For this last podcast of the year, I had a couple of pieces that were going to become Wees, but I thought I would combine them for synergistic goodness and make this end-of-year podcast. Today, we speak about some tips from a EM Surgical Intensivist and discussion of a brand new sedative, Remimazolam.
Surgical Critical Care Tips with Joe Shiber
Joseph R. Shiber M.D. is a Professor & Co-Medical Director of the Intensive Care Unit at Univ. Florida Health North.
Don't Perform Unnecessary Large Volume Paracentesis
How to do a tube exchange when you are on your own
Consider the Pit-Double for Access and Monitoring
Raise the Pacemaker Heart Rate in Patients with Shock
Joe's Books
Remimazolam with Sean Rees
Sean M. Rees, MD, FACEP, FAAEM is Director of Emergency Medicine, Director of Trauma, Medical Director of Infection Control, Medical Director Pharmacy and Therapeutics, Medical Director of SANE/DV Programs at the Steele Memorial Medical Center.
Remimazolam
A more rapidly and consistently metabolized variant of midazolam, converted into ineffective form by tissue esterases.
Dosing: 5 mg IVP, Top-Up dosing 2.5 mg (consider initial dose reduction in the elderly)
Duration of Relevant Clinical Action: 6-10 minutes for moderate/deep sedation
Side-Effects: Standard benzo as well as myoclonus
Cost: 20 mg vial of Remimazolam is $42 vs. 20 ml vial of propofol at $9-13 or 50 mg vial of midazolam at $12-15
Reversal: Can be reversed with flumazenil
- Guo, Jian, Yitao Qian, Xiaojin Zhang, Shuangjian Han, Qinye Shi, and Jianhong Xu. “Remimazolam Tosilate Compared with Propofol for Gastrointestinal Endoscopy in Elderly Patients: A Prospective, Randomized and Controlled Study.” BMC Anesthesiology 22, no. 1 (June 10, 2022): 180. https://doi.org/10.1186/s12871-022-01713-6.
- Kim, Seong-Hyop, and Jörg Fechner. “Remimazolam – Current Knowledge on a New Intravenous Benzodiazepine Anesthetic Agent.” Korean Journal of Anesthesiology 75, no. 4 (August 2022): 307–15. https://doi.org/10.4097/kja.22297.
- Noor, Nazir, Rhorer Legendre, Alexandra Cloutet, Ahish Chitneni, Giustino Varrassi, and Alan D. Kaye. “A Comprehensive Review of Remimazolam for Sedation.” Health Psychology Research 9, no. 1 (n.d.): 24514. https://doi.org/10.52965/001c.24514.
- Rex, Douglas K., Raj Bhandari, Daniel G. Lorch, Michael Meyers, Frank Schippers, and David Bernstein. “Safety and Efficacy of Remimazolam in High Risk Colonoscopy: A Randomized Trial.” Digestive and Liver Disease 53, no. 1 (January 1, 2021): 94–101. https://doi.org/10.1016/j.dld.2020.10.039.
- Sneyd, J. Robert, and Ann E. Rigby-Jones. “Remimazolam for Anaesthesia or Sedation.” Current Opinion in Anaesthesiology 33, no. 4 (August 2020): 506–11. https://doi.org/10.1097/ACO.0000000000000877.
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Pastis, Nicholas J., Lonny B. Yarmus, Frank Schippers, Randall Ostroff, Alexander Chen, Jason Akulian, Momen Wahidi, et al. “Safety and Efficacy of Remimazolam Compared With Placebo and Midazolam for Moderate Sedation During Bronchoscopy.” Chest 155, no. 1 (January 1, 2019): 137–46. https://doi.org/10.1016/j.chest.2018.09.015.
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White, Paul F. “Remimazolam – Can It Become a Cost-Effective Alternative to Propofol for Intravenous Anesthesia and Sedation?” Journal of Clinical Anesthesia 84 (February 2023): 110977. https://doi.org/10.1016/j.jclinane.2022.110977.
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this episode was interesting. are there articles or resources that document the harm from large volume paracentesis or is just logic or presumption? if there are resources can you share them?
I think this is just Joe’s experience–have not seen any supporting literature for good or bad. It is definitive that they quickly reaccumulate in refractory ascites unless other steps are taken.
I found references for harms of large volume paracentesis. Ive always known about hypotension and the need for albumin over a certain volume taken. But did not know about the tendency to accumulate more fluid and the fact that the fluid has lots of ?albumin/protein and other essential factors. he mentioned going up to 300 mg of aldactone. what do you start at and how often to increase the dose?
It seems like this would make sense. An US guided subclavian is basically the axillary vein. So it seems like you move a few cm lower in the axillary vein at the level of entry for the axillary art line. Basically and arm pit “dirty double”. I don wonder if there is a higher rate of DVT with this approach as the outer lumen of the central line, mould take up a greater percentage of the more distal (im assuming smaller) ax vein. Can’t find much evidence on this
Do you have any pictures demonstrating the location of cannulation for this double setup axillary? What kind of a- line catheters would you use at this location (and for femoral)?. We only have radial lines and PICCO lines at my place.
it is in the armpit use 20 cm triple lumen and femoral aline kit
Any data RE the axillary CVL? Love the art lines but have gotten pushback from some attendings on putting CVL there. Loved the point RE paras.
this episode was fascinating. are there articles or assets that report the damage from huge volume paracentesis or is it just rationale or assumption? on the off chance that there are assets might you at any point share them?