Remimazolam vs Propofol

[Ronin786]

https://bmcanesthesiol.biomedcentral.com/track/pdf/10.1186/s12871-022-01713-6.pdf

Interesting trial. In my opinion, as long as respiratory depression is not 0, you still need an anesthesiologist administering. Could be a useful drug, but the lack of time difference when compared to propofol means it'll just be an expensive analogue.

Data from 77 patients were analysed. The success rate of sedation in both groups was 100%. The time
to LOC (MOAA/S score ≤ 1) in the RT group was longer than that in the propofol group (20.7 ± 6.1s vs. 13.2 ± 5.2s,
P < 0.001). There were fewer patients in the RT group reporting injection pain than that in the propofol group (0/39 vs. 5/38, P = 0.025). Haemodynamic events and respiratory depression in the RT group were less frequent than those in the propofol group ((6/39 vs. 17/38, P = 0.005), (2/39 vs. 9/38, P = 0.026), respectively). The number of supplemen- tal doses after successful induction in the RT group was greater than that in the propofol group (4/9/11/13/1/1 vs. 8/4/18/6/2/0 requiring 0, 1, 2, 3, 4 or 5 supplemental doses, P = 0.014). The characteristics of the patients enrolled,postoperative parameters of the patients, and patients’ and physician’s satisfaction of the procedure were comparable in the two groups.

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[Beeftenderloin]

Significantly less hemodynamic events and respiratory depression with similar sedating effect. Great. I look forward to using it in about 17 years when it’s available as a generic.

 

[drmwvr]

Significantly less hemodynamic events and respiratory depression with similar sedating effect. Great. I look forward to using it in about 17 years when it’s available as a generic.

But think of the awesome rep provided food....

 

[nimbus]

Interesting both groups got alfenta. Why?

 

[pgg]

Interesting both groups got alfenta. Why?

In the last year, I've seen a vial of alfentanil exactly as many times as I've seen a vial of remimazolam ... zero. I'm not even sure if either are on formulary here.

 

[jwk]

In the last year, I've seen a vial of alfentanil exactly as many times as I've seen a vial of remimazolam ... zero. I'm not even sure if either are on formulary here.

I'm not sure we even have it on formulary. I've never seen it - and haven't seen a rep either.

We barely use remifentanil either - and the use is restricted to a specific surgeon's cases because he demands it. I haven't used it in more than 25 years. I just don't see a place for it in our practice.

 

[Hork Bajir]

Had a patient recently for ECT who despite all the usual measures was not having good seizures. Suggested adding alfentanil next time (we do have it on formulary)- pharmacy is going to start stocking it in our ECT Pyxis, we’ll see how it goes.

Personally, I find remi and alfenta are useful for a few very specific indications. For example, I will bolus either one for retrobulbar blocks for example. Remi is also nice for cases that are short, very stimulating during the surgery, cannot paralyze the patient, need a fast wake up with a quick neuro exam, and have very little postop pain… Thyroids, rigid bronch, and carotids come to mind (although in the age of sugammadex all of the above have gotten easier). Of course there are other ways to do those cases, but I think using remi and alfenta in that context is a sensible approach. Don’t get me started on the people who run high-dose remi as part of TIVA for all day long spines and cranis…

 

[nimbus]

Had a patient recently for ECT who despite all the usual measures was not having good seizures. Suggested adding alfentanil next time (we do have it on formulary)- pharmacy is going to start stocking it in our ECT Pyxis, we’ll see how it goes.

Personally, I find remi and alfenta are useful for a few very specific indications. For example, I will bolus either one for retrobulbar blocks for example. Remi is also nice for cases that are short, very stimulating during the surgery, cannot paralyze the patient, need a fast wake up with a quick neuro exam, and have very little postop pain… Thyroids, rigid bronch, and carotids come to mind (although in the age of sugammadex all of the above have gotten easier). Of course there are other ways to do those cases, but I think using remi and alfenta in that context is a sensible approach. Don’t get me started on the people who run high-dose remi as part of TIVA for all day long spines and cranis…

Very reasonable. But do you use either of those for EGDs or colonoscopies? I just use propofol.

 

[anbuitachi]

But think of the awesome rep provided food....

reps not allowed to provide food here.. =(

 

[anbuitachi]

Had a patient recently for ECT who despite all the usual measures was not having good seizures. Suggested adding alfentanil next time (we do have it on formulary)- pharmacy is going to start stocking it in our ECT Pyxis, we’ll see how it goes.

Personally, I find remi and alfenta are useful for a few very specific indications. For example, I will bolus either one for retrobulbar blocks for example. Remi is also nice for cases that are short, very stimulating during the surgery, cannot paralyze the patient, need a fast wake up with a quick neuro exam, and have very little postop pain… Thyroids, rigid bronch, and carotids come to mind (although in the age of sugammadex all of the above have gotten easier). Of course there are other ways to do those cases, but I think using remi and alfenta in that context is a sensible approach. Don’t get me started on the people who run high-dose remi as part of TIVA for all day long spines and cranis…

remi for long spines and cranis work really well. i dont use it for patients already in a lot of pain preop though. they do fine in pacu too
we used alfentanil when remi was short supply for ent cases and stuff. not a huge fan

 

[Volatile]

Had a patient recently for ECT who despite all the usual measures was not having good seizures. Suggested adding alfentanil next time (we do have it on formulary)- pharmacy is going to start stocking it in our ECT Pyxis, we’ll see how it goes.

Personally, I find remi and alfenta are useful for a few very specific indications. For example, I will bolus either one for retrobulbar blocks for example. Remi is also nice for cases that are short, very stimulating during the surgery, cannot paralyze the patient, need a fast wake up with a quick neuro exam, and have very little postop pain… Thyroids, rigid bronch, and carotids come to mind (although in the age of sugammadex all of the above have gotten easier). Of course there are other ways to do those cases, but I think using remi and alfenta in that context is a sensible approach. Don’t get me started on the people who run high-dose remi as part of TIVA for all day long spines and cranis…

I’ve done so much locums work and still have never come across a hospital that does retrobulbar blocks.

 

[Hork Bajir]

I’ve done so much locums work and still have never come across a hospital that does retrobulbar blocks.

Some of the ophthalmologists I work with do them with some regularity for the oculoplastics stuff, certain retinal cases, etc. Others do sub tenon which is less painful if done after topical drops. One even does them occasionally for cataracts (she also takes 45 minutes to do a cataract, sooooo maybe not the best example to follow)

 

[DrOwnage]

No offense but I would never use remifentanil for peribulbars or retrobulbars... I do a lot of peri and retros for cataracts (not sure why). All the patients are 75-90 years old, the chance for apnea is too high. All they need is between 30-50 of prop, 10-15 of ketamine, +/- 25 mcg fent when the enter the room. Waiting a decent amount of time before the surgeon stabs them is key.

 

[Hork Bajir]

No offense but I would never use remifentanil for peribulbars or retrobulbars... I do a lot of peri and retros for cataracts (not sure why). All the patients are 75-90 years old, the chance for apnea is too high. All they need is between 30-50 of prop, 10-15 of ketamine, +/- 25 mcg fent when the enter the room. Waiting a decent amount of time before the surgeon stabs them is key.

No offense taken. Many ways to skin a cat. To your point, they sometimes do go apneic for a second- then start breathing again when they stab the eye. Knock on wood, haven’t had to do more than a temporary jaw thrust to get someone breathing again (so far anyway). I don’t use very high doses, either. Essentially just using alfenta instead of fent as you suggested above

 

[GassYous]

No offense but I would never use remifentanil for peribulbars or retrobulbars... I do a lot of peri and retros for cataracts (not sure why). All the patients are 75-90 years old, the chance for apnea is too high. All they need is between 30-50 of prop, 10-15 of ketamine, +/- 25 mcg fent when the enter the room. Waiting a decent amount of time before the surgeon stabs them is key.

Why do you need ketamine and fentanyl if you have prop and a block

 

[Beeftenderloin]

Why do you need ketamine and fentanyl if you have prop and a block

This. We had one ophtho in residency that did retrobulbar blocks for everything, even straight forward cataracts. Little bit of prop for the block, typically nothing after that. Occasionally someone got squirrelly and you give ‘em another little bump or two, but that was rare. No reason to deal with the headache of pulling/wasting narcs for these cases.

 

[2Fast2Des]

Why do you need ketamine and fentanyl if you have prop and a block

Multimodal eras duh! Why keep a small thing simple 😂

 

[epidural man]

In the last year, I've seen a vial of alfentanil exactly as many times as I've seen a vial of remimazolam ... zero. I'm not even sure if either are on formulary here.

Propofol mixed with Alfentanil …wonderful anesthetic.

Try it…and see what you think. I bet you’ll like it.

2000mcg/100ml of propofol.

I’ve sometimes had to mix 3000 (and one time 4000) in the 100ml bottle - but 2000 seems the perfect mix.

The context sensitive 1/2 life is perfect for this. After the propofol wears off, the alfenta hangs around just a bit longer for a very comfortable and happy patient.

 

[pgg]

Propofol mixed with Alfentanil …wonderful anesthetic.

Try it…and see what you think. I bet you’ll like it.

2000mcg/100ml of propofol.

I’ve sometimes had to mix 3000 (and one time 4000) in the 100ml bottle - but 2000 seems the perfect mix.

The context sensitive 1/2 life is perfect for this. After the propofol wears off, the alfenta hangs around just a bit longer for a very comfortable and happy patient.

View attachment 356440

I used to use alfentanil with propofol for very short very stimulating procedures, like stunning people for 2 minutes while one particular ophthalmologist did his retrobulbar blocks, or closed reductions.

I don't think there's any must-have use case for it, but it's nice for some stuff.

As for doing a TIVA with it and propofol - I have some reservations about infusing potent synthetic opioids like remi/alf/suf just for the hell of it because opioid induced hyperalgesia is a thing. I put up with them for neuro cases where I want an off switch for an early lucid exam afterwards but that's about it.

 

[narcusprince]

The ghost of Walter Maurer here. We used prop alfenta where I trained. It has utility in asc procedures that require LMA use.

 

[nimbus]

In residency we often used propofol/alfenta for induction and intubation because it was the pet project of 2 of our faculty. I much prefer roc. They eventually abandoned it too.

 

[DrOwnage]

Why do you need ketamine and fentanyl if you have prop and a block

For immobility and them not to squeeze and get a hematoma. If you just use prop you have to use much more for them to not squeeze, risk for apnea is higher. Multimodal anesthesia. I use a little bit of ketamine for all my cataracts and it works wonderfully.

 

[epidural man]

For immobility and them not to squeeze and get a hematoma. If you just use prop you have to use much more for them to not squeeze, risk for apnea is higher. Multimodal anesthesia. I use a little bit of ketamine for all my cataracts and it works wonderfully.

Dose?

 

[jwk]

For immobility and them not to squeeze and get a hematoma. If you just use prop you have to use much more for them to not squeeze, risk for apnea is higher. Multimodal anesthesia. I use a little bit of ketamine for all my cataracts and it works wonderfully.

We have two eye docs out of about 50 that do RBB/PBB for their cataracts. We used to do them and decided the potential risk simply wasn't worth it. We give pts maybe 30 of propofol while they do the block. Nothing else. For our topical cataracts, our surgeons still want us there, so patients get midaz 1-2mg.

 

[OTCAwesome]

We have two eye docs out of about 50 that do RBB/PBB for their cataracts. We used to do them and decided the potential risk simply wasn't worth it. We give pts maybe 30 of propofol while they do the block. Nothing else. For our topical cataracts, our surgeons still want us there, so patients get midaz 1-2mg.

same here