Continuous intravenous versus intermittent bolus midazolam with remifentanil during arteriovenous fistula placement with monitored anesthesia care in chronic renal failure patients: a randomized controlled trial

BACKGROUND: There is limited data on the use of intravenous continuous infusion (CI) versus intravenous intermittent bolus (IB) doses of midazolam for conscious sedation in patients with chronic renal failure. Unexpected adverse events can occur in chronic renal failure patients undergoing short procedures. OBJECTIVE: Investigate and compare the sedoanalgesic and adverse effects of intravenous continuous infusion (CI) use of midazolam with intravenous intermittent bolus (IB) doses of midazolam while using intravenous remifentanil as a rescue medication, and assess patient and surgeon satisfaction. DESIGN: Prospective, randomized, single-blind controlled study. SETTINGS: Two tertiary care hospitals. PATIENTS AND METHODS: Study included patients aged 43-81 years with a diagnosis of chronic renal failure who were referred for an arteriovenous fistula procedure with modified anesthesia care between August 2012 and April 2016. The patients were randomized to intravenous CI or IB doses of midazolam. IB doses of remifentanil were used as a rescue medication. MAIN OUTCOME MEASURES: Primary outcomes were amounts of midazolam and remifentanil medications during the operation, the amount of remifentanil as a rescue medication, and the satisfaction of patient and surgeon. SAMPLE SIZE: 116 assessed for eligibility; 99 randomized to CI (n=50) or IB doses (n=49 of midazolam). RESULTS: The total dose of midazolam by CI was greater than with midazolam by IB (P=.002). The total dose of remifentanil was higher with IB doses of midazolam in comparison to CI of midazolam (P=.001). The groups were similar in sedation and pain control, duration of procedure, recovery time, patient satisfaction and adverse events; surgeon satisfaction was greater with CI versus IB (P=.035). CONCLUSION: Intravenous CI midazolam during MAC provides better surgeon satisfaction then IB midazolam and can be used safely for arteriovenous fistula procedures. LIMITATIONS: Two different surgeon groups. CONFLICT OF INTEREST: None.