Acute and Critical Care

Original Article

CPR/Resuscitation
Effects of ketamine on the severity of depression and anxiety following postoperative mechanical ventilation: a single-blind randomized clinical trial in Iran: Seyedbabak Mojaveraghili, Fatemeh Talebi, Sima Ghorbanoghli, Shahram Moghaddam, Hamidreza Shakouri, Ruzbeh Shamsamiri, Fatemeh Mehravar; Acute Crit Care. 2024;39(2):243-250. Published online May 24, 2024; DOI: https://doi.org/10.4266/acc.2023.01186

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Background
In this study, we compare the effects of ketamine and the combination of midazolam and morphine on the severity of depression and anxiety in mechanically ventilated patients after discharge from the intensive care unit (ICU).
Methods
This randomized single-blind clinical trial included 50 patients who were candidates for craniotomy and postoperative mechanical ventilation in the ICU of 5 Azar Teaching Hospital in Gorgan City, North Iran, from 2021 to 2022. Patients were allocated to two groups by quadruple block randomization. In group A, 0.5 mg/kg of ketamine was infused over 15 minutes after craniotomy and then continued at a dose of 5 µ/kg/min during mechanical ventilation. In group B, midazolam was infused at a dose of 2–3 mg/hr and morphine at a dose of 3–5 mg/hr. After patients were discharged from the ICU, if their Glasgow Coma Scale scores were ≥14, Beck’s anxiety and depression inventories were completed by a psychologist within 2 weeks, 2 months, and 6 months after discharge.
Results
The mean scores of depression at 2 months (P=0.01) and 6 months (P=0.03) after discharge were significantly lower in the ketamine group than in the midazolam and morphine group. The mean anxiety scores were significantly lower in the ketamine group 2 weeks (P=0.006) and 6 months (P=0.002) after discharge.
Conclusions
Ketamine is an effective drug for preventing and treating anxiety and depression over the long term in patients discharged from the ICU. However, further larger volume studies are required to validate these results.

Citations

Citations to this article as recorded by

Increased morning cortisol after ketamine treatment for suicidal depression: Exploratory report from a randomized trial
Tse-Hwei Choo, Hanga C. Galfalvy, John G. Keilp, Ainsley K. Burke, J. John Mann, Michael F. Grunebaum
Journal of Affective Disorders.2026; 412: 122175. CrossRef

Review Article

Basic Science and Research
Review of remimazolam and sedatives in the intensive care unit: Hey-Ran Choi, In-Ae Song; Acute Crit Care. 2022;37(2):151-158. Published online May 30, 2022; DOI: https://doi.org/10.4266/acc.2022.00619

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Abstract PDF

Remimazolam is a novel intravenous ultra-short acting benzodiazepine that has the potential of being a safe and effective new sedative for use in intensive care unit (ICU) settings. Because remimazolam metabolizes rapidly by being hydrolyzed to an inactive metabolite (CNS 7054) through non-specific tissue esterase activity, specific dosing adjustment for older adults and for patients with renal or hepatic impairment patients (except for those with severe hepatic impairment) is not required. In addition, research has shown that remimazolam may be reversed by administration of flumazenil, as its half time was sufficiently short compared to flumazenil. It shows a lower incidence of cardiorespiratory depression, less injection pain, and no fatal complications such as propofol infusion syndrome and malignant hyperthermia of inhalational anesthetics. Future studies to study the suitability of remimazolam for managing the sedation of ICU patients who need sedation for a long time over several days is required.

Citations

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Clinical applications and pharmacological characteristics of remimazolam, a short-acting sedative: a narrative review
Kyung Mi Kim
Journal of the Korean Medical Association.2026; 69(4): 335. CrossRef
Effect and hemodynamics of remimazolam besylate on sedation of mechanically ventilated patients: a propensity score-matched study
Wenjie Xie, Xiaoyu Fang, Zhaokun Shi, Wei Wu, Miao Wu, Handong Zou, Shasha Wang, Huifang Wan, Guang Li, Wenfang Xia, Wenwei Gao, Zhenwen Li, Zhou Liu, Lingxia Qin, Guijun Jiang, Lu Wang, Liying Zhan
BMC Anesthesiology.2026;[Epub] CrossRef
Remimazolam Versus Midazolam for Sedation in Mechanically Ventilated Patients with Severe Pneumonia: A Randomized Controlled Trial
Haobo Kong, Jingjing Pan, Min Liang, Shufeng Yu, Xuehui Fang Xuehui
Journal of Intensive Care Medicine.2026;[Epub] CrossRef
Age‑stratified median effective dose (ED₅₀) of remimazolam besylate for successful gastroscope insertion without body movement in geriatric patients
Si-Qi Hao, Zhe Ma, Fang-Yu Zhang, Yi-Xin Hu, Li-Xin An
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Seizure adequacy and safety of remimazolam in electroconvulsive therapy for patients with psychiatric disorders: a double-blind randomized crossover trial
Tianqi Shen, Xingxing Yin, Yongming Zhang, Feng Wang, Haipeng Wang, Xiufang Shi, Yanmiao Qiu, Jia Li, Xinhong Du
BMC Psychiatry.2026;[Epub] CrossRef
Efficacy of remimazolam besylate versus propofol on hemodynamics during anesthetic induction in elderly patients undergoing bronchoscopy: a randomized controlled trial
Danni Li, Yang Cheng, YuanYuan Zhou, Siyi Wei, Dan Fan
BMC Anesthesiology.2026;[Epub] CrossRef
Consensus statement for managing patients with ARDS in low-resource settings: a Delphi study
Pedja Kovacevic, Jesús Villar, Boris Tomic, Fabio Silvio Taccone, Giacomo Grasselli, Luigi Camporota, Marlies Ostermann, Ivan Palibrk, Rajesh Mishra, Sasa Dragic, Jose Diaz-Gomez, Danica Momcicevic, Ali Ait Hssain, Biljana Zlojutro, Jihad Mallat, Milka Ja
Annals of Intensive Care.2026; 16: 100144. CrossRef
The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist
Allison Rhodes, Christopher Wilson, Dimitar Zelenkov, Kathryne Adams, Janelle O. Poyant, Xuan Han, Anthony Faugno, Cristina Montalvo
Journal of Intensive Care Medicine.2025; 40(12): 1223. CrossRef
Con: Remimazolam: The New Miracle Cure for Critically Ill Patients
Rayssa Becerra Orjuela, Juan G. Ripoll
Journal of Cardiothoracic and Vascular Anesthesia.2025; 39(4): 1082. CrossRef
Optimizing Pediatric Sedation: Evaluating Remimazolam and Dexmedetomidine for Safety and Efficacy in Clinical Practice
Vera Scheckenbach, Frank Fideler
Pediatric Drugs.2025; 27(2): 181. CrossRef
Comparison of remimazolam–flumazenil versus propofol on delayed emergence from anaesthesia in major spine surgery: protocol for a multicentre, single-blinded, randomised controlled trial
Jingjing Sun, Wei Luo, Liang Wen, Yanying Xiao, Ruping Dai
BMJ Open.2025; 15(8): e097541. CrossRef
The degree of respiratory depression according to the effect-site concentration in remimazolam target-controlled infusion
Soo Jung Park, Sang Kee Min, Gyubin Choi, Ji Eun Kim, Ha Yeon Kim
European Journal of Anaesthesiology.2024; 41(10): 728. CrossRef
Remimazolam Anesthesia for a Pediatric Patient With Glutaric Aciduria Type I: A Case Report
Tomoko Tsuruno, Hiroki Tateiwa, Yuki Hashimoto, Yoshifumi Katsumata, Takashi Kawano
Cureus.2024;[Epub] CrossRef
Remimazolam – Update zu Grundlagen und klinischem Potenzial
Vera Scheckenbach, Berthold Drexler
Die Anaesthesiologie.2024; 73(9): 617. CrossRef
Remimazolam: A New Ingress in Cardiac Surgical Intensive Care Unit
Minati Choudhury, Poonam Malhotra Kapoor
Journal of Cardiac Critical Care TSS.2023; 7: 133. CrossRef
Safety and efficacy of remimazolam tosilate combined with low-dose fentanyl for procedural sedation in obese patients undergoing gastroscopy: study protocol for a single-centre, double-blind, randomised controlled trial
Lijuan Yan, Xiao Wang, Zhenyi Chen, Ningning Wu, Hao Li, Bin Yang
BMJ Open.2023; 13(12): e079095. CrossRef
Remimazolam: An Updated Review of a New Sedative and Anaesthetic
Qinxue Hu, Xing Liu, Chengli Wen, Duo Li, Xianying Lei
Drug Design, Development and Therapy.2022; Volume 16: 3957. CrossRef
National analysis of applied sedation in critical care patients
Grace Pamela López Pérez , Melani Dayana Carrera Casa , Gissela Lizbeth Amancha Moyulema , Yadira Nathaly Chicaiza Quilligana , Ana Belén Guamán Tacuri , Joselyn Mireya Iza Arias
Salud, Ciencia y Tecnología.2022; 2: 234. CrossRef

Original Article

Pharmacology
The Optimal Dose of Midazolam for Promoting Sleep in Critically Ill Patients: A Pilot Study: Se Joong Kim, Jisoo Park, Yeon Joo Lee, Jong Sun Park, Ho Il Yoon, Jae Ho Lee, Choon Taek Lee, Young Jae Cho; Korean J Crit Care Med. 2014;29(3):166-171. Published online August 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.3.166

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Abstract PDF

BACKGROUND
Many critically ill patients treated in the intensive care unit (ICU) experience sleep disruption. Midazolam is commonly used for the sedation of critically ill patients. This pilot study is aimed to identify the optimal dose of midazolam for achieving sound sleep in critically ill patients.
METHODS
This prospective study was conducted in the medical ICU of a tertiary referral hospital. Polysomnography recording was performed over 24 hours to assess the quantity and quality of sleep in patients sedated with midazolam.
RESULTS
A total of five patients were enrolled. Median total sleep time was 494.0 (IQR: 113.5-859.0) min. The majority of sleep was stage 1 (median 82.0 [IQR 60.5-372.5] min) and 2 (median 88.0 [60.5-621.0] min) with scant REM (median 10.0 [6.0-50.5] min) and no stage 3 (0.0 min) sleep. The median number of wakings in 1 hour was 16.1 (IQR: 7.6-28.6). The dose of midazolam showed a positive correlation with total sleep time (r = 0.975, p = 0.005).
CONCLUSIONS
The appropriate quantity of sleep in critically ill patients was achieved with a continuous infusion of 0.02-0.03 mg/kg/h midazolam. However, the quality of sleep was poor. Further study is required for the promotion of quality sleep in such patients.

Citations

Citations to this article as recorded by

Effect of prolonged sedation with dexmedetomidine, midazolam, propofol, and sevoflurane on sleep homeostasis in rats
Brian H. Silverstein, Anjum Parkar, Trent Groenhout, Zuzanna Fracz, Anna M. Fryzel, Christopher W. Fields, Amanda Nelson, Tiecheng Liu, Giancarlo Vanini, George A. Mashour, Dinesh Pal
British Journal of Anaesthesia.2024; 132(6): 1248. CrossRef
Reliability of the Korean version of the Richards-Campbell Sleep Questionnaire
Jae Kyoung Kim, Ju-Hee Park, Jaeyoung Cho, Sang-Min Lee, Jinwoo Lee
Acute and Critical Care.2020; 35(3): 164. CrossRef
Pharmacological interventions to improve sleep in hospitalised adults: a systematic review
Salmaan Kanji, Alexandru Mera, Brian Hutton, Lisa Burry, Erin Rosenberg, Erika MacDonald, Vanessa Luks
BMJ Open.2016; 6(7): e012108. CrossRef
Sedation in Critically Ill Patients
Mark Oldham, Margaret A. Pisani
Critical Care Clinics.2015; 31(3): 563. CrossRef

Case Report

A Case of Functioning Paraganglioma Mimicking Anaphylactic Shock: A Case Report: Ju Young Han, Oh Hyun Lee, Gyung Eun Kim, Seung Baik Han, So Hun Kim, Moonsuk Nam, Yong Seong Kim, Seongbin Hong; Korean J Crit Care Med. 2013;28(2):152-155.; DOI: https://doi.org/10.4266/kjccm.2013.28.2.152

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Abstract PDF: Paraganglioma is a tumor originating from the extra-adrenal chromaffin cells, and functional paraganglioma causes paroxysmal hypertension, headache and tachycardia, due to excess excretion of catecholamine. However, rarely, ARDS, acute myocardial infarction, heart failure, arrhythmia, and pulmonary edema are also seen in patients with paraganglioma and clinical manifestations are depending on the patient's intravascular volume status. Seventy one-years-old male was presented with hypotension and pulmonary edema after intravenous midazolam injection during colonoscopy under conscious sedation. The patient was initially suspected with anaphylactic shock, due to midazolam injection. However, later, he was diagnosed with paraganglioma, and blood pressure was successfully controlled with alpha adrenergic blockade. We suggest that when we encounter heart failure, pulmonary edema and shock of unknown origin, pheochromocytoma must be taken into consideration.

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