Current status of perioperative hypnotics, role of benzodiazepines, and the case for remimazolam: a narrative review

Abstract

Anaesthesiologists and non-anaesthesiologist sedationists have a limited set of available i.v. hypnotics, further reduced by the withdrawal of thiopental in the USA and its near disappearance in Europe. Meanwhile, demand for sedation increases and new clinical groups are using what traditionally are anaesthesiologists' drugs. Improved understanding of the determinants of perioperative morbidity and mortality has spotlighted hypotension as a potent cause of patient harm, and practice must be adjusted to respect this. High-dose propofol sedation may be harmful, and a critical reappraisal of drug choices and doses is needed. The development of remimazolam, initially for procedural sedation, allows reconsideration of benzodiazepines as the hypnotic component of a general anaesthetic even if their characterisation as i.v. anaesthetics is questionable. Early data suggest that a combination of remimazolam and remifentanil can induce and maintain anaesthesia. Further work is needed to define use cases for this technique and to determine the impact on patient outcomes.

Quality of Recovery After General Anesthesia with Remimazolam in Patients’ Undergoing Urologic Surgery: A Randomized Controlled Trial Comparing Remimazolam with Propofol

“…However, patients’ postoperative recovery should be concerned in general anesthesia with remimazolam before it is widely promoted. 40 We demonstrated that general anesthesia with remimazolam temporarily impaired the quality of recovery in patients undergoing urologic surgery. Further clinical trials with other types of operation are needed to confirm the long-term impact of remimazolam on patients’ recovery.…”

The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial

“…14 Recent studies have reported that RT is suitable for short operations, such as gastrointestinal endoscopy, hysteroscopy, bronchoscopy, and closed reductions of long-bone fractures. 15 In addition, it can also be used for the induction and maintenance of anesthesia, and its efficacy is non-inferior to propofol. 16 However, the efficacy and safety of RT compared with etomidate-propofol (EP) in patients undergoing colonoscopy are unclear.…”

Review of remimazolam and sedatives in the intensive care unit

“…Remimazolam was used as a general anesthetic, using induction doses of 6 and 12 mg/kg/hr and maintenance rates of 1 mg/kg/hr. Remimazolam was superior to propofol in terms of its efficacy for general anesthesia, and it showed a significantly lower incidence of hypotension and other adverse events [ 37 , 59 , 60 ].…”