Effect of remimazolam vs. propofol on hemodynamics during general anesthesia induction in elderly patients: Single-center, randomized controlled trial

Abstract

The current study aimed to compare the effects between remimazolam and propofol on hemodynamic stability during the induction of general anesthesia in elderly patients. We used propofol at a rate of 60 mg/(kg·h) in the propofol group (group P) or remimazolam at a rate of 6 mg/(kg·h) in the remimazolam group (group R) for the induction. A processed electroencephalogram was used to determine whether the induction was successful and when to stop the infusion of the study drug. We measured when patients entered the operating room (T₀), when the induction was successful (T₁), and when before (T₂) and 5 min after successful endotracheal intubation (T₃). We found that mean arterial pressure (MAP) was lower at T_1-3, compared with T₀ in both groups, but higher at T₂ in the group R, while ΔMAP_T0-T2 and ΔMAP_max were smaller in the group R (ΔMAP_T0-T2: the difference between MAP at time point T₀ and T₂, ΔMAP_max: the difference between MAP at time point T₀ and the lowest value from T₀ to T₃). Cardiac index and stroke volume index did not differ between groups, whereas systemic vascular resistance index was higher at T_1-3 in the group R. These findings show that remimazolam, compared with propofol, better maintains hemodynamic stability during the induction, which may be attributed to its ability to better maintain systemic vascular resistance levels.

Keywords

remimazolam / propofol / elderly patients / hypotension / left ventricular systolic function / systematic vascular resistance

Fundings

This work received no funding from any source.

Acknowledgments

None.

References

[1] Green RS, Butler MB. Postintubation hypotension in general anesthesia: a retrospective analysis[J]. J Intensive Care Med, 2016, 31(10): 667-675. doi: 10.1177/0885066615597198

[2] Kozarek K, Sanders RD, Head D. Perioperative blood pressure in the elderly[J]. Curr Opin Anaesthesiol, 2020, 33(1): 122. doi: 10.1097/ACO.0000000000000820

[3] Paton DM. Remimazolam: a short-acting benzodiazepine for procedural sedation[J]. Drugs Today, 2021, 57(5): 337-346. doi: 10.1358/dot.2021.57.5.3264119

[4] Sneyd JR, Rigby-Jones AE. Remimazolam for anaesthesia or sedation[J]. Curr Opin Anaesthesiol, 2020, 33(4): 506-511. doi: 10.1097/ACO.0000000000000877

[5] Chen S, Wang J, Xu X, et al. The efficacy and safety of remimazolam tosylate versus propofol in patients undergoing colonoscopy: a multicentered, randomized, positive-controlled, phase Ⅲ clinical trial[J]. Am J Transl Res, 2020, 12(8): 4594-4603. https://pubmed.ncbi.nlm.nih.gov/32913533/

[6] Keam SJ. Remimazolam: first approval[J]. Drugs, 2020, 80(6): 625-633. doi: 10.1007/s40265-020-01299-8

[7] Hu Q, Liu X, Wen C, et al. Remimazolam: an updated review of a new sedative and anaesthetic[J]. Drug Des Devel Ther, 2022, 16: 3957-3974. doi: 10.2147/DDDT.S384155

[8] Liu T, Lai T, Chen J, et al. Effect of remimazolam induction on hemodynamics in patients undergoing valve replacement surgery: a randomized, double-blind, controlled trial[J]. Pharmacol Res Perspect, 2021, 9(5): e00851. doi: 10.1002/prp2.851

[9] Doi M, Hirata N, Suzuki T, et al. Safety and efficacy of remimazolam in induction and maintenance of general anesthesia in high-risk surgical patients (ASA Class Ⅲ): results of a multicenter, randomized, double-blind, parallel-group comparative trial[J]. J Anesth, 2020, 34(4): 491-501. doi: 10.1007/s00540-020-02776-w

[10] Qiu Y, Gu W, Zhao M, et al. The hemodynamic stability of remimazolam compared with propofol in patients undergoing endoscopic submucosal dissection: a randomized trial[J]. Front Med, 2022, 9: 938940. doi: 10.3389/fmed.2022.938940

[11] Tang F, Yi J, Gong H, et al. Remimazolam benzenesulfonate anesthesia effectiveness in cardiac surgery patients under general anesthesia[J]. World J Clin Cases, 2021, 9(34): 10595-10603. doi: 10.12998/wjcc.v9.i34.10595

[12] Doi M, Morita K, Takeda J, et al. Efficacy and safety of remimazolam versus propofol for general anesthesia: a multicenter, single-blind, randomized, parallel-group, phase Ⅱb/Ⅲ trial[J]. J Anesth, 2020, 34(4): 543-553. doi: 10.1007/s00540-020-02788-6

[13] Chen L, Lu K, Luo T, et al. Observer's assessment of alertness/sedation-based titration reduces propofol consumption and incidence of hypotension during general anesthesia induction: a randomized controlled trial[J]. Sci Prog, 2021, 104(4): 368504211052354. doi: 10.1177/00368504211052354

[14] Nakasuji M, Nakasuji K. Causes of arterial hypotension during anesthetic induction with propofol investigated with perfusion index and ClearSightTM in young and elderly patients[J]. Minerva Anestesiol, 2021, 87(6): 640-647. doi: 10.23736/S0375-9393.21.15226-5

[15] Fernández-Candil JL, Terradas SP, Barriuso EV, et al. Predicting unconsciousness after propofol administration: qCON, BIS, and ALPHA band frequency power[J]. J Clin Monit Comput, 2021, 35(4): 723-729. doi: 10.1007/s10877-020-00528-5

[16] Shin HW, Kim HJ, Jang YK, et al. Monitoring of anesthetic depth and EEG band power using phase lag entropy during propofol anesthesia[J]. BMC Anesthesiol, 2020, 20(1): 49. doi: 10.1186/s12871-020-00964-5

[17] Dai G, Pei L, Duan F, et al. Safety and efficacy of remimazolam compared with propofol in induction of general anesthesia[J]. Minerva Anestesiol, 2021, 87(10): 1073-1079. doi: 10.23736/S0375-9393.21.15517-8

[18] Miyanishi M, Yaguramaki T, Maehara Y, et al. Three cases of difficulty in achieving definitive loss of consciousness with remimazolam[J]. JA Clin Rep, 2022, 8(1): 4. doi: 10.1186/s40981-021-00485-1

[19] Shirozu K, Nobukuni K, Tsumura S, et al. Neurological sedative indicators during general anesthesia with remimazolam[J]. J Anesth, 2022, 36(2): 194-200. doi: 10.1007/s00540-021-03030-7

[20] Feng SM, Liu J. Electrical velocimetry has limited accuracy and precision and moderate trending ability compared with transthoracic echocardiography for cardiac output measurement during cesarean delivery: a prospective observational study[J]. Medicine, 2020, 99(34): e21914. doi: 10.1097/MD.0000000000021914

[21] Moura TS, Rosa SA, Germano N, et al. The accuracy of PiCCO® in measuring cardiac output in patients under therapeutic hypothermia: comparison with transthoracic echocardiography[J]. Med Intensiva, 2018, 42(2): 92-98. doi: 10.1016/j.medin.2017.03.007

[22] Suehiro K, Tanaka K, Funao T, et al. Systemic vascular resistance has an impact on the reliability of the Vigileo-FloTrac system in measuring cardiac output and tracking cardiac output changes[J]. Br J Anaesth, 2013, 111(2): 170-177. doi: 10.1093/bja/aet022

[23] Biais M, Mazocky E, Stecken L, et al. Impact of systemic vascular resistance on the accuracy of the pulsioflex device[J]. Anesth Analg, 2017, 124(2): 487-493. doi: 10.1213/ANE.0000000000001591

[24] Fischer MO, Balaire X, Le Mauff De Kergal C, et al. The diagnostic accuracy of estimated continuous cardiac output compared with transthoracic echocardiography[J]. Can J Anaesth, 2014, 61(1): 19-26. doi: 10.1007/s12630-013-0055-z

[25] Royse CF, Haji DL, Faris JG, et al. Evaluation of the interpretative skills of participants of a limited transthoracic echocardiography training course (H.A.R.T.scan® course)[J]. Anaesth Intensive Care, 2012, 40(3): 498-504. doi: 10.1177/0310057X1204000316

[26] Seif D, Perera P, Mailhot T, et al. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol[J]. Crit Care Res Pract, 2012, 2012: 503254. doi: 10.1155/2012/503254

[27] Price ML, Millar B, Grounds M, et al. Changes in cardiac index and estimated systemic vascular resistance during induction of anaesthesia with thiopentone, methohexitone, propofol and etomidate[J]. Br J Anaesth, 1992, 69(2): 172-176. doi: 10.1093/bja/69.2.172

[28] Saugel B, Bebert EJ, Briesenick L, et al. Mechanisms contributing to hypotension after anesthetic induction with sufentanil, propofol, and rocuronium: a prospective observational study[J]. J Clin Monit Comput, 2022, 36(2): 341-347. doi: 10.1007/s10877-021-00653-9

[29] Couture P, Denault AY, Shi Y, et al. Effects of anesthetic induction in patients with diastolic dysfunction[J]. Can J Anaesth, 2009, 56(5): 357-365. doi: 10.1007/s12630-009-9068-z