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and remifentanil. Remimazolam combines virtually all the traditional benefits befitting a classic benzodiazepine, with an extremely rapid onset and favorable emergence profile facilitated by esterase-based metabolism. As a γ-aminobutyric acid type A (GABA a )-positive allosteric modulator, remimazolam is a potent sedative-hypnotic agent producing dose-dependent depression of the central nervous system (CNS), anxiolysis, anterograde amnesia, and anticonvulsant effects. It causes minimal cardiovascular and respiratory depression when judiciously administered alone

not without risks. Barbiturates support addictive behavior, can have a variety of unpleasant side effects, and their effectiveness is greatly increased when taken concurrently with other CNS depressants. In fact, barbiturate sleeping pills can quickly cause death when taken with alcohol due to their significant cardiovascular and respiratory depressant effects. It is this narrow margin of safety that prompted the development of safer sedative/hypnotic medications (eg, benzodiazepines) during the next few decades. Due to their unacceptable safety profile, the use of

of a single ideal technique. Additionally, the need and demand for sedation services is on the rise. The search of an ideal sedative agent is centered on the ability to provide amnesia, anxiolysis, and analgesia while providing both practitioner and patient satisfaction. Rapid onset and offset, ease in adjustability, wide margin of safety, and a high-quality procedural sedation are other desirable features. Fospropofol, which is a new sedative/hypnotic agent, is being evaluated for potential benefits compared to existing drugs such as a well-known and widely used

combinations of a narcotic (eg, morphine or meperidine), a sedative-hypnotic (eg, chloral hydrate), a benzodiazepine (eg, midazolam or diazepam), and/or an antihistamine (eg, hydroxyzine HCl) ( Figure 1 ) at the following dosages: 0.66 mg/kg for morphine, 2 mg /kg for meperidine, 0.5–0.7 mg/kg for midazolam, 0.5–.7 mg/kg for diazepam, and 2 mg/kg for hydroxyzine HCl. Figure 1. Distribution of oral sedation regimens. Figure 1. Distribution of oral sedation regimens. Following the

and the amplitude increases. The bispectral index (BIS) monitor (Aspect Medical Systems, Newton, Mass) is an FDA-approved monitor that has been used in clinical practice since 1997. 17 It gathers processed EEG parameters to provide a numeric measure of the hypnotic effect of anesthetic or sedative drugs on brain activity. It is derived from the EEG by a computer algorithm that produces a single numeric value, scaled from 0 to 100. 18 According to the manufacturer, a BIS score of >90 indicates an awake patient; 71–90, mild to moderate sedation; 61–70, deep sedation

;131(5):1004–1017. Dexmedetomidine is a sedative with modest analgesic efficacy, whereas remifentanil is an opioid analgesic with modest sedative efficacy. Synergy is often observed when sedative-hypnotics are combined with opioid analgesics in anesthetic practice. A 3-phase crossover trial was conducted to study the pharmacodynamic interaction between remifentanil and dexmedetomidine. Thirty healthy volunteers, stratified by age and sex, were recruited to undergo target-controlled infusions of dexmedetomidine, remifentanil, and remifentanil with a fixed dexmedetomidine background concentration

steady state, and once it is removed, the residual fentanyl in the skin continues to be absorbed for hours. It takes approximately 17 hours for fentanyl blood levels to drop by 50% once the patch is removed, so fentanyl interactions with sedatives, hypnotics, and other opioids are still possible hours after the patch has been removed. Thus removal of the patch does not quickly eliminate the risk of fentanyl interactions with other drugs. The rate of absorption of the medication can also be influenced by the degree of blood flow through the skin where the patch