Clinical Trial/Experimental Study Medicine ®

OPEN

Differences in midazolam premedication effects

on recovery after short-duration ambulatory
anesthesia with propofol or sevoflurane for
gynecologic surgery in young patients
A randomized controlled trial
∗
Hyunjee Kim, MD, PhD , Sung-Sik Park, MD, PhD, Jihye Shim, MD

Abstract
Background: Anxiolytic premedication requires careful consideration owing to potential side effects including delayed recovery
after ambulatory anesthesia. We aimed to compare the effect of midazolam on recovery profiles postoperatively, depending on
whether propofol or sevoflurane was the primary anesthetic.
Methods: We enrolled 226 patients (age, 18–50 years) undergoing ambulatory gynecologic laparoscopic surgery. Patients were
categorized into propofol without midazolam (P), propofol with midazolam (MP), sevoflurane without midazolam (S), and sevoflurane
with midazolam (MS) groups. As premedication, placebo or 0.02 mg/kg intravenous midazolam was used. The primary outcome was
the difference in the time from anesthetic discontinuation to eye opening in response to verbal command. Secondary outcomes
included postoperative nausea and pain occurrence and time to reach the discharge score.
Results: The time from anesthetic discontinuation to eye opening was longer in the MP group (n = 49) than in the P group (n = 50;
P < .001) but was not significantly different between the MS (n = 50) and S groups (n = 49; P = .1). Midazolam premedication did not
significantly affect postoperative nausea in the MP group compared with that in the P group (P = .3) but had a nausea prevention
effect in the MS group compared with that in the S group (P < .001). The time to reach the discharge score was similar in all patients
regardless of midazolam administration.
Conclusion: In the recovery from short-duration ambulatory gynecologic surgery in young patients, intravenous midazolam
premedication showed positive effects on postoperative nausea without affecting the time from anesthetic discontinuation to eye
opening with sevoflurane-based anesthesia but prolonged the time from anesthetic discontinuation to eye opening with propofol-
based anesthesia. Because this difference between the propofol groups is not clinically significant, the results support midazolam
premedication in young women. Further studies assessing larger populations are needed.
Abbreviations: BIS = bispectral index, MAC = minimum alveolar concentration, MOASS = Modified Observer’s Assessment of
Alertness/Sedation Scale, NRS = numerical rating scale, Nu-DESC = Nursing Delirium Screening Scale, PACU = postanesthesia
care unit, PONV = postoperative nausea and vomiting.
Keywords: ambulatory care, anesthesia recovery period, midazolam, postoperative nausea and vomiting, premedication

Editor: Zongwang Zhang.

The authors have no conflicts of interest to disclose. 1. Introduction
The datasets generated during and/or analyzed during the current study are In the ambulatory setting in particular, both preoperative
available from the corresponding author on reasonable request. anxiolysis and early recovery are important and are a major
Department of Anesthesiology and Pain Medicine, School of Medicine, concern for clinicians. Thus, anxiolytic premedication should be
Kyungpook National University, Jung-gu, Daegu, Republic of Korea.
∗
carefully selected to avoid delayed recovery after short-duration
Correspondence: Hyunjee Kim, Department of Anesthesiology and Pain outpatient surgeries. Short-duration anesthesia may have differ-
Medicine, School of Medicine, Kyungpook National University, 130 Dongdeok-ro,
Jung-gu, Daegu 41944, Republic of Korea (e-mail: [email protected]).
ent effects on the emergence from general anesthesia depending
on the premedication status.
Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative Midazolam is a drug that is commonly prescribed before
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is surgery as premedication. The effects of midazolam premed-
permissible to download, share, remix, transform, and buildup the work provided ication include reduced anxiety, postoperative nausea, and
it is properly cited. The work cannot be used commercially without permission amnesia.[1] Midazolam has a sedative effect and may affect the
from the journal.
emergence from anesthesia.[2,3]
How to cite this article: Kim H, Park SS, Shim J. Differences in midazolam
We hypothesize that the presence or absence of midazolam
premedication effects on recovery after short-duration ambulatory anesthesia
with propofol or sevoflurane for gynecologic surgery in young patients: A premedication would have different effects on the emergence time
randomized controlled trial. Medicine 2020;99:47(e23194). if different primary anesthetics were used to achieve short-
Received: 5 July 2020 / Received in final form: 11 October 2020 / Accepted: 17 duration anesthesia. Hence, this prospective, randomized,
October 2020 controlled trial was designed to compare the effects of midazolam
http://dx.doi.org/10.1097/MD.0000000000023194 premedication on recovery depending on whether propofol or

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Kim et al. Medicine (2020) 99:47 Medicine

sevoflurane was used as the primary anesthetic. In addition, anxiety) and the Modified Observer’s Assessment of Alertness/
postoperative nausea and pain were assessed. Midazolam was Sedation Scale (MOASS; 0 = no response to painful stimulation,
administered by an intravenous route with a faster onset.[4] To 1 = responds only to painful stimulation, 2 = responds only after
reduce confusion due to surgery type and evaluate the effects of mild prodding or shaking, 3 = responds after name called loudly or
midazolam premedication on postoperative nausea, the study repeatedly or both, 4 = lethargic response to name spoken in a
was restricted to laparoscopic surgery. normal tone, and 5 = responds readily to name spoken in a normal
tone) (modified from Sun et al[6]) were used twice: 30 minutes
before the administration of the allocated premedication drug at
2. Materials and methods
the outpatient center and shortly after entering the operating room
2.1. Study design (30 minutes after the allocated premedication drug administra-
tion). The anxiety and sedation levels were evaluated by a
The Institutional Review Board of Keimyung University Dongsan
designated investigator (JHS) who was blinded to the allocated
Hospital (DSMC 2017–07-021; September 12, 2017) approved
groups. When the NRS score for a patient’s anxiety level was >6 at
this study. This study was designed as a prospective, randomized,
the outpatient center, the patient was excluded from the study and
controlled trial and was conducted at the Keimyung University
stabilized by the administration of anxiolytics.
Dongsan Hospital. Patients scheduled for ambulatory gynecologic
The patients’ electrocardiography, noninvasive blood pressure,
laparoscopic surgeries under general anesthesia were enrolled and
pulse oximetry, temperature, bispectral index (BIS), and train-of-
provided written informed consent for participation.
four in the operating room were monitored. Vital signs were
recorded at 3- to 5-minute intervals in the operating room and
2.2. Inclusion/exclusion criteria postanesthesia care unit (PACU), as appropriate. To induce
Patients who were undergoing ambulatory gynecologic laparo- anesthesia, intravenous propofol 1.5 to 2 mg/kg and sufentanil
scopic surgeries under general anesthesia; were 18 to 50 years of 0.1 mg/kg were administered to all patients, and rocuronium 0.6
age; were nonsmokers; had a surgery and anesthesia duration of mg/kg was administered through tracheal intubation. To maintain
1 hour; and had an American Society of Anesthesiologists the BIS value between 40 and 60 during anesthesia, a continuous
physical status class of I–II were included in the study. Those who intravenous infusion of propofol 4 to 6 mg/kg/h was applied in the
P and MP groups, and the end-tidal concentration of sevoflurane
were severely obese (body mass index ≥35 kg/m2)[5]; were
smokers; had a history of postoperative nausea and vomiting was maintained at 0.8 to 1.2 minimum alveolar concentration
(PONV) or motion sickness; experienced nausea or vomiting (MAC) using an age-related iso-MAC chart[7] in the S and MS
within 48 hours before surgery; were taking psychotropic groups. Intravenous dexamethasone 5 mg and sufentanil 0.1 mg/kg
medications (benzodiazepines, antidepressants, antiepileptics, were administered before incision. Before surgery completion,
and antipsychotics); experienced depression, cirrhosis, heart intravenous ketorolac 30 mg was administered. Propofol and
failure, and renal failure; and were pregnant or lactating were sevoflurane were discontinued at surgery completion, and the fresh
excluded from the study. gas flow was increased to 10 L/min. Intravenous pyridostigmine
0.2 mg/kg and glycopyrrolate 0.01 mg/kg were administered when
3 twitch responses to train-of-four stimuli were observed.
2.3. Study procedures Verbal commands were repeated at 30-second intervals to
The patients were categorized into 4 groups: propofol without assess the patient’s consciousness. The BIS value at the time of
midazolam (P), propofol with midazolam (MP), sevoflurane anesthetic discontinuation and the time from anesthetic discon-
without midazolam (S), and sevoflurane with midazolam (MS) tinuation to eye opening were recorded by an investigator (JHS)
groups. A randomization sequence for the 4 groups in a 1:1:1:1 who was blinded to the allocation. The endotracheal tube was
ratio was produced in blocks of 8 using a computer-generated removed when the patient could open their eyes on verbal
random number sequence. Group allocation was conducted the command and when spontaneous ventilation was adequate.
day before the surgery using sealed, number-coded envelopes. In Upon arrival at the PACU, the severities of postoperative nausea
the outpatient center, where patients received the premedication and pain were graded using a 4-point NRS (0 = none, 1 =
before surgery and were prepared for discharge after surgery, an minimal, 2 = moderate, and 3 = severe), and the incidence of
intravenous catheter was inserted and secured. The premed- dizziness was assessed by a nurse who was unaware of the
ication drug was prepared and administered by a nurse who had conditions of the study. Both vomiting and dry retching were
no further study involvement. The purpose of premedication was considered as 3 points on the NRS. Intravenous ramosetron and
to reduce anxiety from the time a patient entered the operating paracetamol were administered for nausea and pain, respectively,
room until the induction of anesthesia. Thirty minutes before when the relevant NRS scores were ≥2 or when the patient
entering the operating room, intravenous midazolam 0.02 mg/kg requested the medications. When the score on the modified
(not exceeding 2.5 mg)[6] or normal saline 2.5 mL (placebo) was Aldrete scoring system reached 9,[8] an investigator unaware of
administered over ≥15 seconds to each patient following pulse the conditions of the study evaluated postoperative delirium
oximetry and noninvasive blood pressure monitoring. Decrease using the Nursing Delirium Screening Scale (Nu-DESC)[9,10] (5
in arterial oxygen saturation (SpO2 < 92%), hypotension items including disorientation, inappropriate behavior, inappro-
(decrease in systolic blood pressure of >30% from baseline), priate communication, hallucination, and psychomotor retarda-
and other side effects were assessed and recorded. tion are rated from 0 to 2; 0 = no symptom, 1 = mild, and 2 =
pronounced), and the patients were transferred from the PACU to
the outpatient center. Nausea, pain, and dizziness were assessed
2.4. Study assessments and medication
on arrival at the outpatient center. The patients were discharged
To evaluate preoperative anxiety and sedation levels, the after reaching 9 points in the discharge criteria.[11] Nausea, pain,
numerical rating scale (NRS; from 0 = no anxiety to 10 = extreme dizziness, and cognitive impairment were assessed in 3 follow-up

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telephone calls to all patients at 24, 48, and 120 hours after different in each comparison. Additionally, differences in blood
surgery.[12] pressure and heart rate before and after premedication drug
administration were not statistically significant. No patient
exhibited significant hypotension (decrease in systolic blood
2.5. Study endpoints
pressure of >30% from the baseline value). Two patients in the
The primary outcome was the difference in the time from MS group showed decreases in SpO2 (90%–91%), but no
anesthetic discontinuation to eye opening in response to verbal treatment was required and provided. The incidence of
command. The secondary outcomes were the differences in intraoperative hypotension was not significantly different in
anxiety NRS and MOASS scores before and after administration each comparison.
of the allocated premedication, incidence of PONV during the The preoperative anxiety and consciousness and postoperative
recovery period in the PACU and outpatient center, NRS scores variables in the P and MP groups are shown in Table 2. The data
for nausea/pain and the use of rescue antiemetics and analgesics for the S and MS groups are shown in Table 3. When changes in
in the PACU and outpatient center, Nu-DESC symptom scores anxiety NRS and MOASS scores before and after premedication
≥2, time to reach a 9-point score on the modified Aldrete scale, drug administration were analyzed, the scores were significantly
time to reach a 9-point score in the discharge criteria, NRS scores reduced in the midazolam-treated groups (i.e., MP vs P and MS vs
for nausea/pain/dizziness, and the presence of cognitive im- S).
pairment after discharge. The systolic blood pressure and heart There was no statistically significant difference in the BIS
rate values, measured on arrival at the outpatient center and values at surgery completion. The time from anesthetic
operating room (i.e., before and after administration of the discontinuation to eye opening was significantly longer in the
allocated premedication drug), and the incidence of intraoper- MP group than in the P group but was not significantly different
ative hypotension were also compared among the groups. between the MS and S groups. The incidence of PONV (including
at the PACU and outpatient center), nausea scores, and pain
2.6. Statistical analyses scores were not significantly different between the MP and P
groups; however, the incidence of PONV and nausea scores were
Statistical analyses were performed using SPSS version 24.0 (IBM significantly lower in the MS group than in the S group, and both
Corporation, Armonk, NY). The sample size was calculated from groups had similar pain scores during the postanesthesia recovery
a pilot study, in which the time from anesthetic discontinuation to period. The time to reach 9-point ratings on the modified Aldrete
eye opening were (mean ± standard deviation) 6.0 ± 1.3, 6.9 ± scoring system at the PACU and the time to reach 9-point scores
1.2, 7.3 ± 1.5, and 7.4 ± 1.2 minutes in the P, MP, S, and MS in the discharge criteria at the outpatient center were not
groups, respectively (n = 10 per group). Assuming a two-tailed a significantly different in each comparison. No occurrence of
of 0.05 and power of 90%, the required sample size was delirium (evaluated using the Nu-DESC) was noted in the PACU,
determined as 98 (49 per group) for the time from anesthetic and the incidence of dizziness was not significantly different in
discontinuation to eye opening to demonstrate a statistically each comparison. There was no difference in nausea, pain, and
significant difference between the P and MP groups. Thus, dizziness assessed through telephone calls after discharge in each
assuming a dropout rate of 10%, a target sample size of 55 comparison. No development of cognitive impairment was noted
patients per group was planned. None of the patients in the pilot after discharge.
study were included in this study. To compare continuous
variables, the independent Student t test or Mann–Whitney U test
was performed according to the data distribution. Levene test 4. Discussion
was used to assess the homogeneity of variances. Categorical data This study differs from previous studies in that the effects of
in the cross-tabulation tables were compared using Pearson chi- midazolam premedication on each patient under propofol-based
square or Fisher exact test. P < .05 was considered to indicate and sevoflurane-based anesthesia were assessed and the differ-
statistical significance. No direct comparison was made between ences were identified. Intravenous midazolam premedication
the anesthetic agents. reduced the patients’ anxiety when the patients arrived at the
operating room. The time from anesthetic discontinuation to eye
opening was significantly longer in the group who received
3. Results midazolam as premedication and propofol-based anesthesia, but
Overall, 226 patients were enrolled between March 2018 and there were no changes in the group who received midazolam as
June 2019 from a total of 318 patients assessed for eligibility. premedication and sevoflurane-based anesthesia. Midazolam
Sixty-eight patients were excluded based on the exclusion criteria, premedication did not have an effect on the incidence of PONV in
24 declined to participate, and 9 were excluded as they had patients who received propofol-based anesthesia but had a
anxiety NRS scores of >6 at the outpatient center. Nineteen nausea-preventing effect in patients who received sevoflurane-
patients were not included in the analysis because the duration of based anesthesia. The time to reach the satisfactory discharge
their surgeries and anesthesia exceeded 1 hour. Thus, 198 score was similar in all groups regardless of whether midazolam
patients were included in the analysis (P group, 50; MP group, premedication was administered.
49; S group, 49; and MS group, 50; Fig. 1). The surgeries Recently, a meta-analysis reported that the administration of
performed for the patients were ovarian cystectomy, salpingo- benzodiazepine premedication does not seem to prolong the
oophorectomy, excision of endometriosis, and myomectomy. recovery time after ambulatory surgery under short-duration
Demographic data and vital signs of the patients and procedure anesthesia.[3] The studies included in this meta-analysis varied in
durations are presented in Table 1. The patients’ age, height, the type and route of administration of the premedication drug,
weight, duration of anesthesia, systolic blood pressure, and heart that is, oral midazolam, intramuscular midazolam, intravenous
rate on arrival at the outpatient center were not significantly midazolam, oral temazepam, oral alprazolam, oral diazepam,

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oral lorazepam, and intravenous lorazepam. Among the present study might have opened their eyes when the effect-site
benzodiazepines, midazolam has a rapid onset of action and sevoflurane concentration became very low, and it can be
short half-life.[4] It has a shorter duration of action when surmised that midazolam did not affect eye-opening time at this
administered intravenously than when administered via other low sevoflurane concentration. Short-duration ambulatory
routes.[4,13] In addition, intramuscular injections can cause pain, anesthesia may be a key factor in this difference. For surgeries
but intravenous administration does not make the patient with longer durations, the effect of intravenously administered
uncomfortable if intravenous access is already available. These midazolam premedication may not last until surgery completion
points confer validity on intravenous midazolam premedication and is therefore less likely to affect recovery postoperatively. In
for short-duration ambulatory anesthesia. As assessed and addition, the synergistic sedation by the combination of
verified in this study, however, patients should be carefully midazolam and propofol may have affected the time from
monitored as midazolam can affect their level of consciousness. anesthetic discontinuation to eye opening in this study.[16]
This study was conducted on patients aged <50 years, and there Although the mean difference in eye-opening time from 4.9 to 7.0
was no occurrence of delirium after surgery. However, minutes when using propofol-based anesthesia was statistically
midazolam premedication in elderly patients who will receive significant in the present study, this is not considered to indicate a
ambulatory anesthesia requires careful consideration.[14] clinically meaningful delayed recovery. The results of this study
In the present study, the time from anesthetic discontinuation can contribute to the selection and decision making in various
to eye opening in response to verbal command differed between clinical situations because midazolam premedication may have
the midazolam premedication group and placebo group when different effects on the patients’ recovery depending on the
using propofol-based anesthesia. In a study of responses to verbal primary anesthetics used.
commands during sedation under BIS monitoring, the probability Midazolam premedication effectively reduces the incidence of
of responding was significantly higher in patients receiving postoperative nausea.[1] However, in this study, administering
propofol than that in patients receiving sevoflurane.[15] The midazolam as a premedication did not significantly affect
coexistence of midazolam with propofol-based anesthesia may postoperative nausea when propofol-based anesthesia was used;
have interfered with such early eye opening; that is, with conversely, the severity of nausea was decreased postoperatively
midazolam, eye opening may have been delayed until after when midazolam premedication was administered and sevoflur-
propofol concentrations rapidly decreased to very low levels. ane-based anesthesia was used. The predictors of postoperative
Based on the aforementioned results,[15] the patients in the nausea in this study were young age, female sex, and being

Figure 1. Patient flow diagram.

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Table 1
Demographic data, blood pressure, and heart rate before and after premedication, and the duration of anesthesia.
Group P Group MP P value Group S Group MS P value P value
(n = 50) (n = 49) (P vs PM) (n = 49) (n = 50) (S vs SM) (all groups)
Age, y 42 ± 5 41 ± 7 .3 42 ± 6 41 ± 6 .6 .7
Height, cm 161 ± 5 162 ± 4 .2 162 ± 4 162 ± 4 .9 .6
Weight, kg 56 ± 5 56 ± 4 .8 57 ± 4 56 ± 5 .2 .1
BP at outpatient center, mmHg 118 ± 14 117 ± 13 .4 118 ± 12 120 ± 13 .3 .5
BP on arriving in operating room, mmHg 119 ± 12 115 ± 11 .3 118 ± 12 120 ± 13 .3 .5
HR at outpatient center, beats/min 80 ± 9 82 ± 9 .4 81 ± 9 80 ± 10 .6 .6
HR on arriving in operating room, beats/min 81 ± 10 83 ± 9 .6 84 ± 10 82 ± 9 .2 .6
Duration of anesthesia, min 45 ± 6 44 ± 8 .4 44 ± 6 45 ± 7 .6 .8
Data are presented as mean ± SD.

nonsmokers.[17] In contrast, the use of dexamethasone and short allocated premedication. A single measurement of the patients’
anesthesia durations were factors in reducing postoperative blood pressure may have large intra-individual variability and
nausea. Because propofol-based anesthesia reduced the incidence may lead to inconclusive interpretation of the study outcomes. In
of postoperative nausea, the combination of the abovementioned the present study, midazolam reduced the patients’ anxiety (as
nausea-reducing factors and the use of propofol seemed to measured by the subjective expressions of the patients), but the
prevent statistically significant differences in nausea scores. Thus, study was unlikely to identify how midazolam premedication
sevoflurane-based anesthesia benefited from the nausea-reducing affected blood pressure or heart rate changes associated with
effect of midazolam in this study. In the group who received preoperative anxiety.
sevoflurane-based anesthesia in the present study, midazolam In conclusion, anxiolytic premedication with midazolam in
premedication reduced the postoperative nausea NRS scores by young women showed different effects on postoperative recovery
0.7 on a 0 to 3 scale and the incidence of PONV by 21%. Short- depending on whether the primary anesthetic used was propofol
duration surgeries, previous PONV, and dexamethasone admin- or sevoflurane. When the postoperative period was compared
istration were associated with the overall reduction in PONV after short-duration ambulatory anesthesia, midazolam premed-
incidence, which is thought to result in less significant clinical ication prolonged the time from anesthetic discontinuation to eye
differences. opening but did not affect postoperative nausea when propofol-
The limitations of this study include the fact that all the selected based anesthesia was used; however, midazolam premedication
study subjects were young women, although the reason for this had a positive effect on postoperative nausea without affecting
selection was that the anti-anxiety effects of midazolam the time from anesthetic discontinuation to eye opening when
premedication are particularly useful in young women.[6] Thus, sevoflurane-based anesthesia was used. The difference in eye-
further research is needed to determine sex-related and age- opening time when propofol-based anesthesia is used is not
related differences in the effects of midazolam premedication considered to exhibit a clinically meaningful delay in recovery.
when using different primary anesthetics. Another limitation is Thus, the results presented in this study can be interpreted as
the fact that the blood pressure and heart rate of the patients were providing additional evidence for the clinical application of
only measured once before and after the administration of the midazolam as premedication without discrediting its use in young

Table 2
Preoperative anxiety and consciousness and postoperative variables in patients receiving propofol-based anesthesia.
Group P (n = 50) Group MP (n = 49) P value Difference or odds ratio (95% CI)
Anxiety severity at outpatient center (NRS, 0–10) 3.7 ± 0.8 3.8 ± 0.8
Anxiety severity on arriving in operating room (NRS, 0–10) 4.1 ± 0.9 1.8 ± 1.2
∗
NRS difference 0.4 ± 0.5 2.0 ± 1.1 <.001 2.4 (2.1, 2.7)
∗
MOASS difference between outpatient center and operating room 0 0.2 ± 0.4 .001 0.2 ( 0.3, 0.1)
Incidence of intraoperative hypotension 9 (18) 13 (27) .3 1.6 (0.6,4.3)
BIS at surgery completion 51.0 ± 3.1 49.8 ± 3.9 .2 1.1 ( 0.3, 2.5)
∗
Eye opening time, min 4.9 ± 1.3 7.0 ± 1.8 <.001 2.1 ( 2.8, 1.5)
PACU + outpatient center
Incidence of PONV 24 (48) 16 (33) .15 0.5 (0.2, 1.2)
Nausea NRS (0–3) 0.5 ± 0.4 0.4 ± 0.5 .3 0.1 ( 0.1, 0.4)
Pain NRS (0–3) 1.3 ± 0.7 1.2 ± 0.7 .57 0.8 ( 0.2, 0.3)
Rescue antiemetics 4 (8) 3 (6) 1.0 0.8 (0.2, 3.5)
Rescue analgesics 13 (26) 13 (27) 1.0 1.0 (0.4, 2.5)
Time to Aldrete 9 points, min 15.7 ± 3.0 15.8 ± 3.6 .6 0.3 ( 1.6, 0.9)
Time to discharge score, min 71.3 ± 12.2 74.9 ± 13.7 .3 2.8 ( 8.0, 2.4)
Data are presented as mean ± SD or number (%). BIS = bispectral index, MOASS = Modified Observer’s Assessment of Alertness/Sedation Scale score, NRS = numerical rating scale, PACU = postanesthesia care
unit, PONV = postoperative nausea and vomiting.
∗
P < .05.

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Table 3
Preoperative anxiety and consciousness and postoperative variables in patients receiving sevoflurane-based anesthesia.
Group S (n = 49) Group MS (n = 50) P value Difference or odds ratio (95% CI)
Anxiety severity at outpatient center (NRS, 0–10) 3.9 ± 0.8 3.9 ± 0.9
Anxiety severity on arriving in operating room (NRS, 0–10) 4.5 ± 0.8 1.7 ± 1.2
∗
NRS difference 0.6 ± 0.8 2.2 ± 1.4 <.001 2.8 (2.3, 3.2)
∗
MOASS difference between outpatient center and operating room 0 0.2 ± 0.4 .002 0.2 ( 0.3, 0.1)
Incidence of intraoperative hypotension 15 (31) 10 (20) .3 0.6 (0.2, 1.4)
BIS at surgery completion 48.3 ± 3.3 50.1 ± 3.7 .09 1.4 ( 2.8, 0.1)
Eye opening time, min 7.4 ± 1.3 7.8 ± 1.5 .1 0.45 ( 1.0, 0.1)
PACU + outpatient center
∗
Incidence of PONV 32 (65) 22 (44) .04 0.4 (0.2, 0.9)
∗
Nausea NRS (0–3) 1.2 ± 0.5 0.5 ± 0.5 <.001 0.7 (0.4, 1.1)
Pain NRS (0–3) 1.4 ± 0.7 1.3 ± 0.7 .8 0.03 ( 0.3, 0.2)
Rescue antiemetics 10 (20) 5 (10) .2 0.4 (0.1, 1.4)
Rescue analgesics 15 (31) 16 (32) 1.0 1.1 (0.5, 2.5)
Time to Aldrete 9 points, min 17.0 ± 3.6 16.4 ± 3.0 .5 0.5 ( 0.9, 1.8)
Time to discharge score, min 77.1 ± 12.3 77.9 ± 14.3 .9 0.2 ( 5.5, 5.1)
Data are presented as mean ± SD or number (%). BIS = bispectral index, MOASS = Modified Observer’s Assessment of Alertness/Sedation Scale score, NRS = numerical rating scale, PACU = postanesthesia care
unit, PONV = postoperative nausea and vomiting.
∗
P < .05.

women. As benzodiazepines should be carefully selected in [5] Consultation WHOEAppropriate body-mass index for Asian popula-
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Author contributions [7] Nickalls RW, Mapleson WW. Age-related iso-MAC charts for isoflurane,
sevoflurane and desflurane in man. Br J Anaesth 2003;91:170–4.
Conceptualization: Hyunjee Kim.
[8] Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth
Data curation: Hyunjee Kim. 1995;7:89–91.
Formal analysis: Hyunjee Kim. [9] Luetz A, Heymann A, Radtke FM, et al. Different assessment tools for
Investigation: Jihye Shim. intensive care unit delirium: which score to use? Crit Care Med
Methodology: Hyunjee Kim, Jihye Shim. 2010;38:409–18.
[10] Bilotta F, Lauretta MP, Borozdina A, et al. Postoperative delirium: risk
Supervision: Sung-Sik Park. factors, diagnosis and perioperative care. Minerva Anestesiol
Validation: Hyunjee Kim, Jihye Shim. 2013;79:1066–76.
Writing – original draft: Hyunjee Kim, Jihye Shim. [11] Marshall SI, Chung F. Discharge criteria and complications after
Writing – review & editing: Hyunjee Kim. ambulatory surgery. Anesth Analg 1999;88:508–17.
[12] Knopman DS, Roberts RO, Geda YE, et al. Validation of the telephone
interview for cognitive status-modified in subjects with normal cognition, mild
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