Effect of remimazolam vs. propofol on hemodynamics during general anesthesia induction in elderly patients: Single-center, randomized controlled trial

Comparison of the efficacy and safety of remimazolam and propofol for fiberoptic bronchoscopy in older patients: a prospective, randomized controlled study

OBJECTIVE

The aim of this study was to compare the efficacy and safety of remimazolam with those of propofol in older patients undergoing fiberoptic bronchoscopy with preserved spontaneous breathing.

METHODS

Sixty older patients were randomly and equally divided into a remimazolam group (group R) and a propofol group (group P). Both groups received 0.15 µg/kg of sufentanil for analgesia. Group R received an initial dose of 0.2 mg/kg remimazolam and was injected with a maintenance dose of 1 mg/kg/h. Group P received an initial dose of 2 mg/kg propofol and was injected with a maintenance dose of 4 mg/kg/h. The primary evaluation indicators were the success rate of sedation and the incidence of hypotension. The secondary evaluation indicators were respiratory depression, hypertension, tachycardia, bradycardia, awakening time, quality of recovery-15 (QOR-15) score, patient satisfaction, physician satisfaction, and adverse events.

RESULTS

Success rates of sedation were similar between group R (96.7%) and group P (100%). The incidence of hypotension in group R was lower than that in group P (2/30 vs. 10/30, p = 0.01). Respiratory depression was lower in group R than in group P (3/30 vs. 10/30, p = 0.03). Fewer patients reported injection pain in group R (0/30 vs. 7/30, p = 0.01). There were no significant differences in hypertension, tachycardia, bradycardia, awakening time, QoR-15 score, patient satisfaction, physician satisfaction, or adverse events between the two groups.

CONCLUSIONS

Remimazolam has a high sedation success rate for painless fiberoptic bronchoscopy in older patients, and the incidence of hypotension and respiratory depression is lower than that of propofol. Remimazolam may be a better choice for sedation during painless fiberoptic bronchoscopy in older patients with preserved spontaneous breathing.

TRIAL REGISTRATION

ChiCTR2300069041; 6/3/2023.

Comparison of Remimazolam and Propofol on Post-Induction Hypotension in Elderly Hypertensive Patients: A Randomized Controlled Trial

Purpose

Post-induction hypotension (PIH) is a common complication in elderly hypertensive patients, posing significant risks of inadequate organ perfusion and increased postoperative morbidity and mortality. This study evaluated the effectiveness of remimazolam in preventing PIH.

Patients and methods

In this randomized controlled trial, 196 elderly hypertensive patients undergoing elective general anesthesia surgery were randomly allocated to either the remimazolam group (Group R) or the propofol group (Group P). Group R received remimazolam at a dose of 0.15-0.2 mg/kg via intravenous infusion at a rate of 6.0 mg/kg/h, while Group P received propofol at a dose of 1.0-1.5 mg/kg via intravenous infusion at a rate of 60 mg/kg/h during induction. Primary outcome was the incidence of PIH. Secondary outcomes included the time-weighted average (TWA) of hypotension, norepinephrine usage, key time-point blood pressures from induction to skin incision, and postoperative quality of recovery-15(QoR-15) scale on postoperative day 1 and day 3 (POD1 and POD3).

Results

Among the 196 patients analyzed, Group R showed a significantly lower incidence of PIH compared to the Group P (46.5% vs 73.2%; P < 0.001). Additionally, Group R exhibited reduced frequency of hypotension (0 [0, 2] vs 2 [0, 3], P < 0.001), lower total time in hypotension (0 [0, 4] min vs 4 [0, 7] min, P < 0.001), lower TWA (0 [0, 0.67] mmHg vs 0.56 [0, 4.72] mmHg, P < 0.001), and decreased norepinephrine usage (0 [0, 16] μg vs 16 [0, 28] μg, P < 0.001). Hemodynamic stability was better maintained in Group R during anesthesia induction. No significant differences were observed in QoR-15 scores between the two groups on POD1 and POD3.

Conclusion

Compared with propofol, remimazolam significantly reduces the incidence of PIH in elderly hypertensive patients.

Effect of remimazolam on intraoperative hemodynamic stability in patients undergoing cerebrovascular bypass surgery: a prospective randomized controlled trial

BACKGROUND

Maintenance of stable blood pressure (BP) during cerebrovascular bypass surgery is crucial to prevent cerebral ischemia. We compared the effect of remimazolam anesthesia with that of propofol-induced and desflurane-maintained anesthesia on intraoperative hemodynamic stability and the need for vasoactive agents in patients undergoing cerebrovascular bypass surgery.

METHODS

Sixty-five patients were randomized into remimazolam (n = 31, remimazolam-based intravenous anesthesia) and control groups (n = 34, propofol-induced and desflurane-maintained anesthesia). The primary outcome was the occurrence of intraoperative hypotension. The secondary outcomes included hypotension duration, lowest mean BP (MBP), generalized average real variability (ARV) of MBP, and consumption of phenylephrine, norepinephrine, or remifentanil.

RESULTS

Occurrence rate and duration of hypotension were significantly lower in the remimazolam group (38.7% vs. 73.5%, P = 0.005; 0 [0, 10] vs. 7.5 [1.25, 25] min, P = 0.008). Remimazolam also showed better outcomes for lowest MBP (78 [73, 84] vs. 69.5 [66.25, 75.8] mmHg, P < 0.001) and generalized ARV of MBP (1.42 ± 0.49 vs. 1.66 ± 0.52 mmHg/min, P = 0.036). The remimazolam group required less phenylephrine (20 [0, 65] vs. 100 [60, 130] μg, P < 0.001), less norepinephrine (162 [0, 365.5] vs. 1335 [998.5, 1637.5] μg, P < 0.001), and more remifentanil (1750 [1454.5, 2184.5] vs. 531 [431, 746.5] μg, P < 0.001) than the control group.

CONCLUSIONS

Remimazolam anesthesia may provide better hemodynamic stability during cerebrovascular bypass surgery than propofol-induced and desflurane-maintained anesthesia.

Hypotension after induction of anesthesia with remimazolam or etomidate: a non-inferiority randomized controlled trial in patients undergoing coronary artery bypass grafting

BACKGROUND

Remimazolam is a novel ultra-short-acting benzodiazepine known for its hemodynamic stability over propofol. However, its hemodynamic effects compared to those of etomidate are not well established. This study aimed to determine whether the use of remimazolam is non-inferior to etomidate with regard to the occurrence of post-induction hypotension in patients undergoing coronary artery bypass grafting.

METHODS

Patients were randomly assigned to either the remimazolam group (6 mg/kg/h) or the etomidate group (0.3 mg/kg) for induction of anesthesia. Anesthetic depth was adjusted based on the bispectral index. Primary outcome was the incidence of post-induction hypotension, defined as a mean arterial pressure less than 65 mmHg within 15 min after endotracheal intubation, with a non-inferiority margin of 12%.

RESULTS

A total of 144 patients were finally analyzed. Incidence of post-induction hypotension was 36/71 (50.7%) in the remimazolam group and 25/73 (34.2%) in the etomidate group, with a rate difference of 16.5% (95% CI [3.0-32.6]) between the two groups that was beyond the prespecified non-inferiority margin of 12.0%. The number of patients who needed vasopressors was similar in the two groups.

CONCLUSIONS

In this non-inferiority trial, remimazolam failed to show non-inferiority to etomidate in terms of post-induction hypotension when used as an induction drug for general anesthesia in patients undergoing coronary artery bypass grafting. However, different doses or infusion techniques of remimazolam should be compared with etomidate in various patient groups to fully assess its hemodynamic non-inferiority during induction of anesthesia.

Comparison of the safety of remimazolam and propofol during general anesthesia in elderly patients: systematic review and meta-analysis

Background

Remimazolam is a novel sedative drug approved for procedural sedation and general anesthesia. Clinical trials have already explored its use in elderly patients for general anesthesia. For elderly patients with declining physical and physiological function, anesthesia safety is crucial. Most current clinical studies compare the safety of remimazolam and propofol, though the results are inconsistent. Therefore, we conducted a meta-analysis to compare the safety of remimazolam and propofol in general anesthesia for elderly patients.

Methods

We systematically searched the PubMed, Cochrane Library, Embase, and Web of Science databases for all published randomized controlled trials comparing remimazolam and propofol for general anesthesia in elderly patients. We synthesized data from eligible studies using relative risk or mean difference, and analyzed differences in hemodynamic stability and adverse effects between the two drugs. Data extraction and quality assessment were performed independently by two researchers.

Results

Eight randomized controlled trials involving 571 participants were included. Compared to propofol, remimazolam was associated with a lower incidence of hypotension (RR = 0.51, 95% CI: [0.33, 0.81], I 2 = 18%, p = 0.3 > 0.1) and bradycardia (RR = 0.56, 95% CI: [0.31, 1.02], Z = 1.88, p = 0.06 < 0.05). The mean arterial pressure after induction was higher in the remimazolam group (WMD = 3.95, 95% CI: [3.197, 9.498], Z = 3.95, p < 0.00001). The remimazolam group had a higher heart rate (HR) after induction compared to the propofol group (WMD = 7.89, 95% CI: [-2.39, 18.17], Z = 1.5, p = 0.13 > 0.05), but this result was not statistically significant. Among other secondary outcomes, the remimazolam group had lower incidences of injection site pain, nausea and vomiting, and hypoxemia compared to the propofol group, and also had a shorter extubation time.

Conclusion

In this meta-analysis, compared to propofol, remimazolam reduced the incidence of hypotension, bradycardia, and injection site pain during general anesthesia in elderly patients. The mean arterial pressure (MAP) and heart rate (HR) were more stable after induction. Remimazolam may be a safer sedative for elderly patients.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024516950, CRD42024516950.

Remimazolam Reduces Vasopressor Use Post-Induction and During Maintenance of General Anesthesia in Patients Undergoing Laparoscopic Gynecology: A Propensity Score-Matched Analysis

Objectives: Laparoscopic gynecological surgeries are commonly performed under general anesthesia and can induce cardiovascular depression and hypotension, requiring vasopressor support. Remimazolam, a novel ultra-short-acting benzodiazepine, is used to treat minimal cardiovascular depression. This study compared the hemodynamic effects of remimazolam and sevoflurane anesthesia in patients undergoing laparoscopic gynecological surgery. Methods: A retrospective analysis was conducted on 474 patients who underwent laparoscopic gynecological surgery at Korea University Anam Hospital between September 2021 and December 2022. The patients were categorized into two groups based on the anesthetic agent used: remimazolam or sevoflurane. Hemodynamic parameters, vasopressor use, and intraoperative variables were compared between anesthetic agents. Propensity score matching was applied to account for potential confounders, and logistic regression was utilized to assess the relationship between anesthesia type and outcomes. Results: Remimazolam anesthesia was linked to a significantly lower incidence of vasopressor use compared to sevoflurane-based anesthesia (3.7% vs. 19.5%, p < 0.0001). The odds of requiring vasopressor support were significantly lower during the post-induction and maintenance phases in the remimazolam group. Furthermore, hemodynamic stability, particularly systolic and mean arterial pressures, was better maintained with remimazolam than sevoflurane. Conclusions: Remimazolam provides superior hemodynamic stability and reduces the need for vasopressor support during laparoscopic gynecological surgery compared with sevoflurane.

Remimazolam vs. propofol for general anaesthesia in elderly patients: a meta-analysis with trial sequential analysis

BACKGROUND

Elderly patients comprise an increasing proportion of patients undergoing surgery, and they require special attention due to age-related physiological changes. Propofol is the traditional agent for anaesthesia, and recently, remimazolam, a novel ultra-short-acting benzodiazepine, has emerged as an alternative to propofol in general anaesthesia.

OBJECTIVES

We aim to compare remimazolam vs . propofol for general anaesthesia in elderly patients regarding hypotension, induction characteristics, haemodynamics and recovery outcomes.

DESIGN

Meta-analysis with sensitivity and trial sequential analyses (TSA) to assess inconsistencies. Risk ratios and mean differences with 95% confidence intervals (95% CIs) were computed using a random effects model. Subgroups and meta-regression according to anaesthesia methods were also performed.

DATA SOURCES

We systematically searched MEDLINE, Embase and Cochrane for randomised controlled trials (RCTs) up to January 1, 2024.

ELIGIBILITY CRITERIA

Patients at least 60 years old, comparing remimazolam vs . propofol for general anaesthesia.

RESULTS

Eleven RCTs (947 patients) were included. Compared with propofol, remimazolam was associated with lower postinduction and intra-operative hypotension (RR 0.41, 95% CI 0.27 to 0.62, P  < 0.001) and incidence of bradycardia (risk ratio 0.58, 95% CI 0.34 to 0.98, P  = 0.04), with a higher heart rate ( P  = 0.01). The incidence of injection pain was lower ( P  < 0.001), but remimazolam was associated with a longer time to loss of consciousness ( P  < 0.001) and a higher bispectral index at loss of consciousness ( P  = 0.04). No differences were found for mean arterial pressure, emergence time, extubation time and incidence of emergence agitation. The TSA was consistent and achieved the required information size for hypotension.

CONCLUSIONS

Remimazolam significantly reduced the risk of hypotension, bradycardia and injection pain, despite an increase in the time to loss of consciousness. Remimazolam appears to be an effective and well tolerated alternative to propofol in elderly patients undergoing general anaesthesia.

Remimazolam-based total intravenous anesthesia in a patient with a confirmed diagnosis of malignant hyperthermia: a case report

BACKGROUND

Malignant hyperthermia (MH) is a rare, life-threatening disorder of calcium homeostasis in skeletal muscle cells that is triggered by volatile anesthetics and succinylcholine, leading to a hypermetabolic reaction. The pathogenic ryanodine receptor 1 (RYR1) gene variant is critical. Patients susceptible to MH should avoid triggering agents, and total intravenous anesthesia (TIVA) is preferred. Remimazolam is safe in patients with suspected MH.

CASE PRESENTATION

We present the first case of remimazolam treatment in a genetically confirmed patient with MH without MH development. A 72-year-old man with a family history of MH underwent remimazolam-based TIVA. After informed consent was obtained, a muscle biopsy and genetic testing were performed. Intraoperatively and postoperatively, the patient exhibited no signs of MH. An enhanced function of the RYR1 channel into releasing calcium was indicated, and the genetic testing revealed a pathogenic variant of RYR1.

CONCLUSIONS

Remimazolam-based TIVA is safe in patients confirming the diagnosis of MH.

A highly sensitive flexible capacitive pressure sensor with hierarchical pyramid micro-structured PDMS-based dielectric layer for health monitoring

Herein, a flexible pressure sensor with high sensitivity was created using a dielectric layer featuring a hierarchical pyramid microstructure, both in simulation and fabrication. The capacitive pressure sensor comprises a hierarchically arranged dielectric layer made of polydimethylsiloxane (PDMS) with pyramid microstructures, positioned between copper electrodes at the top and bottom. The achievement of superior sensing performance is highly contingent upon the thickness of the dielectric layer, as indicated by both empirical findings and finite-element analysis. Specifically, the capacitive pressure sensor, featuring a dielectric layer thickness of 0.5 mm, exhibits a remarkable sensitivity of 0.77 kPa-1 within the pressure range below 1 kPa. It also demonstrates an impressive response time of 55 ms and recovery time of 42 ms, along with a low detection limit of 8 Pa. Furthermore, this sensor showcases exceptional stability and reproducibility with up to 1,000 cycles. Considering its exceptional achievements, the pressure sensor has been effectively utilized for monitoring physiological signals, sign language gestures, and vertical mechanical force exerted on objects. Additionally, a 5 × 5 sensor array was fabricated to accurately and precisely map the shape and position of objects. The pressure sensor with advanced performance shows broad potential in electronic skin applications.