Remimazolam – current status, opportunities and challenges

The short acting benzodiazepine remimazolam has been well characterised for use during procedural sedation. Onset of hypnotic effect is swifter than midazolam and recovery is faster with a period of antegrade amnesia. Haemodynamic changes associated with remimazolam sedation are modest and there is no pain on injection. General anaesthesia may be induced and maintained by infusion of remimazolam in combination with a suitable opioid. Hypotension is less frequent than when propofol is used. In addition, remimazolam may be a suitable alternative to propofol or etomidate for inducing anaesthesia in haemodynamically compromised patients prior to maintenance with a volatile agent. A small proportion of patients are slow to recover consciousness after total intravenous anaesthesia (TIVA) with remimazolam/opioid combinations. Preliminary experience suggests that flumazenil may be useful in this group however studies are required to define the appropriate dosage and timing for flumazenil administration. Future developments may include sedation and anaesthesia for infants and children as well as intensive care sedation for all age groups. These indications require demonstration in well designed clinical trials.

Graphical Abstract