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Remifentanil-propofol also has applications in pediatric deep sedation. In a ran­domized clinical trial, Seol etal. sedated 1–3-year-olds undergoing burn dressing changes with propofol (2 mg/kg) and either ketamine (1 mg/kg) or remifentanil (0.1μg/kg+0.5μg/kg/min infusion). The primary outcome was recovery time, as dened by achieving a Steward Recovery Score of 6. They found that remifentanil­propofol resulted in a signicantly shorter recovery time (10.3min versus 22.5min). There were no events of signicant hypotension or bradycardia during the proce­dures [27].

Remifentanil complements propofol with its strong analgesic effects. Haytural etal. compared the effects of propofol alone versus propofol in combination with either remifentanil or fentanyl for patients undergoing endoscopic retrograde chol­angiopancreatography. Ninety patients were divided into three groups. The rst group was given propofol (1.5mg/kg) loading dose followed by a 1mg/kg/h. infu­sion. The second group was loaded with remifentanil (0.05μg/kg) and propofol (1.5mg/kg) and given the same 1mg/kg/hr. infusion of propofol thereafter. The third group was loaded with fentanyl (1μg/kg) and propofol (1.5mg/kg) and given the same infusion of propofol as the other groups. In order to maintain sedation at between 3 and 4 on the Ramsey Sedation Scale, members of each group were given

While fast and effective, the major downside of a remifentanil-propofol anes­thetic technique is respiratory depression and potential desaturation. This is not uncommon for oral surgery procedures as a whole and can be attenuated by lower­ing infusion rates or administering smaller boluses [37]. These changes often take a minute or less to take effect. In a prospective study implementing a propofol­remifentanil target-controlled infusion (TCI) sedation technique for patients under­going dental extractions, Nagels etal. showed the number of oxygen-desaturation

Morimoto in his paper looked at remimazolam efcacy and safety for short pro­cedural sedation. He reviewed three clinical trials and specically noted that at the time of publication there were no clinical studies that evaluated remimazolam and short procedural sedations. In the rst trial reviewed, a phase Ib study [44], partici­pants undergoing a colonoscopy procedure were cohorted to remimazolam 0.04mg/ kg, 0.075mg/kg, or 0.1mg/kg bolus with each group receiving a standard 50μg of fentanyl. In all cohorts, >70% of the patients were well sedated and awake within 10min after administration. Additionally, there were no reports of adverse events. Morimoto looked at phase IIa study of patients undergoing upper endoscopy, com­paring remimazolam at three bolus doses of 0.1mg/kg, 0.15mg/kg, and 0.2mg/kg with a fourth arm of midazolam 0.075mg/kg. Each arm had 825 participants. The remimazolam groups had a shorter onset to sedation of 1.5–2.5min when compared to 5min for the midazolam group. Yet procedural success rates were only 32%, 56%, and 64%, respectively, for the remimazolam groups and 44% for the mid­azolam group. A third, phase III study evaluated patients undergoing a colonoscopy. The study enrolled 461 patients and had 3 arms: 5mg dose of remimazolam fol­lowed by an additional 2.5mg dose of remimazolam, placebo, and a single mid­azolam dose of 1.75mg. Successful endoscopy was performed in 91.3%, 1.7%, and

Newer anesthesia medications which provide innovative mechanisms of metabo­lism (remimazolam and remifentanil) and medications that function by targeting historically nontargeted receptors (Dexmedetomidine) have proven effective in pro­viding safe outpatient anesthesia. Esterase-metabolized anesthesia medications, specically remimazolam and remifentanil, provide a “fast on-fast off” anesthetic that allows for effective titration of medication and a shortened recovery time. Both are amicable attributes for outpatient sedation anesthesia.