Comparison of the effects of remimazolam and inhalational anesthesia on postoperative recovery in patients undergoing general anesthesia: a systematic review and meta-analysis of randomized controlled trials.

Abstract

Background: Remimazolam is an ultra-short-acting benzodiazepine characterized by rapid onset and recovery with minimal accumulation after continuous infusion. This systematic review and meta-analysis aimed to evaluate whether remimazolam use results in better postoperative recovery as compared to inhalational anesthetics.

Methods: Databases including MEDLINE, EMBASE, CENTRAL, Web of Science, Google Scholar, and Scopus were searched up to August 2024. Randomized controlled trials (RCTs) in adult patients comparing remimazolam with volatile agents were included. The primary outcome was incidence of postoperative nausea and vomiting (PONV) at 24 h. Secondary outcomes included use of rescue antiemetics and analgesics, pain scores, intraoperative hypotension, and other postoperative recovery parameters. Trial sequential analysis (TSA) was performed to validate the robustness of the primary outcome.

Results: Twelve RCTs involving 853 patients were analyzed. Remimazolam significantly reduced the incidence of PONV (relative risk [RR] 0.51; 95% confidence interval [CI] 0.27-0.96; I² = 43%; P = 0.04) and need for rescue antiemetics (RR 0.30; 95% CI 0.10-0.89; I² = 0%; P = 0.03) compared to inhalational agents. No significant differences were found in postoperative pain scores (standardized mean difference -0.17; P = 0.11) or analgesic requirement (RR 0.95; P = 0.82). Remimazolam was associated with a significantly lower incidence of intraoperative hypotension (RR 0.58; P = 0.01). Time to extubation, sedation scores, and post-anesthesia care unit stay were comparable. TSA confirmed that the required information size for the primary outcome was reached, indicating statistical conclusiveness.

Conclusions: Remimazolam use is associated with significantly reduced PONV, rescue antiemetic use, and intraoperative hypotension compared to inhalational agents. TSA confirms the robustness of these findings.