Comparing the safety and efficacy of remimazolam-based total intravenous anesthesia versus volatile agent-based anesthesia: a meta-analysis of randomized controlled trials

Abstract

Background: Remimazolam is a novel short-acting benzodiazepine that has recently been used for general anesthesia. This study compared the safety and efficacy of remimazolam-based total intravenous anesthesia (TIVA) and volatile agent-based anesthesia in adults undergoing general anesthesia.

Methods: We searched electronic databases including PubMed, Embase, CENTRAL, and Scopus for relevant studies. The primary outcome was the proportion of patients who experienced hypotension during surgery. Secondary outcomes included incidence of bradycardia, extubation time, duration in the post-anesthesia care unit hospital stay, and incidence of postoperative nausea and/or vomiting (PONV). We estimated the relative risk (RR) and mean difference with 95% CIs using a random-effects model.

Results: A total of 969 patients from 12 randomized controlled trials were included. The incidence of hypotension was 14% and 34% in the remimazolam and volatile agent groups, respectively. Remimazolam significantly lowered the incidence of hypotension (RR: 0.43, 95% CI [0.29-0.63], P = 0.0000, I2 = 26%). The remimazolam group had a PONV incidence of 13%, compared to 28% in the volatile agent group, indicating a significant difference (RR: 0.51, 95% CI [0.37-0.72], P = 0.0001, I2 = 15%). No significant differences were observed in the other outcomes.

Conclusions: Remimazolam-based TIVA demonstrated favorable hemodynamic effects, with a lower incidence of hypotension and similar bradycardia rates, compared to volatile agent-based anesthesia. Furthermore, the reduction in PONV supports the use of remimazolam-based TIVA as a valuable method for general anesthesia.

Keywords: Anesthesia, general; Anesthesia, inhalation; Anesthesia, intravenous; Postoperative nausea and vomiting; Remimazolam; Safety..

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram of study selection. A total of 215 articles were identified through the electronic databases. After excluding 58 studies for duplication, 85 and 60 articles were removed from the article pool based on the fitness of the title and abstract, respectively. The full texts of 12 eligible studies were then reviewed and included in the final analysis.

Fig. 2.

Forest plot for the incidence of hypotension during surgery. Significant differences were noted in the incidence of hypotension between the remimazolam and volatile agent groups. ‘-H’ refers to the group that received 0.3 µg/kg/min of remifentanil; ‘-L’ refers to the group that received 0.05 µg/kg/min of remifentanil.

Fig. 3.

Forest plot for the incidence of bradycardia during surgery. No significant differences were observed in the incidence of bradycardia between the two groups. ‘-H’ refers to the group that received 0.3 µg/kg/min of remifentanil; ‘-L’ refers to the group that received 0.05 µg/kg/min of remifentanil.

Fig. 4.

Forest plots for extubation time. No significant difference was noted in the extubation time between the remimazolam and the control groups.

Fig. 5.

Forest plot for PONV. Participants in the remimazolam group reported a significantly lower incidence of PONV than those in the volatile agent group. PONV: postoperative nausea and vomiting.

Fig. 6.

Forest plot for the duration of PACU stay. The overall effect size demonstrated comparable PACU stay time between the remimazolam and volatile agent groups. PACU: post-anesthesia care unit.

Fig. 7.

Forest plot for the length of hospital stay. No significant difference was noted in the length of hospital stay between the two groups.