactoid shock Kim 15 Korea THA Anaesthesia 1 100% Psychogenic coma Kim 16 Korea Laparotomy Anaesthesia 1 0% Kitaura 17 Japan TMVR Anaesthesia 1 0% Koh 18 Japan Spine Anaesthesia 1 100% Heart failure Lee 19 Korea RALP Anaesthesia 1 0% Liu 110 China RALP Anaesthesia 1 100% Precipitation Matsumoto 20 Japan Liver transplantation Anaesthesia 1 0% Matsuo 111 Japan Orthopaedic Anaesthesia 1 100% Precipitation Nakayama 21 Japan Minor orthopaedic Anaesthesia 2 0% Onoda 22 Japan Laparoscopy Anaesthesia 1 0% Saito 23 Japan Cardiac Anaesthesia 1 100% Hypotension Sasaki 112 Japan Dental Anaesthesia 1 100% Precipitation Sato 24 Japan Trepanation Anaesthesia 1 0% Sato 25 Japan Cardiac Anaesthesia 1 100% Hypertension Singal 102 USA Endoscopy Anaesthesia 1 100% Delayed emergence Suzuki 26 Japan ENT Anaesthesia 1 100% Delayed emergence Takemori 27 Japan RALP Anaesthesia 1 100% Delayed emergence Tsurumi 104 Japan Minor orthopaedic Anaesthesia 1 100% Anaphylaxis Uchida 28 Japan ENT Anaesthesia 1 100% Delayed emergence Uchida 29 Japan TEVAR Anaesthesia 1 100% Delayed emergence Uchida 106 Japan Skin graft; laparoscopy Anaesthesia 2 100% Anaphylaxis Yamada 30 Japan Neurosurgery Anaesthesia 3 0% Yamadori 31 Japan Laparotomy Anaesthesia 1 0% Yamamoto …”

Section: Discussionmentioning

confidence: 99%

Remimazolam and serious adverse events

Kempenaers,

Hansen,

Van de Velde

2023

European Journal of Anaesthesiology

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Remimazolam is anticipated to be an interesting anaesthetic and sedative. It combines the pharmacodynamic properties of midazolam with pharmacokinetic properties similar to remifentanil. However, worrisome case reports of anaphylaxis, delayed emergence and re-sedation have emerged recently and necessitate further investigation. PubMed (including MEDLINE) and EMBASE were searched for all studies reporting serious adverse events where remimazolam was administered for sedation or anaesthesia. Thirty-six case reports and 73 trials were identified, involving a total of 6740 patients who received remimazolam. Hypotension was reported in 911 cases, delayed emergence in 68 cases, anaphylaxis in 10 cases and re-sedation in 8 cases. The incidence of hypotension seems to be lower compared with other anaesthetics, even in high-risk patients. Delayed emergence might be related to the metabolism of remimazolam through carboxylesterase 1 (CES1), a tissue esterase predominant in the liver. There is significant interindividual variation, and it is inhibited by flavonoids, fatty acids and alcohol. Individual benzodiazepine sensitivity has also been reported. A higher BMI, older age and low plasma albumin concentration are risk factors for delayed emergence. Anaphylaxis might be related to a non-IgE-mediated effect of the excipient dextran-40 or a partially IgE-mediated reaction to remimazolam itself. Resedation has been reported after flumazenil reversal and is explained by the specific pharmacokinetic properties of flumazenil and remimazolam. Reversal by flumazenil should be reserved for and used carefully in patients with delayed emergence. Visual Abstract http://links.lww.com/EJA/A864.

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“…Intraoperative blood pressure elevation was suggested to be associated with postoperative complications, although not to the same extent as hypotension, and some reports indicated that intraoperative hypertension was a risk for postoperative acute kidney injury [ 13 , 16 ]. In addition, there have been case reports of unexpected hypertension during the induction of anesthesia with remimazolam [ 17 ]. There was no significant difference in the frequency and duration of intraoperative hypertension in Group R compared with Group S (Supplementary Table 2 ).…”

Section: Discussionmentioning

confidence: 99%

Effect of remimazolam versus sevoflurane on intraoperative hemodynamics in noncardiac surgery: a retrospective observational study using propensity score matching

Katsuragawa,

Mimuro,

Sato

et al. 2023

JA Clin Rep

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Background This study compared the effects of remimazolam and sevoflurane on intraoperative hemodynamics including intraoperative hypotension (IOH). Results This study involved adult patients undergoing noncardiac surgery using remimazolam (Group R) or sevoflurane (Group S) for maintenance anesthesia, and invasive arterial pressure measurements, from September 2020 to March 2023 at our hospital. IOH was defined as a mean blood pressure < 65 mmHg occurring for a cumulative duration of at least 10 min. A 1:1 propensity score-matching method was used. The primary endpoint was the occurrence of IOH, and the secondary endpoints were the cumulative hypotensive time, incidence of vasopressor use, and dose of vasopressor used (ephedrine, phenylephrine, dopamine, and noradrenaline). Group R comprised 169 patients, Group S comprised 393 patients, and a matched cohort of 141 patients was created by propensity score matching. There was no significant difference in the incidence of IOH between the two groups (85.1% in Group R vs. 91.5% in Group S, p = 0.138). Patients in Group R had a significantly lower cumulative hypotension duration (55 [18–119] vs. 83 [39–144] min, p = 0.005), vasopressor use (81.6% vs. 91.5%, p = 0.023), and dose of ephedrine (4 [0–8] vs. 12 [4–20] mg, p < 0.001) than those in Group S. There were no significant differences in the doses of other vasopressors between groups. Conclusions Compared with sevoflurane, the maintenance of anesthesia with remimazolam was not associated with a decreased incidence of IOH; however, it reduced the cumulative hypotension time, incidence of vasopressor use, and dose of ephedrine.

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Unexpected tachycardia and hypertension during anesthetic induction with remimazolam in cardiac surgery: a case report

Cited by 8 publications

References 4 publications

Comparative Analysis of the Hemodynamic Effects of Remimazolam and Propofol During General Anesthesia: A Retrospective Study

Comparative Analysis of the Hemodynamic Effects of Remimazolam and Propofol During General Anesthesia: A Retrospective Study

Remimazolam and serious adverse events

Effect of remimazolam versus sevoflurane on intraoperative hemodynamics in noncardiac surgery: a retrospective observational study using propensity score matching

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