McPhaden E, Tobias JD, Smith A. Clinical Experience With Remimazolam in Neuroanesthesiology and Neurocritical Care: An Educational Focused Review. J Clin Med Res. 2025 Mar;17(3):125-135. doi: 10.14740/jocmr6193. Epub 2025 Mar 10. PMID: 40115836; PMCID: PMC11922631.
Free full text access.
Abstract
Remimazolam is an ultrashort-acting benzodiazepine, approved for clinical use by the United States Food & Drug Administration in 2020. Similar to other benzodiazepines, its clinical effects of sedation, anxiolysis, and amnesia are mediated through the gamma-aminobutyric acid A (GABAA) receptor. A unique metabolic pathway via tissue esterases results in a rapid elimination, a limited context-sensitive half-life, and prompt dissipation of its effect when administration is discontinued. Preliminary clinical experience has demonstrated its efficacy in the adult and pediatric population as a primary agent for procedural sedation or as an adjunct to general anesthesia. Given its rapid onset and recovery, preliminary clinical experience has demonstrated its potential utility in neuroanesthesia including procedural sedation for neuroimaging as well as a primary agent and adjunct for general anesthesia during neurosurgical procedures including awake craniotomy. This narrative review outlines the pharmacological properties of this unique medication, reviews previous published reports of its role in neuroanesthesia and neurocritical care, and discusses dosing parameters and clinical use in this population.
Mendez D, Paul KK, O’Connell D, Michler O, Schultz H, Hill K, Jehle DV. Retrospective Study on Mortality and Adrenal Insufficiency Following Emergency Intubation With Etomidate Versus Ketamine in Children. Cureus. 2025 Feb 24;17(2):e79581. doi: 10.7759/cureus.79581. PMID: 40151734; PMCID: PMC11945125.
Free full text access.
Abstract
Background: Etomidate is a sedative-hypnotic used for intubation in children. Its use in airway management has been controversial since etomidate may induce adrenal insufficiency. Ketamine is frequently used for intubation in children and has not been reported to be associated with adrenal insufficiency. We evaluated the risk of death and adrenal suppression after rapid sequence intubation (RSI) with either etomidate or ketamine.
Methods: This retrospective study was performed using the TriNetX database in the United States from 61 healthcare organizations (HCOs). The final cohort after propensity matching included 1,191 patients who were ≤17 years of age and were given etomidate or ketamine for RSI but not both. The time frame was from December 22, 2003, to October 22, 2022.
Results: After propensity matching, the etomidate and ketamine groups each contained 565 patients, and there was a significantly lower risk of adrenal suppression with etomidate (1.8%) compared to ketamine (4.2%) (RR=0.43, 95% CI=0.21-0.90, p=0.02). There were similar results regarding adrenal insufficiency when no propensity matching was performed. There were no differences in mortality when comparing intubation with etomidate or ketamine with and without propensity matching.
Conclusion: There was not an increased risk of adrenal insufficiency for etomidate administered as a single dose in children undergoing RSI in the emergency department (ED) when compared with ketamine. Additionally, there was no difference in mortality for those intubated with ketamine or etomidate.
Cravero J, Brown ML. Database and registry research in pediatric anesthesiology. Curr Opin Anaesthesiol. 2025 Jun 1;38(3):217-221. doi: 10.1097/ACO.0000000000001502. Epub 2025 Apr 28. PMID: 40260597; PMCID: PMC12043254.
Free full text access.
Abstract
Purpose of the review: The collection and analysis of large amounts of data has revolutionized almost every aspect of our lives. In this review, we will explore several of the databases that are providing data on pediatric anesthesiology practice and the recent reports that have been published.
Recent findings: Studies from various multicenter databases provide information on outcomes from multiple aspects of pediatric anesthesia care provision. Large databases or registries include detailed information on individual anesthetic practice, airway management, regional anesthetic practice, adverse events, and cardiac anesthesia. These collaboratives are also providing information on health systems and benchmarking of effectiveness and efficiency of care.
Summary:For medical professionals, the ability to collect and learn from large datasets is not new but continues to evolve and improve as technology improves and the science of data analytics has been revolutionized. While the detail and accuracy of observational large data collaboratives may be limited, their ability to describe practice patterns, provide benchmarking for performance, and analyze outcome parameters has the potential to revolutionizing the practice of anesthesia in the future.
Lee JH, Ko HJ, Park JB, Ji SH, Kim JT. Oxygen Supplementation in Pediatric Sedation: Prospective, Multicenter, Randomized Controlled Trial. Anesthesiology. 2025 Jul 1;143(1):132-141. doi: 10.1097/ALN.0000000000005500. Epub 2025 Apr 11. PMID: 40215365; PMCID: PMC12147724.
Free full text access.
Abstract
Background: Children undergoing moderate to deep sedation for diagnostic and therapeutic procedures are susceptible to hypoxemia because of their anatomical and physiologic features. However, optimal oxygen administration methods are unclear. This study aimed to evaluate the efficacy of oxygen supplementation during sedation using either low-flow or high-flow nasal cannula.
Methods:This prospective, multicenter randomized controlled trial included children (younger than 18 yr) undergoing moderate to deep sedation. The participants were randomly assigned to three groups as follows: (1) control (no oxygen), (2) low-flow (2 to 6 l/min oxygen via nasal cannula), and (3) high-flow (oxygen administration via high-flow nasal cannula with a flow rate of 2 l/kg and 50% fraction of inspired oxygen). The primary outcome was hypoxemia incidence (saturation of peripheral oxygen, oxygen saturation measured by pulse oximetry 95% or less for more than 5 s). Secondary outcomes included oxygen saturation measured by pulse oximetry less than 90%, rescue interventions, and sedation-related complications. Between-group differences were compared using a logistic regression model.
Results:A total of 253 participants were randomized, with 250 completing the study. Hypoxemia occurred in 27.6% of participants in the control group, 7.2% in the low-flow group, and 1.2% in the high-flow group ( P < 0.001). The odds of hypoxemia in the low-flow and high-flow groups were lower than that in the control group (odds ratio [OR], 0.184; 95% CI, 0.067 to 0.503; P = 0.001 for low-flow; OR, 0.026; 95% CI, 0.003 to 0.207; P < 0.001 for high-flow). However, hypoxemia incidence of the high-flow group was not statistically lower than the low-flow group (OR, 0.143; 95% CI, 0.017 to 1.245; P = 0.078). Rescue interventions were conducted more frequently in the control group (52.9%) than in the low-flow (10.8%) and high-flow (3.6%) groups ( P < 0.001). Sedation-related complications such as desaturation and apnea were lower in the low-flow and high-flow groups than in the control group ( P < 0.001).
Conclusions:Routine oxygen supplementation prevents hypoxemia during pediatric moderate and deep sedation. Low-flow oxygen can be a reasonable choice as it effectively reduces hypoxemia while being more cost-effective and widely accessible than high-flow oxygen.
Trial registration: ClinicalTrials.gov NCT04852432.
Kannikeswaran N, Roback MG, Burger RK, Barrowman N, Sucha E, Bhatt M. Comparison of Procedural Sedation Outcomes in Children With and Without Autism Spectrum Disorder. Hosp Pediatr. 2025 May 1;15(5):398-406. doi: 10.1542/hpeds.2024-008153. PMID: 40233943.
Full text access for Children’s and Emory users.
Abstract
Objective: Children with autism spectrum disorder (ASD) often have comorbidities predisposing them to higher risk for sedation-related adverse events (AEs). Our objective was to compare sedation-related AEs in children with and without ASD.
Patients and methods:We conducted a multicenter study of children aged 3-18 years with and without ASD who underwent sedation outside the operating room from May 1, 2022, to April 30, 2023, using the Pediatric Sedation Research Consortium database. The primary exposure was ASD diagnosis. We compared AEs in children with and without ASD after matching for age, sex, procedure, and American Society of Anesthesiologists classification.
Results: Of 64 708 children analyzed, 4421 (6.8%) had an ASD diagnosis. A higher proportion of children with ASD were male (75.4% vs 54.7%), obese (6.0% vs 2.9%), and had a comorbid condition (93.5% vs 40.3%). Matched analysis showed no significant difference in critical AEs (odds ratio [OR], 0.63; 95% CI, 0.23-1.49). However, children with ASD had greater odds of high risk (OR, 1.52; 95% CI, 1.26-1.83) and low-risk AEs (OR, 1.39; 95% CI, 1.25-1.55) compared with children without ASD. Specifically, children with ASD had greater odds of hypoxia (OR, 1.31; 95% CI, 1.10-1.56) and complete (OR, 1.89; 95% CI, 1.27-2.81) or partial (OR, 1.43; 95% CI, 1.25-1.63) airway obstruction.
Conclusions: Children with ASD are at a higher risk for sedation-related airway AEs and significant respiratory interventions, although the incidence of critical AEs was low.
pedzzzz.com 
Leave a comment