Remimazolam for Procedural Sedation in Older Patients: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Remimazolam Versus Propofol in General Anesthesia of Complex Surgery in Critical and Non-Critical Patients: Meta-Analysis of Randomized Trials

Objective: To compare the efficacy and safety of remimazolam with propofol in general anesthesia in adult patients. Methods: A systematic search in Pubmed, Scopus, Web of Science, and Embase was performed. Patients undergoing complex surgery who were critically ill or non-critically ill were included. The risk of bias (RoB) 2.0 tool was applied. Random-effects models using the inverse variance method were applied for all meta-analyses. Results: Nine randomized controlled trials were included (patients taking remimazolam, n = 678; propofol, n = 454). Remimazolam compared to propofol is likely to produce a large decrease in intraoperative hypotension (RR 0.62, 95% CI 0.50 to 0.76, I2 = 63%, n = 9, CoE moderate certainty), incidence of respiratory depression (RR 0.28, 95% CI 0.09 to 0. 82, I2 = 0%, n = 3; CoE moderate certainty), injection site pain (RR 0.14, 95% CI 0.02 to 0.94, I2 = 21%, n = 4; CoE moderate certainty), and may produce little or no difference in bradycardia (RR 0.61, 95% CI 0.36 to 1.06, I2 = 0%, n = 4; CoE moderate certainty). Conclusions: In patients undergoing complex surgery who are critically ill or non-critically ill, remimazolam, compared with propofol, is likely to produce a large decrease in intraoperative hypotension, incidence of respiratory depression, and injection site pain, but little or no difference in bradycardia is possible.

Association of remimazolam with delirium and cognitive function: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND AND STUDY OBJECTIVE

Delirium is an organic mental syndrome significantly associated with long-term cognitive decline, increased hospital stays and higher mortality. This systematic review of randomised controlled trials (RCTs) with meta-analysis assesses the association of remimazolam with postoperative cognitive function and delirium compared with non-benzodiazepine hypnotics.

DESIGN

Systematic review of RCTs with meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library and Web of Science databases up to 27 April 2024.

ELIGIBILITY CRITERIA

Adult patients undergoing general anaesthesia or sedation procedures; use of remimazolam as the primary hypnotic or as an adjunct, administered via intermittent bolus or continuous infusion; comparison with other hypnotics or sedatives; evaluation of cognitive function or delirium.

MAIN RESULTS

Twenty-three RCTs with 3598 patients were included. The incidence of delirium was not significantly different between remimazolam and other sedatives in general anaesthesia and sedation procedures [n = 3261; odds ratio (OR) = 1.2, 95% confidence interval (CI), 0.76 to 1.91; P = 0.378843; I2 = 17%]. Regarding cognitive function evaluation, remimazolam showed no difference compared with the control group in Mini-Mental State Examination (MMSE) scores on the first postoperative day (n = 263; mean difference = 0.60, 95% CI, -1.46 to 2.66; P = 0.5684; I2 = 90%) or on the third postoperative day (n = 163; mean difference  = 1.33, 95% CI, -0.72 to 3.38; P = 0.2028; I2 = 93%). Remimazolam exhibited superiority over the control group in MMSE scores on the seventh postoperative day (n = 247; mean difference = 0.53, 95% CI, 0.30 to 0.75; P < 0.0001; I2 = 28%).

CONCLUSION

Remimazolam does not increase the incidence of delirium or cognitive impairments compared with non-benzodiazepine hypnotics. However, the analysis showed that the type of surgery significantly influenced the incidence of delirium. Additionally, remimazolam was associated with better short-term postoperative cognitive function.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42024532751.

Effect of remimazolam on intra-operative hypotension: Systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Hypotension is common during anaesthesia. Increasing number of studies have reported that remimazolam may be associated with lower incidence of intra-operative hypotension compared with other anaesthetics. However, the results remain controversial.

OBJECTIVE

This study aimed to evaluate the influence of remimazolam on intra-operative hypotension and its related outcomes (hypoxaemia, bradycardia and time to awake).

DESIGN

A systematic review of randomised controlled trials (RCTs) with meta-analyses.

DATA SOURCES

PubMed, Cocharane and Embase databases were searched to identify eligible RCTs published up to June 2024.

ELIGIBILITY CRITERIA

RCTs published in English were eligible for inclusion. The study patients were 18 years or older who were administered with remimazolam and other positive control agents in either the pre-operative or intra-operative period. The incidence of intra-operative hypotension was identified in these studies.

RESULTS

This study evaluated 34 trials including 4847 individuals. Basing on moderate-certainty evidence, we found that remimazolam administration reduced the incidence of intra-operative hypotension [risk ratio (RR) = 0.48, 95% confidence interval (95% CI): 0.41 to 0.57] and bradycardia (16 studies, n  = 2869, RR = 0.40, 95% CI: 0.29 to 0.54). No difference was observed in the incidence of hypoxaemia (RR = 0.70, 95% CI: 0.48 to 1.01) and time to awake (MD = -0.91, 95% CI: -2.42 to 0.60). The remarkable association between remimazolam and hypotension remained robust and significant, regardless of general anaesthesia or procedural sedation ( P  < 0.01, I2  = 82%). No significant difference was found between different control drugs ( P  = 0.97, I2  = 82%).

CONCLUSION

Moderate-quality evidence shows that remimazolam administration to patients undergoing general anaesthesia or procedural sedation decreases the incidence of intra-operative hypotension and bradycardia.

Age-Related Response to Remimazolam among Older Patients Undergoing Orthopedic Surgery: A Single-Center Prospective Observational Study

Background and Objectives: Remimazolam, an ultra-short-acting benzodiazepine, is increasingly used in procedural sedation and general anesthesia. It is characterized by rapid onset of action, inactive metabolites, no delay in recovery, and few adverse events. Its hemodynamic and respiratory stability are comparable to other anesthetics, and it is safe in high-risk and geriatric patients. Materials and Methods: This prospective, observational study enrolled 110 geriatric patients (aged 65 to 85 years) scheduled for primary total knee arthroplasty (TKA). The patients were divided into the old (65 to <75 years; n = 52) and the elderly (75 to 85 years; n = 47) geriatric groups. All surgical and anesthetic methods were applied in the same manner, and TKA was performed by one surgeon. Remimazolam was infused at 6 mg/kg/h for 3 min and then at 1 mg/kg/h until the end of surgery The primary study endpoint was the requirement for flumazenil; secondary endpoints were the times to reach a bispectral index (BIS) < 60 and >80, as well as the rate of apnea occurrence. Results: Flumazenil administration was similar in both groups. There were no differences in the time to reach BIS < 60 or the rate of apnea occurrence. Recovery characteristics, including the time to reach BIS > 80 and the achievement of full consciousness, were also comparable between the groups. Conclusions: Remimazolam is well-tolerated in geriatric patients undergoing orthopedic surgery, with minimal age-related differences in response. These results suggest that remimazolam is an appropriate anesthetic for geriatric patients, even with similar dosing strategies. It provides effective anesthetic depth with no significant increases in adverse outcomes during orthopedic surgery.

Comparison of Remimazolam and Propofol in Recovery of Elderly Outpatients Undergoing Gastrointestinal Endoscopy: A Randomized, Non-Inferiority Trial

Purpose

We designed this trial to compare the recovery time of remimazolam and propofol in elderly patients undergoing painless gastrointestinal endoscopy.

Patients and Methods

In this randomized, non-Inferiority trial, 360 patients aged 65 years or older, scheduled for elective outpatient gastrointestinal endoscopy, were randomly assigned to the remimazolam combined with fentanyl (RF) group or the propofol combined with fentanyl (PF) group. The primary outcome was the post-anesthesia care unit (PACU) stay time, defined as the time from the end of the examination to scoring 9 points using the Modified Post-Anesthetic Discharge Scoring System (MPADSS) criteria. Secondary outcomes included sedation-related adverse events, recall, injection pain, as well as postoperative Quality of Recovery-15 (QoR-15) scores and Pittsburgh Sleep Quality Index (PSQI) scores at 1 day, 1 week, and 1 month postoperatively.

Results

A total of 351 patients completed the study, with 174 receiving remimazolam and 177 receiving propofol. The PACU stay time in RF group was non-inferior to that in PF group [14 (11, 18) vs 13 (10, 17), mean difference 1 (95% confidence interval 0, 2), P=0.084 for noninferiority]. However, remimazolam was associated with lower rate of hypoxemia [4.7% (8/180) vs 12.4% (22/180), P=0.011], reduced use of vasoactive drugs [1 (0, 1) vs 1 (1, 2), P<0.001], less injection pain [2 (1.2%) vs 35 (21.3%), P<0.001], and lower recall [20 (11.8%) vs 36 (20.3%), P=0.034]. There were no differences in the QoR-15 scores and PSQI scores at postoperative 1 day, 1 week, and 1 month between groups.

Conclusion

This non-inferiority study revealed that in elderly outpatients undergoing gastrointestinal endoscopy, remimazolam achieved recovery times comparable to propofol, with fewer associated complications.

Remimazolam in intensive care unit: Potential applications and considerations

This manuscript explores the potential use of Remimazolam in the intensive care unit (ICU) and critical care units, considering its pharmacological characteristics, clinical applications, advantages, and comparative effectiveness over current sedatives and anesthetics. We reviewed existing PubMed and Google Scholar literature to find relevant studies on Remimazolam in ICU. We created search criteria using a combination of free text words, including Remimazolam, critical care, intensive care, sedation, anesthesia, pharmacokinetics, and pharmacodynamics. Relevant articles published in the English language were analyzed and incorporated. Remimazolam is an ultra-short-acting benzodiazepine derivative promising for sedation and anesthesia. It is a safer option for hemodynamically unstable, elderly, or liver or kidney issues. It also has comparable deep sedation properties to propofol in the ICU. Furthermore, it reduces post-procedural delirium and patient comfort and reduces the need for additional sedatives in pediatric patients. In conclusion, Remimazolam is an excellent alternative to current sedatives and anesthetics in the ICU. Its cost is comparable to that of current medications. Further research on its long-term safety in the ICU and its broader application and incorporation into routine use is necessary.