Comparison of the safety of remimazolam and propofol during general anesthesia in elderly patients: systematic review and meta-analysis.

Summary

Meta-analysis of eight RCTs (n=571) shows remimazolam reduces hypotension, bradycardia, and injection-site pain versus propofol in elderly general anesthesia, with more stable MAP and HR after induction. Results support remimazolam as a safer alternative in geriatric patients.

Key Findings

• Eight RCTs (571 participants) compared remimazolam vs propofol in elderly general anesthesia.
• Remimazolam lowered incidence of hypotension and bradycardia versus propofol.
• Injection-site pain was less frequent with remimazolam.
• MAP and HR were more stable after induction with remimazolam.

Clinical Implications

Consider remimazolam as first-line or alternative induction/maintenance sedative in elderly where hypotension/bradycardia risk is a concern; maintain individualized dosing and monitoring given study heterogeneity.

Limitations

• Total sample size moderate; potential heterogeneity in dosing, anesthesia protocols, and outcome definitions
• Limited long-term outcomes; focus primarily on peri-induction safety endpoints

Future Directions

Head-to-head pragmatic trials comparing remimazolam-based vs propofol-based pathways in high-risk geriatric surgery, including recovery profiles and cost-effectiveness.