Research ArticleResearchMedication Safety

Randomized trial of 150 traumatic brain injury patients finds adjunctive ketamine cuts propofol and opioid requirements during decompressive craniectomy

Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia (PubMed)Sep 8, 2026

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Brief summary

A prospective, double-blind randomized controlled trial of 150 adults undergoing emergency decompressive craniectomy for traumatic brain injury found that subanaesthetic ketamine (0.5 mg/kg/h) significantly reduced propofol consumption, fentanyl use, and vasopressor requirements without worsening intracranial pressure or cerebral perfusion.

What NurseJet pulled from the source

During emergency decompressive craniectomy for traumatic brain injury (TBI) with acute subdural hematoma, maintaining cerebral perfusion pressure while controlling intracranial pressure (ICP) is paramount. Propofol-based total intravenous anesthesia (TIVA) provides favorable metabolic suppression but frequently induces dose-dependent vasodilation and hypotension requiring vasopressor support. In this prospective, double-blind, three-arm randomized controlled trial, 150 adults undergoing emergency craniectomy were randomized 1:1:1 to receive adjunctive subanaesthetic ketamine (0.5 mg/kg/h), lidocaine (2 mg/kg/h), or placebo alongside target-controlled infusion of propofol titrated to maintain mean arterial pressure within 20% of baseline. Mean propofol consumption was significantly lowest in the ketamine group (100.73 ± 31.72 µg/kg/min) compared with lidocaine (115.86 ± 38.11 µg/kg/min) and placebo (131.53 ± 44.54 µg/kg/min; p < 0.001). Ketamine administration also significantly decreased intraoperative fentanyl requirements (63.85 ± 36.23 µg vs 83.64 ± 32.27 µg for lidocaine vs 153.55 ± 57.28 µg for placebo; p < 0.001) and reduced median vasopressor boluses (2 vs 3 vs 3; p = 0.031). Importantly, intracranial pressure, cerebral perfusion pressure, intraoperative brain relaxation scores, and Glasgow Outcome Scale-Extended scores were comparable across all three groups, demonstrating that low-dose ketamine did not adversely affect intracranial dynamics.

Why this matters for nurses

Neurocritical care and perioperative nurses frequently navigate the challenge of hemodynamic instability and hypoperfusion in patients with acute traumatic brain injury. Historically, ketamine was avoided due to unsubstantiated fears of worsening intracranial hypertension. This trial reinforces growing clinical consensus that low-dose ketamine provides valuable opioid- and sedative-sparing effects while stabilizing systemic hemodynamics without compromising intracranial dynamics.

Bedside takeaway

An RCT of 150 emergency craniectomy patients found subanaesthetic ketamine cut propofol and fentanyl use and reduced vasopressors without raising ICP or lowering CPP.

Key takeaways

Prospective, double-blind RCT randomized 150 adults undergoing emergency decompressive craniectomy for traumatic acute subdural hematoma.
Subanaesthetic ketamine (0.5 mg/kg/h) reduced propofol consumption from 131.53 to 100.73 µg/kg/min (p < 0.001).
Intraoperative fentanyl requirements dropped by more than 58% in the ketamine group compared with placebo (p < 0.001).
Vasopressor requirements were significantly decreased in the ketamine arm (median 2 vs 3 boluses, p = 0.031).
Intracranial pressure, cerebral perfusion pressure, brain relaxation, and neurological recovery scores showed no detrimental differences.

Practice implications

When caring for neurotrauma patients receiving subanaesthetic ketamine infusions, maintain continuous arterial line hemodynamic monitoring and ICP/CPP tracking per unit protocol. Recognize that low-dose ketamine stabilizes mean arterial pressure and lowers sedative needs, but ensure close monitoring of pupil reactivity, neurological assessment, and ventilator synchrony.

Limitations & cautions

Single-center trial in patients with acute subdural hematoma undergoing surgical decompression; TIVA was titrated to hemodynamic targets rather than processed EEG; findings cannot be generalized to unoperated traumatic brain injuries.
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Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia (PubMed)

Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia (PubMed). Comparison of subanaesthetic ketamine and lidocaine as adjuvants to propofol-based total intravenous anesthesia on propofol requirement during emergency decompressive craniectomy for traumatic brain injury: a prospective, double-blind, three-arm randomized controlled trial.

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https://pubmed.ncbi.nlm.nih.gov/42710328/

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Journal of bronchology & interventional pulmonology (PubMed)Oct 27, 2026Systematic Review

A meta-analysis of 16 randomized controlled trials involving 2,325 adults undergoing fiberoptic bronchoscopy demonstrated that remimazolam significantly reduced the risk of respiratory depression by 49%, hypotension by 50%, and bradycardia by 63% while accelerating PACU discharge compared with traditional sedatives.

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Systematic ReviewResearchMedication SafetyAI summary · original source linked below

Procedural sedation during fiberoptic bronchoscopy requires maintaining patient comfort while preventing airway compromise, respiratory depression, and hemodynamic instability. Remimazolam, an ultra-short-acting ester-based benzodiazepine hydrolyzed by tissue esterases, was evaluated in this meta-analysis of 16 randomized controlled trials comprising 2,325 adult patients undergoing fiberoptic bronchoscopy across five databases through January 2026. Compared with active controls (dexmedetomidine, midazolam, and propofol), remimazolam significantly reduced the incidence of respiratory depression (relative risk [RR]: 0.51, 95% CI: 0.36–0.73, p < 0.001), hypotension (RR: 0.50, 95% CI: 0.34–0.73, p < 0.001), and bradycardia (RR: 0.37, 95% CI: 0.22–0.65, p = 0.001). Sedation onset was significantly faster than dexmedetomidine (mean difference [MD]: -2.19 minutes), though slightly slower than propofol (MD: +0.49 minutes). Procedural success rates were high and comparable between groups (RR: 1.12, 95% CI: 0.98–1.28, p = 0.097). Patients receiving remimazolam experienced significantly shorter emergence times (-1.79 minutes vs dexmedetomidine; -4.37 minutes vs midazolam) and spent significantly less time in the post-anesthesia care unit (PACU stay shortened by 3.58 minutes vs dexmedetomidine and 6.70 minutes vs midazolam).

Key takeaways

Meta-analysis synthesized 16 randomized controlled trials encompassing 2,325 adult bronchoscopy patients.
Remimazolam cut respiratory depression by 49% (RR 0.51, 95% CI: 0.36–0.73, p < 0.001) compared with control sedatives.
Hemodynamic instability was significantly lower, with 50% less hypotension (p < 0.001) and 63% less bradycardia (p = 0.001).
Procedure completion success rates were comparable to traditional agents (RR 1.12, p = 0.097).
PACU recovery times were significantly reduced by 3.58 minutes versus dexmedetomidine and 6.70 minutes versus midazolam.

Why this matters on shift

Procedural sedation nurses in endoscopy and interventional pulmonology suites constantly balance adequate depth of sedation with airway and cardiovascular safety. Evidence showing that remimazolam provides equivalent procedural completion with half the rate of respiratory depression and hypotension—paired with a flumazenil-reversible safety profile and faster PACU discharge—supports its growing role in ambulatory and inpatient procedural workflows.

Bedside takeaway

A meta-analysis of 16 RCTs and 2,325 patients showed remimazolam halved respiratory depression and hypotension during bronchoscopy compared to traditional sedatives.

Nursing implications

During bronchoscopy sedation with remimazolam, continue continuous capnography, pulse oximetry, and frequent automated blood pressure cycling as mandated by procedural sedation policies. While remimazolam demonstrates favorable hemodynamics and rapid emergence, maintain airway rescue equipment and flumazenil immediately available at the bedside.

Limitations & cautions

Control groups combined different pharmacological agents (propofol, midazolam, dexmedetomidine); variability in adjunctive opioid dosing, topical local anesthesia protocols, and bronchoscopy duration across the 16 trials.
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Citations · exact source links

Journal of bronchology & interventional pulmonology (PubMed). Comparison of the Safety and Efficacy of Remimazolam for Sedation in Adults Undergoing Fiberoptic Bronchoscopy: A Meta-Analysis of Randomized Controlled Trials.

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The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians (PubMed)Oct 14, 2026Research Article

A secondary analysis of 1,322 patients undergoing standardized term labor induction found that individuals with severe obesity (BMI >= 40 kg/m2) experienced 3.5 hours longer total labor duration, required more misoprostol doses, and had 40% lower odds of vaginal delivery compared to patients with BMI < 40 kg/m2.

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Research ArticleResearchMedication SafetyWorkflowAI summary · original source linked below

Maternal obesity is a major contributor to prolonged labor and cesarean birth, but the specific dynamics of prostaglandin cervical ripening in severe obesity remain incompletely defined. This study analyzed data from 1,322 patients at >= 37 weeks gestation with cervical dilation <= 2 cm who received vaginal misoprostol (25 µg every 3 hours for up to 5 doses followed by standardized oxytocin) in a cluster randomized controlled trial conducted between May 2021 and September 2022. Overall, 264 participants (20.0%) had severe obesity (BMI >= 40 kg/m2) and 1,058 (80.0%) had BMI < 40 kg/m2. Patients with severe obesity were significantly more likely to present with a completely closed cervix at induction initiation. After controlling for hospital clustering, initial cervical dilation, chronic hypertension, and diabetes using generalized estimating equations, individuals with severe obesity experienced significantly longer total induction duration (adjusted mean difference: 3.5 hours, 95% CI: 1.9–4.8), longer first stage of labor (adjusted mean difference: 2.2 hours, 95% CI: 0.6–3.8), and extended oxytocin administration (adjusted mean difference: 2.5 hours, 95% CI: 1.1–3.8). Furthermore, patients with BMI >= 40 kg/m2 required more misoprostol doses and had significantly reduced odds of achieving vaginal delivery (adjusted odds ratio: 0.6, 95% CI: 0.4–0.8).

Key takeaways

Analysis evaluated 1,322 term labor inductions using standardized vaginal misoprostol (25 µg q3h up to 5 doses).
264 patients (20.0%) presented with severe obesity (BMI >= 40 kg/m2) and were more likely to begin induction with a closed cervix.
Total induction time was 3.5 hours longer (95% CI: 1.9–4.8) and first stage was 2.2 hours longer (95% CI: 0.6–3.8) in patients with BMI >= 40.
Duration of oxytocin infusion was increased by 2.5 hours (95% CI: 1.1–3.8), with higher total misoprostol requirements.
Severe obesity was associated with 40% lower odds of successful vaginal delivery (aOR 0.6, 95% CI: 0.4–0.8).

Why this matters on shift

Labor and delivery nurses manage complex cervical ripening and oxytocin titration pathways for pregnant individuals across diverse BMI categories. Recognizing that severe obesity independently prolongs induction duration by several hours and increases medication requirements helps bedside nurses set realistic expectations with laboring families, plan for extended electronic fetal monitoring, and avoid premature declarations of failed induction before adequate ripening time has elapsed.

Bedside takeaway

In a trial of 1,322 inductions, severe obesity (BMI >= 40) added 3.5 hours to labor duration and lowered odds of vaginal delivery by 40% under vaginal misoprostol.

Nursing implications

When caring for laboring patients with BMI >= 40 kg/m2 undergoing cervical ripening, anticipate longer progression times through the latent and active phases of labor. Maintain continuous fetal and uterine contraction monitoring, advocate for patience during early ripening per standardized labor guidelines, and monitor closely for oxytocin-related tachysystole.

Limitations & cautions

Secondary observational analysis of a trial cohort limited to vaginal misoprostol and oxytocin; cannot evaluate whether mechanical ripening (e.g., Foley balloon) or alternative pharmacological dosing would alter delivery outcomes in this population.
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Citations · exact source links

The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians (PubMed). Characterizing vaginal misoprostol induction in individuals with and without severe obesity.

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Journal of intensive care medicine (PubMed)Sep 2, 2026Systematic Review

A systematic review and meta-analysis of seven randomized controlled trials involving 910 patients found that midline venous catheters had significantly higher risks of overall complications, premature catheter removal, occlusion, and infiltration, alongside shorter dwell times compared with PICCs.

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Systematic ReviewResearchWorkflowQuality ImprovementAI summary · original source linked below

Midline venous catheters (MVCs) have been increasingly utilized as alternatives to peripherally inserted central catheters (PICCs) for intermediate-duration intravenous therapy to preserve central veins and reduce central line-associated bloodstream infections. This systematic review and meta-analysis synthesized data from seven randomized controlled trials (RCTs) encompassing 910 pediatric and adult patients (454 MVC, 456 PICC) identified across PubMed, Embase, Scopus, and Cochrane Central through March 2025. Compared with PICCs, MVCs were associated with a more than twofold higher risk of total complications (RR: 2.57; 95% CI: 1.54–4.31; p = 0.0003), nearly fourfold higher risk of premature catheter removal (RR: 3.91; 95% CI: 1.85–8.27; p = 0.0004), and significantly shorter median dwell time (weighted mean difference: -2.06 days; 95% CI: -3.18 to -0.94; p = 0.0003). Specific mechanical complications were markedly increased with MVCs, including catheter occlusion (RR: 3.61; 95% CI: 2.13–6.11; p < 0.00001), infiltration (RR: 3.77; 95% CI: 1.08–13.14; p = 0.04), and leakage (RR: 2.91; 95% CI: 1.00–8.50; p = 0.05). In contrast, no statistically significant differences were observed between MVCs and PICCs for catheter-related bloodstream infections, venous thrombosis, phlebitis, dislodgement, internal malposition, or local insertion site infections, although event rates were low and confidence intervals wide.

Key takeaways

Meta-analysis included seven RCTs encompassing 910 patients (454 receiving midlines and 456 receiving PICCs).
Midline catheters demonstrated higher risk of overall complications (RR 2.57, 95% CI: 1.54–4.31, p = 0.0003) and premature removal (RR 3.91, 95% CI: 1.85–8.27, p = 0.0004).
Median catheter dwell time was 2.06 days shorter in the midline group compared to PICCs (p = 0.0003).
Mechanical failures were more frequent with midlines, including occlusion (RR 3.61, p < 0.00001), infiltration (RR 3.77, p = 0.04), and leakage (RR 2.91, p = 0.05).
Infection and thrombosis rates did not differ significantly between lines, though low event counts preclude claiming clinical equivalence.

Why this matters on shift

Vascular access device selection directly impacts inpatient therapy completion, nurse workload, and patient comfort. While midline catheters are frequently selected to avoid central line placement, understanding that midlines carry substantially higher rates of premature failure, occlusion, and extravasation reinforces that device choice must match anticipated therapy duration and infusate properties rather than treating midlines as universal drop-in substitutes.

Bedside takeaway

A meta-analysis of 7 RCTs and 910 patients found midline catheters had a 2.6-fold higher complication rate, more occlusions, and 2 days shorter dwell time than PICCs.

Nursing implications

When maintaining midline catheters, monitor closely for early signs of occlusion, sluggish flush resistance, and insertion site leakage. For patients requiring extended intravenous therapy beyond 1 to 2 weeks, consult with vascular access teams and follow institutional device selection algorithms rather than presuming midlines will achieve dwell longevity comparable to PICCs.

Limitations & cautions

Analysis included seven RCTs with a total of 910 patients; event rates for bloodstream infections and venous thrombosis were low, resulting in wide confidence intervals and limited statistical power to establish equivalence for infectious outcomes.
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Citations · exact source links

Journal of intensive care medicine (PubMed). Comparison of Midline Venous Catheters Versus Peripherally Inserted Central Catheters for Intravenous Therapy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

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More updates for this clinical area

Meta-analysis of 2,325 adults finds remimazolam halves respiratory depression and hypotension during bronchoscopy compared to traditional sedatives

Trial of 1,322 term inductions finds severe obesity extends labor by 3.5 hours and reduces odds of vaginal delivery under vaginal misoprostol

Meta-analysis of 910 patients finds midline catheters carry higher mechanical complications and shorter dwell times than PICCs