• Eduardo Maia Pereira, Vitor Ryuiti Moraes, Gaya da CostaMarianaM, Tatiana Souza do Nascimento, Eric Slawka, Carlos Galhardo Júnior, and Michel Mrf Struys.
• From the Federal University of Minas Gerais, Department of Medicine, Belo Horizonte, Brazil (EMP), Evangelical University of Goias, Department of Medicine, Anápolis, Brazil (VRM), University of Groningen and University Medical Center of Groningen, Department of Anaesthesiology, Groningen, The Netherlands (MGdC, MMRFS), Cardoso Fontes Federal Hospital, Department of Anaesthesiology (TSdN), Federal University of Rio de Janeiro, Department of Medicine, Rio de Janeiro, Brazil (ES), McMaster University & DeGroote School of Medicine, Department of Anaesthesiology, Hamilton, Ontario, Canada (CGJ), and Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium (MMRFS).
• Eur J Anaesthesiol. 2024 Oct 1; 41 (10): 738748738-748.

BackgroundElderly patients comprise an increasing proportion of patients undergoing surgery, and they require special attention due to age-related physiological changes. Propofol is the traditional agent for anaesthesia, and recently, remimazolam, a novel ultra-short-acting benzodiazepine, has emerged as an alternative to propofol in general anaesthesia.ObjectivesWe aim to compare remimazolam vs . propofol for general anaesthesia in elderly patients regarding hypotension, induction characteristics, haemodynamics and recovery outcomes.DesignMeta-analysis with sensitivity and trial sequential analyses (TSA) to assess inconsistencies. Risk ratios and mean differences with 95% confidence intervals (95% CIs) were computed using a random effects model. Subgroups and meta-regression according to anaesthesia methods were also performed.Data SourcesWe systematically searched MEDLINE, Embase and Cochrane for randomised controlled trials (RCTs) up to January 1, 2024.Eligibility CriteriaPatients at least 60 years old, comparing remimazolam vs . propofol for general anaesthesia.ResultsEleven RCTs (947 patients) were included. Compared with propofol, remimazolam was associated with lower postinduction and intra-operative hypotension (RR 0.41, 95% CI 0.27 to 0.62, P  < 0.001) and incidence of bradycardia (risk ratio 0.58, 95% CI 0.34 to 0.98, P  = 0.04), with a higher heart rate ( P  = 0.01). The incidence of injection pain was lower ( P  < 0.001), but remimazolam was associated with a longer time to loss of consciousness ( P  < 0.001) and a higher bispectral index at loss of consciousness ( P  = 0.04). No differences were found for mean arterial pressure, emergence time, extubation time and incidence of emergence agitation. The TSA was consistent and achieved the required information size for hypotension.ConclusionsRemimazolam significantly reduced the risk of hypotension, bradycardia and injection pain, despite an increase in the time to loss of consciousness. Remimazolam appears to be an effective and well tolerated alternative to propofol in elderly patients undergoing general anaesthesia.Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology.

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