The use of remimazolam versus propofol for induction and maintenance of general anesthesia: A systematic review and meta-analysis

Abstract

Background: The primary objective of this study was to compare the risk of hypotension, as well as the induction and recovery characteristics between remimazolam and propofol in patients receiving surgery under general anesthesia.Methods: The Embase, Medline, Google scholar, and the Cochrane Library databases were searched from inception to March 2022 for randomized controlled trials The primary outcome was the risk of post-induction hypotension between the two agents, while the secondary outcomes included anesthetic depth, induction efficacy, time to loss of consciousness (LOC), hemodynamic profiles, time to eye opening, extubation time as well as the incidence of injection pain and postoperative nausea/vomiting (PONV).Results: Meta-analysis of eight studies published from 2020 to 2022 involving 738 patients revealed a significantly lower risk of post-induction hypotension with the use of remimazolam compared to that with propofol [risk ratio (RR) = 0.57, 95% confidence interval (CI): 0.43 to 0.75, p < 0.0001, I2 = 12%, five studies, 564 patients]. After anesthetic induction, the anesthetic depth measured by bispectral index (BIS) was lighter in the remimazolam group than that in the propofol group (MD = 9.26, 95% confidence interval: 3.06 to 15.47, p = 0.003, I2 = 94%, five studies, 490 patients). The time to loss of consciousness was also longer in the former compared to the latter (MD = 15.49 s, 95%CI: 6.53 to 24.46, p = 0.0007, I2 = 61%, three studies, 331 patients). However, the use of remimazolam correlated with a lower risk of injection pain (RR = 0.03, 95%CI: 0.01 to 0.16, p < 0.0001, I2 = 0%, three studies, 407 patients) despite comparable efficacy of anesthetic induction (RR = 0.98, 95%CI: 0.9 to 1.06, p = 0.57, I2 = 76%, two studies, 319 patients). Our results demonstrated no difference in time to eye opening, extubation time, and risk of PONV between the two groups.Conclusion: Remimazolam was associated with a lower risk of post-induction hypotension after anesthetic induction compared with propofol with similar recovery characteristics. Further studies are required to support our findings.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/; Identifier: CRD42022320658.

Remimazolam and serious adverse events

“…These results were confirmed by four meta-analyses that reported that remimazolam is more haemodynamically stable than propofol or midazolam during sedation 116–119 . A recent meta-analysis by Ko et al , 120 published 2 days after conducting our literature search, confirms the haemodynamic stability of remimazolam for induction of general anaesthesia when compared with propofol. It seems that all commonly used sedatives, except for dexmedetomidine, show better haemodynamic stability during sedation than propofol 121 .…”

Comparison of the negative effect of remimazolam and propofol on cardiac contractility: Analysis of a randomised parallel‐group trial and a preclinical ex vivo study

“…First, in our clinical study, although the doses of propofol and remimazolam were decided according to the manufacturer's instructions and based on the results of our previous study, 8 and the T LOC was comparable between the study groups, the BIS value was significantly higher in the remimazolam group than in the propofol group, especially at T 4 . Remimazolam‐based anaesthesia showed a higher BIS value than propofol‐based anaesthesia, despite comparable anaesthetic effects due to the nature of benzodiazepines 7,30,31 . However, this might have been a confounding factor in our study.…”

“…Remimazolam-based anaesthesia showed a higher BIS value than propofol-based anaesthesia, despite comparable anaesthetic effects due to the nature of benzodiazepines. 7,30,31 However, this might have been a confounding factor in our study. Second, we examined the haemodynamic effects of the studied drugs during the induction of general anaesthesia; however, the haemodynamics during surgery Male Wistar rats were purchased from Sankyo Laboratory Service Corporation (Sapporo, Japan), and rats aged 10-13 weeks were used in the experiments.…”

Can remimazolam be safely used in cardiac tamponade?: A case report

“…It has better hemodynamic stability than other intravenous anesthetic agents except ketamine. [11,12] Also, it has less respiratory inhibition. however, unlike midazolam, it can be used for maintenance of anesthesia because it has a short context-sensitive half time.…”