Reader response

Myron Yaster MD

From Bob Spear MD (retired), Rady Children’s Hospital-San Diego, PICU/Anesthesia

The drug remimazolam sounds like an ideal drug for procedural sedation/anesthesia in children. However, I disagree with your favorable opinion regarding the name remimazolam. It seems inevitable that a serious mistake will be made because of the similarity in the names remimazolam and remifentanil. I can picture a busy anesthesiologist or pharmacist mistakenly hitting the wrong medication on the computer or mobile device when both drugs appear on autofill on the drop-down menu resulting in the potential for a fat-finger mistake. Also, we know from the “Telephone Game” that communication of relatively simple words or phrases whispered from person to person frequently results in a different word or phrase by the time it has reached the final person in the chain. Similarly, we all have made the common mistake of thinking about one word, accidentally saying the wrong word…but insisting that we didn’t. I can hear the anesthesia resident saying, “No, you definitely said remifentanil”. 

Isn’t having the identical “remi” prefix increasing the potential for a mistake akin to having a glass vial of succinylcholine identical in shape/size to a glass vial of zofran? Finally, why not come up with a trade name that is friendlier to lay persons? The trade name for remimazolam is “Byfavo”…although I’d prefer “MyFav”. We all have had parents or patients tell us “the sedation they used when we travelled to ____ was the best...I just can’t remember the name”.  In that vein, “versed” the trade name for midazolam, is much easier to remember than midazolam. Finally (the real “finale”), what a monumental missed opportunity in drug-naming occurred when flumazenil was approved and given the trade name romazicon? No, no, no…it should have been “re-versed”, get it? 

From Mark Schreiner MD

Beyond the effects of PM_2·5 air pollution in children and anesthesia, the long term effects on older adults is also a serious and frightening problem. Shi et al. found that “PM_2·5 is significantly associated with an increased hazard of first hospital admission with Parkinson's disease and Alzheimer's disease and related dementias. For the ageing American population, improving air quality to reduce PM_2·5 concentrations to less than current national standards could yield substantial health benefits by reducing the burden of neurological disorders.” Take a look at this article:

Shi L et al. A. Long-term effects of PM_2·5 on neurological disorders in the American Medicare population: a longitudinal cohort study. Lancet Planet Health. 2020 Dec;4(12):e557-e565. doi: 10.1016/S2542-5196(20)30227-8. Epub 2020 Oct 19. PMID: 33091388; PMCID: PMC7720425.

And another article from JAMA

Fadadu RP, Solomon G, Balmes JR. Wildfires and Human Health. JAMA. 2024 Sep 24;332(12):1011-1012. doi: 10.1001/jama.2024.13600. PMID: 38985542.

From Bommy Hong Mershon MD

In re: using an LMA with paralysis, I have done it (not intentionally but after it was placed, surgeon asked for paralysis and because the LMA was seated well, I decided not to exchange it to a tube). What I mean by "if the LMA is seated well" is this:  I test the LMA placement by placing them on the vent and look at the tidal volumes and most importantly, the ETCO2 waveform. If it is well placed, then the waveform looks indistinguishable from an ETT waveform). In this case where the patient had an LMA and was paralyzed, I was able to use mechanical ventilation. (And of course I reversed at the end). But when an LMA is seated well, I have used mechanical ventilation with LMAs and it works very well. 

From Walter I. Weiss MD DABA FASA, Chief, Pediatric Anesthesiology, NYU Langone Hospital-Long Island

As far as muscle relaxation and LMAs, I’ve been doing it selectively ever since I got my first set of reusable ones (which I still have in a box). I won’t do it for upper abdominal or thoracic procedures but for lower abdomen (eg. inguinal hernias) or limb procedures, or those pesky bladder cystoscopies that benefit from relaxation, I sure do. And curiously, like the Chinese, cisatracurium is my relaxant of choice. 

From Gerald A. Bushman MD, Professor of Anesthesiology, Keck School of Medicine, Children's Hospital Los Angeles

I would NEVER use an LMA for a paralyzed patient undergoing an abdominal procedure, scope or open.  I will defer what could otherwise be lengthy commentary on this and related practices!