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      Anesthesia Management of a Liver Transplant Recipient with Remimazolam

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      Case Reports in Anesthesiology

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          Intraoperative anesthetic requirements might be altered due to the modulated metabolic function in living donor liver transplant recipients. Remimazolam may provide appropriate anesthesia in patients with cirrhosis. However, the efficacy and safety of remimazolam in liver transplant recipients have not been reported. We present the successful anesthesia management of a liver transplant recipient using remimazolam. Case Presentation. A 54-year-old woman who was diagnosed with Child-Pugh C cirrhosis of unknown etiology was scheduled for living donor liver transplantation. Remimazolam was used for anesthesia management under electroencephalogram monitoring, including bispectral index (BIS) and patient state index (PSI) values. Despite the prolonged surgical time (1,037 min) and massive blood loss (22,500 mL), BIS and PSI values were maintained within acceptable ranges intraoperatively. There was no intraoperative awareness/recall or adverse events associated with remimazolam administered perioperatively.


          We safely managed general anesthesia for living donor liver transplantation with remimazolam using electroencephalogram monitoring.

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          Liver cirrhosis

          Cirrhosis is widely prevalent worldwide and can be a consequence of different causes, such as obesity, non-alcoholic fatty liver disease, high alcohol consumption, hepatitis B or C infection, autoimmune diseases, cholestatic diseases, and iron or copper overload. Cirrhosis develops after a long period of inflammation that results in replacement of the healthy liver parenchyma with fibrotic tissue and regenerative nodules, leading to portal hypertension. The disease evolves from an asymptomatic phase (compensated cirrhosis) to a symptomatic phase (decompensated cirrhosis), the complications of which often result in hospitalisation, impaired quality of life, and high mortality. Progressive portal hypertension, systemic inflammation, and liver failure drive disease outcomes. The management of liver cirrhosis is centred on the treatment of the causes and complications, and liver transplantation can be required in some cases. In this Seminar, we discuss the disease burden, pathophysiology, and recommendations for the diagnosis and management of cirrhosis and its complications. Future challenges include better screening for early fibrosis or cirrhosis, early identification and reversal of causative factors, and prevention of complications.
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            Efficacy and safety of remimazolam versus propofol for general anesthesia: a multicenter, single-blind, randomized, parallel-group, phase IIb/III trial

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              The role of human carboxylesterases in drug metabolism: have we overlooked their importance?

              Carboxylesterases are a multigene family of mammalian enzymes widely distributed throughout the body that catalyze the hydrolysis of esters, amides, thioesters, and carbamates. In humans, two carboxylesterases, hCE1 and hCE2, are important mediators of drug metabolism. Both are expressed in the liver, but hCE1 greatly exceeds hCE2. In the intestine, only hCE2 is present and highly expressed. The most common drug substrates of these enzymes are ester prodrugs specifically designed to enhance oral bioavailability by hydrolysis to the active carboxylic acid after absorption from the gastrointestinal tract. Carboxylesterases also play an important role in the hydrolysis of some drugs to inactive metabolites. It has been widely believed that drugs undergoing hydrolysis by hCE1 and hCE2 are not subject to clinically significant alterations in their disposition, but evidence exists that genetic polymorphisms, drug-drug interactions, drug-disease interactions and other factors are important determinants of the variability in the therapeutic response to carboxylesterase-substrate drugs. The implications for drug therapy are far-reaching, as substrate drugs include numerous examples from widely prescribed therapeutic classes. Representative drugs include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, antiplatelet drugs, statins, antivirals, and central nervous system agents. As research interest increases in the carboxylesterases, evidence is accumulating of their important role in drug metabolism and, therefore, the outcomes of pharmacotherapy.

                Author and article information

                Case Rep Anesthesiol
                Case Rep Anesthesiol
                Case Reports in Anesthesiology
                12 January 2023
                : 2023
                : 5935657
                Department of Anesthesiology, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ku, Kumamoto 860-8556, Japan
                Author notes

                Academic Editor: Serkan Tulgar

                Author information
                Copyright © 2023 Takashi Kawasaki et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 28 September 2022
                : 15 December 2022
                : 3 January 2023
                Case Report

                Anesthesiology & Pain management
                Anesthesiology & Pain management


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