Effectiveness of high dose remifentanil in preventing coughing and laryngospasm in non-paralyzed patients for advanced bronchoscopic procedures

Anesthesia for bronchoscopy presents unique challenges, as constant stimulus due to bronchoscope needs to be obtunded using drugs with a minimal post-procedure residual effect. Remifentanil for maintenance is an ideal choice, but optimal doses are yet to be determined. Bronchoscopic procedures were prospectively evaluated for 4 months studying the frequency of complications and anesthesia techniques. Anesthesia was maintained on remifentanil/propofol infusion avoiding neuromuscular blockers. Laryngeal mask airway was used for the controlled ventilation [with high oxygen concentration] that also served as a conduit for bronchoscope insertions. Anesthesiologists were blinded to the study [avoiding performance bias] and the Pulmonologist was blinded to the anesthesia technique [to document unbiased procedural satisfaction scores]. Procedures were divided into 2 groups based on the dose of remifentanil used for maintenance: Group-H [high dose -0.26 to 0.5 micro g/kg/min and Group-NH [non-high dose <0.25 micro,g/kg/min]. Observed 75 procedures were divided into Group-H [42] and Group-NH [33]. Number of statistical difference was found in demography, procedural profile, hemodynamic parameters and total phenylephrine used. Chi-square test showed Group-NH had significantly higher frequency of laryngospasm [P= 0.047] and coughing [F= 0.002]. The likelihood ratio of patient coughing and developing laryngospasm in Group-NH was found to be 4.56 and 10.97 times respectively. Minimum pulse-oximeter saturation was statistically higher in Group-H [98.80% vs. 96.50% P= 0.009]. Pulmonologist satisfaction scores were significantly better in Group-H. High dose of remifentanil infusion is associated with a lower incidence of coughing and laryngospasms during bronchoscopy. Simultaneously, it improves Pulmonologist's satisfaction and procedural conditions

Propofol alternatives in gastrointestinal endoscopy anesthesia

Although propofol has been the backbone for sedation in gastrointestinal endoscopy, both anesthesiologists and endoscopists are faced with situations where an alternative is needed. Recent national shortages forced many physicians to explore these options. A midazolam and fentanyl combination is the mainstay in this area. However, there are other options. The aim of this review is to explore these options. The future would be, invariably, to move away from propofol. The reason is not in any way related to the drawbacks of propofol as a sedative. The mandate that requires an anesthesia provider to administer propofol has been a setback in many countries. New sedative drugs like Remimazolam might fill this void in the future. In the meantime, it is important to keep an open eye to the existing alternatives

Remimazolam: the future of its sedative potential

Remimazolam [CNS 7056] is a new drug innovation in anesthesia. It combines the properties of two unique drugs already established in anesthesia - Midazolam and remifentanil. It acts on GABA receptors like midazolam and has organ-independent metabolism like remifentanil. It is likely to be the sedative of the future, as preliminary phase II trials have shown minimal residual effects on prolonged infusions. It has potential to be used as a sedative in ICU and as a novel agent for procedural sedation. Unlike most rapidly acting intravenous sedatives available presently, the propensity to cause apnea is very low. Availability of a specific antagonist [flumazenil] adds to its safety even in cases of overdose. The present review discusses remimazolam's potential as a new drug in anesthesia along with the presently available literary evidence

Goudra ventilating bite block to reduce hypoxemia during endoscopic retrograde cholangiopancreatography

We describe the airway management of a patient presenting for ERCP with a bite block that allows positive pressure ventilation.