Comparison of hypotension incidence between remimazolam and propofol in patients with hypertension undergoing neurosurgery: prospective, randomized, single-blind trial

Abstract

Background: Remimazolam, a newer benzodiazepine that targets the GABA_A receptor, is thought to allow more stable blood pressure management during anesthesia induction. In contrast, propofol is associated with vasodilatory effects and an increased risk of hypotension, particularly in patients with comorbidities. This study aimed to identify medications that can maintain stable vital signs throughout the induction phase.

Methods: We conducted a single-center, two-group, randomized controlled trial to investigate and compare the incidence of hypotension between remimazolam- and propofol-based total intravenous anesthesia (TIVA). We selected patients aged between 19 and 75 years scheduled for neurosurgery under general anesthesia, who were classified as American Society of Anesthesiologists Physical Status I-III and had a history of hypertension.

Results: We included 94 patients in the final analysis. The incidence of hypotension was higher in the propofol group (91.3%) than in the remimazolam group (85.4%; P = 0.057). There was no significant difference in the incidence of hypotension among the various antihypertensive medications despite the majority of patients being on multiple medications. In comparison with the propofol group, the remimazolam group demonstrated a higher heart rate immediately after intubation.

Conclusions: Our study indicated that the hypotension incidence of remimazolam-based TIVA was comparable to that of propofol-based TIVA throughout the induction phase of EEG-guided anesthesia. Both remimazolam and propofol may be equally suitable for general anesthesia in patients undergoing neurosurgery.

Trial registration: Clinicaltrials.gov (NCT05164146).

Keywords: Anesthetic induction; Drug therapy; Hypertension; Propofol; Remimazolam.

Fig. 1

Patient enrollment flowchart. Of 110 patients slated for elective neurosurgery with general anesthesia, 2 patients were disqualified based on the inclusion criteria, and 8 patients opted not to join. Another 6 patients were excluded from the study because of technical issues, resulting in 94 patients for the final analysis

Fig. 2

MBP during the induction period. Among 94 patients scheduled for elective neurosurgery under general anesthesia, the MBP was examined in the ward, at baseline (immediately before administering the sedative drug in the operation room), and from 0 min (start of drug administration) to 13 min (13 min after administering the sedative drug). MBP values represent the estimated means from the linear mixed model with standard error. *P < 0.05, • < 0.1 in post-hoc analysis

Fig. 3

Comparison of PSI™ values at each time point. The PSI™ on the SedLine® monitor was recorded at baseline (just before the administration of the sedative drug in the operating room), and starting at the moment the drug was initiated (0 min) and continuing up to 13 min after administering the drug. The desired PSI™ was achieved 3 min after sedative drug administration and was maintained until the study endpoint at 13 min