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Citation: Choi, S.; Lee, G.; Jung, J.;
Lee, T.; Park, S. Monitored
Anesthesia Care Using Remimazolam
and Ketamine Combination for Brief
Gynecological Surgeries: A Report
for Four Cases. J. Clin. Med. 2023,12,
3558. https://doi.org/10.3390/
jcm12103558
Academic Editor: Stefan U. Weber
Received: 19 April 2023
Revised: 9 May 2023
Accepted: 17 May 2023
Published: 19 May 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Journal of
Clinical Medicine
Case Report
Monitored Anesthesia Care Using Remimazolam and Ketamine
Combination for Brief Gynecological Surgeries: A Report for
Four Cases
Soron Choi, Ganghyun Lee, Jiwook Jung, Taeyoung Lee and Sangyoong Park *
Department of Anesthesiology and Pain Medicine, Dong-A University College of Medicine,
Busan 49201, Republic of Korea
; choisr@dau.ac.kr (S.C.); gangnuyh@naver.com (G.L.); wnr2749@gmail.com (J.J.);
eggrobo1024@gmail.com (T.L.)
*Correspondence: parksy@dau.ac.kr; Tel.: +82-10-8591-2484
Abstract:
Remimazolam is a benzodiazepine with rapid onset and recovery time. Ketamine provides
analgesia and sedation without compromising hemodynamics. Combining both agents may provide
good anesthesia and analgesia with fewer complications. We report four cases of monitored anesthesia
care with a combination of remimazolam and ketamine for brief gynecological surgeries. We applied
0.5 mg/kg bolus ketamine and infused patients with remimazolam at 6 mg/kg/h for induction and
1 mg/kg/h for maintenance. Then, 25
µ
g of fentanyl was administered for analgesia 4 min before the
procedure, and additional fentanyl was administered as needed. Remimazolam was discontinued
shortly after surgery. We conducted satisfactory monitored anesthesia care with a combination of
remimazolam and ketamine in all four cases.
Keywords:
anesthesia and analgesia; gynecologic surgical procedures; ketamine; monitored anesthesia
care; remimazolam
1. Introduction
Remimazolam is a promising ultra-short-acting benzodiazepine with a more rapid
onset of action and shorter maintenance and recovery time than midazolam, and has been
frequently chosen for procedural sedation [
1
,
2
]. However, hemodynamic compromises,
including hypotension and bradycardia, which require vasopressors and treatment, were
also found when using remimazolam; although, they occurred much less often than with
propofol [
3
]. Brief procedures performed in gynecology, such as hysteroscopic dilata-
tion/curettage/biopsy (DCB) and conization, can cause significant pain and discomfort to
the patients. Therefore, additional opioids for analgesia may need to be combined with
remimazolam to prevent body movement from interfering with the procedure and patient
satisfaction.
Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, provides dissocia-
tive anesthesia and analgesia with rare respiratory depression [
4
,
5
]. Ketamine stimulates
the sympathetic nervous system, leading to tachycardia and increased blood pressure.
Administering small doses of ketamine perioperatively can reduce opioid requirements [
6
].
However, its disadvantages include emergence symptoms such as agitation, hallucinations,
and delirium [
4
]. Therefore, ketamine is often co-administered with benzodiazepines to
reduce the incidence of emergence phenomena [7].
Therefore, combining remimazolam and ketamine (“kemimazolam”) may theoretically
have the advantages of both drugs, compensate for each other’s disadvantages, and provide
satisfactory anesthesia and analgesia. No study has previously used remimazolam and
ketamine for monitored anesthesia care for gynecologic surgical procedures. Therefore, we
present four cases of kemimazolam anesthesia for simple gynecological surgeries.
J. Clin. Med. 2023,12, 3558. https://doi.org/10.3390/jcm12103558 https://www.mdpi.com/journal/jcm
J. Clin. Med. 2023,12, 3558 2 of 6
2. Case Descriptions
2.1. Case 1
A 27-year-old woman (weight, 59 kg; height, 160 cm) who visited our hospital with
atypical uterine bleeding and a high probability of endometrial hyperplasia was scheduled
to undergo hysteroscopic DCB in the operating room under monitored anesthesia care. She
had no underlying diseases, and her physical status was classified as I according to the
American Society of Anesthesiologists (ASA) classification. Preoperative risk evaluation
was performed before surgery, including laboratory examination, chest radiography, and
electrocardiography. After providing a sufficient explanation of the study and the potential
side effects of the drugs to the patient, we obtained written informed consent.
On the day of the surgery, an 18-gauge intravenous catheter was inserted peripher-
ally. Intramuscular glycopyrrolate (0.2 mg) was administered 30 min before entering the
operating room to blunt the hypersalivation. Noninvasive monitoring of blood pressure
(BP), heart rate (HR), respiration rate (RR), saturation of percutaneous oxygen (SpO2),
and bispectral index (BIS) was performed after entering the operating room. Her initial
vital signs were stable (BP, 121/72 mmHg; HR, 69 beats/min; RR, 19 breaths/min, SpO2
100%). Vital signs were monitored continuously, and BP was monitored every 5 min and
additionally as needed. Supplemental oxygen was started shortly before the induction at
a rate of 5 L/min via a non-rebreathing face mask. Then, 0.5 mg/kg bolus ketamine was
applied, and 6 mg/kg/h remimazolam (Byfavo; Hana Pharm CO., Ltd., Seoul, Republic
of Korea) was infused continuously until the patient’s modified observer assessment of
alertness/sedation (MOAA/S) score decreased to <3. The patient reported no injection
pain for either drug.
The target level of sedation was checked every 10 s. After 20 s, the patient’s MOAA/S
score had reached 2, and the BIS value had decreased to 78. Remimazolam was infused at
1 mg/kg/h for targeting BIS values between 60 and 80 and maintaining the target level of
sedation. The remimazolam administration rate was adjusted by 0.2 mg/kg/h only when a
BIS score exceeding 80 and a MOAA/S score exceeding 2 are both satisfied, or the BIS score
is less than 60 and the MOAA/S score is 0 when the BIS score is out of the target range.
The patient’s vital signs were stable after induction, and no other adverse events occurred.
We administered 25
µ
g of bolus fentanyl after the induction to prevent body movement in
the patient during cervical dilatation at the beginning of the surgery. Then, an additional
25
µ
g of fentanyl was given if any signs of insufficient analgesia, such as grimace, body
movement, tachycardia (HR > 100 beats/min), or a sudden rise in systolic BP (> 140 mmHg
or 20% over baseline), were present. We requested the gynecologist to start the surgery
4 min after the first administration of fentanyl. The procedure began 5 min after induction,
and an adduction motion in the lower extremities was observed, and the HR increased
to 105 beats/min. An additional 25
µ
g fentanyl was administered immediately after the
patient’s body movement. Then, 8 min after induction, grimace and body movement were
observed again, and an additional 25
µ
g of fentanyl was administered. The surgery ended
15 min after the induction, and remimazolam was discontinued shortly after the end of the
surgery. In total, 19.6 mg of remimazolam was administered.
Vital signs were stable throughout the procedure, and any other adverse events,
including hypotension, bradycardia, and respiratory depression, were not observed. The
MOAA/S score was below three throughout the procedure, and the range of BIS values
was 72–78. Her MOAA/S score increased gradually after discontinuing the remimazolam
infusion. The patient responded lethargically to verbal commands (MOAA/S score 4)
and voluntarily moved all extremities 4 min after remimazolam discontinuation. She was
discharged from the recovery room 14 min after the end of the surgery when she was fully
awake, and her modified Aldrete score reached 10. There were no adverse events, including
agitation, delirium, bradycardia, hypotension, or respiratory depression. The patient was
totally amnestic and did not report any unsatisfactory symptoms, such as nausea/vomiting,
vivid dreams, or memory of pain during and after the procedure.
J. Clin. Med. 2023,12, 3558 3 of 6
2.2. Case 2
A 41-year-old woman (weight, 51 kg; height, 163 cm) was diagnosed with submucosal
myoma (1.2 cm). Monitored anesthesia care was planned for a resectoscopic myomectomy.
Her ASA score was I, and there were no abnormal findings in the preoperative evaluation.
Written informed consent was obtained. Then, intramuscular glycopyrrolate (0.2 mg)
was injected 30 min before entering the operating room. Her initial vital signs were BP
105/55 mmHg, HR 86 beat/min, RR 23 breaths/min, and SpO2 99%. Supplemental oxygen
was administered before induction. Then 40 s after starting kemimazolam administration,
the patient’s MOAA/S score decreased to 2, and the BIS value reached 75. Injection pain
was not observed. In addition, 25
µ
g of fentanyl was administered 4 min before the
procedure.
At the beginning of the surgery, there was no body movement, grimace, or change in
any vital signs. Then, 6 min into the surgery, the patient’s BIS score increased from 75 to
82, MOAA/S score increased to 3, and body movement of the upper extremity and facial
grimace were observed. An additional 25
µ
g of fentanyl was administered immediately
after movement, and the infusion rate of remimazolam was adjusted to 1.2 mg/kg/h.
Afterward, the range of vital signs remained stable, with no rise or fall in BP beyond 20%,
such as the BIS value (range 75 to 78). In total, 21.4 mg of remimazolam was administered
for 20 min until the end of the surgery. Then, 5 min after the end of the surgery, her
MOAA/S score increased to four, and she was transferred to the recovery room. No
adverse events occurred, including emergence agitation, and the patient did not complain
of pain or other side effects. The patient was fully awake and cooperative (modified
Aldrete score 10) 11 min after discontinuing remimazolam and was discharged from the
recovery room.
2.3. Case 3
A 54-year-old woman (weight, 54 kg; height, 153 cm) was scheduled to undergo
conization for grade III cervical intraepithelial neoplasia. Her ASA score was II, as she was
diagnosed with hypothyroidism. After obtaining written informed consent, we adminis-
tered 0.2 mg glycopyrrolate intramuscularly. The patient’s initial vital signs were taken
(BP 116/70 mmHg, HR 74 beats/min, RR 19 breaths/min, SpO2 100%). Supplemental
oxygen was started, and it took 70 s for the patient to reach a MOAA/S score of two after
kemimazolam induction. Her vital signs were stable, and her BIS score decreased to 74.
Afterward, 25
µ
g of fentanyl was administered, and 1 min later, the patient showed
transient apnea, and oxygen saturation was reduced to 98%. Her breath was shortly
resolved using jaw thrust and chin lift, and her respiratory rate recovered. There was no
hypoxia (oxygen saturation <90%) and no requirement for masks or mechanical ventilation.
Her BIS values ranged from 67 to 74, and there was no body movement throughout
the procedure. The procedure ended 9 min after kemimazolam induction, and 14.6 mg
of remimazolam was infused overall. Then, 6 min after discontinuation, the patient’s
MOAA/S score increased to four, and she was transferred to the recovery room. She was
discharged 5 min after entering the recovery room. She was completely amnestic and
reported no side effects, including vivid dreams, nausea/vomiting, or pain.
2.4. Case 4
A 74-year-old woman (weight, 81 kg; height, 152 cm) with a suspected endometrial
polyp was scheduled to undergo hysteroscopic endometrial polypectomy. She was pre-
viously diagnosed with stable angina, diabetes mellitus, and hypertension, and her ASA
score was II. Written informed consent was obtained, and intramuscular glycopyrrolate
(0.2 mg) was injected 30 min before the surgery. Her initial vital signs were as follows: BP,
180/69 mmHg; HR, 84 beats/min; RR, 20 breaths/min; and SpO2, 99%. Supplemental
oxygen was administered before the induction of kemimazolam; 50 s after the bolus ke-
tamine was applied and remimazolam was infused 6 mg/kg/h, the patient’s MOAA/S
J. Clin. Med. 2023,12, 3558 4 of 6
score reached 2, and the BIS value fell to 72. Shortly after, remimazolam was administered
at 1 mg/kg/h for maintenance.
The vital signs at the time were as follows: BP, 165/52 mmHg; HR, 83 beats/min;
RR, 20 breaths/min; and SpO2, 100%. Then, 25
µ
g of fentanyl was administered 4 min
before the procedure, and the procedure commenced 8 min after induction. Her BP did
not deviate beyond 20% from baseline, and other vital signs remained stable during the
procedure. Her BIS values ranged from 68 to 75, and the MOAA/S score was below
3 throughout the surgery. No adverse events occurred until the end of the surgery, and
remimazolam was discontinued. The surgery ended 31 min after induction, and a total
of 48 mg remimazolam was injected. The MOAA/S score of the patient reached four
after 8 min since remimazolam discontinuation. She did not remember anything about
the procedure and reported a satisfactory experience. The modified Aldrete score of the
patient met the discharge criteria 12 min after discontinuation, and no adverse events were
observed until the patient left the recovery room.
3. Discussion
We conducted satisfactory monitored anesthesia care with kemimazolam in all four
cases, and the timeline table and graph are presented below (Figure 1). A previous study
compared remimazolam with propofol and infused remimazolam at a dose of 6 mg/kg/h
for induction of general anesthesia [
3
]. The mean time to loss of consciousness (LOC) was
102.0 s, and the mean dose to LOC was 0.17 mg/kg. The mean time to LOC of propofol
was 78.7 s. The mean time from the end of the study period to regaining consciousness was
14.9 min. The mean time to LOC in our study was 45 s (20, 40, 70, and 50 s each), and the
mean dose to LOC was 0.075 mg/kg (0.033, 0.067, 0.117, and 0.083 mg/kg, respectively),
which was even faster than propofol infusion. The mean time from remimazolam discon-
tinuation to reaching a MOAA/S score of four was 5.75 min (4, 5, 6, and 8 min each) in
our study. Kemimazolam led to a faster LOC than did remimazolam alone or propofol.
The combination did not prolong sedation time, and it lowered the total induction dose of
remimazolam.
J.Clin.Med.2023,12,xFORPEERREVIEW4of6
reached2,andtheBISvaluefellto72.Shortlyafter,remimazolamwasadministeredat1
mg/kg/hformaintenance.
Thevitalsignsatthetimewereasfollows:BP,165/52mmHg;HR,83beats/min;RR,
20breaths/min;andSpO2,100%.Then,25µgoffentanylwasadministered4minbefore
theprocedure,andtheprocedurecommenced8minafterinduction.HerBPdidnotde-
viatebeyond20%frombaseline,andothervitalsignsremainedstableduringtheproce-
dure.HerBISvaluesrangedfrom68to75,andtheMOAA/Sscorewasbelow3throughout
thesurgery.Noadverseeventsoccurreduntiltheendofthesurgery,andremimazolam
wasdiscontinued.Thesurgeryended31minafterinduction,andatotalof48mgremi-
mazolamwasinjected.TheMOAA/Sscoreofthepatientreachedfourafter8minsince
remimazolamdiscontinuation.Shedidnotrememberanythingabouttheprocedureand
reportedasatisfactoryexperience.ThemodifiedAldretescoreofthepatientmetthedis-
chargecriteria12minafterdiscontinuation,andnoadverseeventswereobserveduntil
thepatientlefttherecoveryroom.
3.Discussion
Weconductedsatisfactorymonitoredanesthesiacarewithkemimazolaminallfour
cases,andthetimelinetableandgrapharepresentedbelow(Figure1).Apreviousstudy
comparedremimazolamwithpropofolandinfusedremimazolamatadoseof6mg/kg/h
forinductionofgeneralanesthesia[3].Themeantimetolossofconsciousness(LOC)was
102.0s,andthemeandosetoLOCwas0.17mg/kg.ThemeantimetoLOCofpropofol
was78.7s.Themeantimefromtheendofthestudyperiodtoregainingconsciousness
was14.9min.ThemeantimetoLOCinourstudywas45s(20,40,70,and50seach),and
themeandosetoLOCwas0.075mg/kg(0.033,0.067,0.117,and0.083mg/kg,respectively),
whichwasevenfasterthanpropofolinfusion.Themeantimefromremimazolamdiscon-
tinuationtoreachingaMOAA/Sscoreoffourwas5.75min(4,5,6,and8mineach)inour
study.KemimazolamledtoafasterLOCthandidremimazolamaloneorpropofol.The
combinationdidnotprolongsedationtime,anditloweredthetotalinductiondoseof
remimazolam.
Figure1.Timelinetableandgraphwithvitalsignsandmajorevents.LOC,lossofconsciousness;
BP,bloodpressure;HR,heartrate;RR,respirationrate;SpO2,saturationofpercutaneousoxygen;
BIS,bispectralindex;MOAA/S,modifiedobserverassessmentofalertness/sedation;sec,second;
min,minute.
Figure 1.
Timeline table and graph with vital signs and major events. LOC, loss of consciousness; BP,
blood pressure; HR, heart rate; RR, respiration rate; SpO2, saturation of percutaneous oxygen; BIS,
bispectral index; MOAA/S, modified observer assessment of alertness/sedation; sec, second; min,
minute.
J. Clin. Med. 2023,12, 3558 5 of 6
Doi et al. revealed that 22% of patients who were administered remimazolam experi-
enced hypotension and required vasopressors, and 6.3% required treatment for bradycar-
dia [
3
]. None of the patients reported injection pain, and 7% and 6% experienced nausea
and vomiting, respectively. Unlike in a previous study, hypotension and bradycardia were
not observed in all four cases, from the induction of sedation to the end of surgery. Regard-
ing other complications, none of the patients in our study reported injection pain at the time
of induction or nausea/vomiting after the procedure, consistent with the previous study.
Pambianco et al. compared remimazolam and midazolam in patients undergoing
colonoscopy [
1
]. They demonstrated that 3 out of 120 patients in the remimazolam group
showed hypoxia (oxygen saturation <90%) and/or respiratory depression (respiratory rate
<8 breaths per minute). Further, 2 of the 3 patients received 100
µ
g of fentanyl shortly before
the respiratory events. None of the patients in our study showed hypoxia or respiratory
depression after receiving an initial 25
µ
g of fentanyl or additional fentanyl. However, one
patient showed transient apnea 1 min after administering the initial fentanyl.
Ketamine provides potent, dissociative anesthesia and analgesia, being a non-competitive
NMDA receptor antagonist [
4
]. At lower doses, ketamine modulates opioid receptors by
desensitizing central pain pathways. In a previous study, 1
µ
g/kg of fentanyl adminis-
tration 4 min before surgery showed similar effects to remifentanil 0.05
µ
g/kg/min in
monitored anesthesia care with propofol on recovery time, discharge time, and satisfaction
scores [
8
]. In another study, patients were administered 0.5 mg/kg ketamine with propofol
for induction, and pain scores for the first 3 h from the end of the operation were much
lower compared to placebo [
9
]. We administered just 25
µ
g of fentanyl 4 min before the start
of the procedure, considering the analgesic effect of ketamine, and two patients needed
additional fentanyl (50
µ
g and 25
µ
g, respectively) intraoperatively. After the procedure, no
additional opioid administration was needed, as none of the four patients reported severe
pain. They did not request analgesia.
The main side effects limiting the use of ketamine during shorter procedures were
recovery agitation and emergence symptoms. Both were more common at higher doses
than at lower doses. Benzodiazepines are effective in reducing the incidence of emergence
phenomena [
4
]. Sener et al. found that adding midazolam to ketamine can significantly
reduce the incidence of recovery agitation, with the number needed to treat estimated at
6 of 90 [
7
]. Furthermore, adding midazolam improved patient satisfaction and did not
significantly prolong sedation time or increase the incidence of other adverse events. This
result corresponds to those of our study; we found no adverse events, such as vivid dreams,
delirium, or emergence agitation.
Administering 0.5 mg/kg of ketamine is known to increase the BIS value, despite
paradoxically deepening the level of hypnosis. BIS does not reflect the level of conscious-
ness; it reflects cortical activity. Ketamine changes the EEG pattern, and these changes
result in an increase in BIS levels independent of the depth of anesthesia [
10
]. Moreover,
to date, the appropriate ranges of the BIS index for remimazolam anesthesia have not
been fully clarified [
2
]. Thus, the infusion rate of remimazolam was adjusted only under
the conditions where the BIS score was over 80 and the MOAA/S score exceeded 2, or
where the BIS score was below 60 and the MOAA/S score reached 0 were simultaneously
satisfied. Intraoperative awareness was evaluated throughout the procedure by checking
the MOAA/S score, and the patients were asked about it after they were fully awakened.
All four patients were totally amnestic and did not remember anything until the surgery
was completed after receiving the remimazolam and ketamine combination.
4. Conclusions
The remimazolam and ketamine combination used for monitored anesthesia care has
not been previously published. Kemimazolam may be an alternative to other agents or
combinations used for monitored anesthesia care in brief gynecological procedures.
J. Clin. Med. 2023,12, 3558 6 of 6
Author Contributions:
Conceptualization, S.C. and G.L.; methodology, G.L., J.J., T.L. and S.P.;
investigation, G.L., J.J. and S.P.; data curation, S.C. and J.J.; writing—original draft preparation, G.L.
and T.L.; writing—review and editing, S.C. and S.P.; visualization, G.L.; supervision, S.C., T.L. and
S.P.; project administration, G.L. and S.P. All authors have read and agreed to the published version
of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are available only on request due to privacy/ethical restrictions.
Conflicts of Interest: The authors declare no conflict of interest.
References
1.
Pambianco, D.J.; Borkett, K.M.; Riff, D.S.; Winkle, P.J.; Schwartz, H.I.; Melson, T.I.; Wilhelm-Ogunbiyi, K. A phase IIb study
comparing the safety and efficacy of remimazolam and midazolam in patients undergoing colonoscopy. Gastrointest. Endosc.
2016,83, 984–992. [CrossRef] [PubMed]
2.
Kim, K.M. Remimazolam: Pharmacological characteristics and clinical applications in anesthesiology. Anesth. Pain Med.
2022
,17,
1–11. [CrossRef] [PubMed]
3.
Doi, M.; Morita, K.; Takeda, J.; Sakamoto, A.; Yamakage, M.; Suzuki, T. Efficacy and safety of remimazolam versus propofol
for general anesthesia: A multicenter, single-blind, randomized, parallel-group, phase Iib/III trial. J. Anesth.
2020
,34, 543–553.
[CrossRef] [PubMed]
4.
Gales, A.; Maxwell, S. Ketamine: Recent evidence and current uses. Updat. Anaesth.
2018
, 43–48. Available online: https:
//www.wfsahq.org/resources/update-in-anaesthesia (accessed on 4 February 2023).
5.
Chudnofsky, C.R.; Weber, J.E.; Stoyanoff, P.J.; Colone, P.D.; Wilkerson, M.D.; Hallinen, D.L.; Jaggi, F.M.; Boczar, M.E.; Perry, M.A.
A combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department patients. Acad.
Emerg. Med. 2000,7, 228–235. [CrossRef] [PubMed]
6.
Bell, R.F.; Dahl, J.B.; Moore, R.A.; Kalso, E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst. Rev.
2006
,
25, CD004603. [CrossRef]
7.
Sener, S.; Eken, C.; Schultz, C.H.; Serinken, M.; Ozsarac, M. Ketamine with and without midazolam for emergency department
sedation in adults: A randomized controlled trial. Ann. Emerg. Med. 2011,57, 109–114. [CrossRef]
8.
Ryu, J.H.; Kim, J.H.; Park, K.S.; Do, S.H. Remifentanil-propofol versus fentanyl-propofol for monitored anesthesia care during
hysteroscopy. J. Clin. Anesth. 2008,20, 328–332. [CrossRef] [PubMed]
9.
Atashkhoyi, S.; Negargar, S.; Hatami-Marandi, P. Effects of the addition of low-dose ketamine to propofol-fentanyl anaesthesia
during diagnostic gynaecological laparoscopy. Eur. J. Obstet. Gynecol. Reprod. Biol. 2013,170, 247–250. [CrossRef] [PubMed]
10.
Hans, P.; Devandre, P.Y.; Brichant, J.F.; Bonhomme, V. Comparative effects of ketamine on Bispectral Index and spectral entropy
of the electroencephalogram under sevoflurane anaesthesia. Br. J. Anaesth. 2005,94, 336–340. [CrossRef]
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