BACKGROUND:Remimazolam is a novel ultra-short-acting intravenous benzodiazepine, while sevoflurane is a widely used inhalational anaesthetic for general anaesthesia (GA). Both agents are associated with risks of haemodynamic instability and postoperative nausea and vomiting (PONV), which can affect patient safety and recovery. OBJECTIVE:To compare the efficacy and safety of remimazolam versus sevoflurane in terms of intraoperative haemodynamic stability during the maintenance phase of GA or deep sedation, and the incidence of PONV. DESIGN:Systematic review of randomised controlled trials (RCTs) and meta-analysis, with trial sequential analysis (TSA). DATA SOURCES:PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science and Scopus were systematically searched from inception to April 2025. ELIGIBILITY CRITERIA:RCTs comparing intraoperative use of remimazolam and sevoflurane with reported intraoperative or postoperative outcomes. Conference abstracts were excluded. RESULTS:Twelve RCTs (n = 739 patients; mean age 61.6 years; 36.8% laparoscopic procedures) were included. Remimazolam significantly reduced the risk of intraoperative hypotension (as a binary event) compared with sevoflurane [risk ratio (RR) 0.38, 95% confidence interval (CI) 0.25 to 0.57; P < 0.001]. Mean arterial pressure (MAP) was higher with remimazolam at 30 min after start of surgery (mean difference 6.05 mmHg, P < 0.03). Heart rate (HR) was consistently higher with remimazolam at 30 min (P = 0.04), at the end of surgery (P < 0.01) and in the postanaesthesia care unit (P < 0.01). Analyses suggested a reduction in PONV incidence up to 24 h with remimazolam [RR 0.65 (95% CI, 0.47 to 0.90); P = 0.01] and 72 h [RR 0.66 (95% CI, 0.50 to 0.89)]. TSA just confirmed favouring remimazolam in reducing intraoperative hypotension. CONCLUSIONS:Remimazolam was associated with a lower incidence of intraoperative hypotension compared with sevoflurane, while differences in MAP and HR were limited to specific time points. Sensitivity analyses suggested a potential reduction in PONV; however, these findings were not statistically significant in the primary analysis and should be interpreted with caution.
BACKGROUND Remimazolam is a novel ultra-short-acting intravenous benzodiazepine, while sevoflurane is a widely used inhalational anaesthetic for general anaesthesia (GA). Both agents are associated with risks of haemodynamic instability and postoperative nausea and vomiting (PONV), which can affect patient safety and recovery. OBJECTIVE To compare the efficacy and safety of remimazolam versus sevoflurane in terms of intraoperative haemodynamic stability during the maintenance phase of GA or deep sedation, and the incidence of PONV. DESIGN Systematic review of randomised controlled trials (RCTs) and meta-analysis, with trial sequential analysis (TSA). DATA SOURCES PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science and Scopus were systematically searched from inception to April 2025. ELIGIBILITY CRITERIA RCTs comparing intraoperative use of remimazolam and sevoflurane with reported intraoperative or postoperative outcomes. Conference abstracts were excluded. RESULTS Twelve RCTs ( n = 739 patients; mean age 61.6 years; 36.8% laparoscopic procedures) were included. Remimazolam significantly reduced the risk of intraoperative hypotension (as a binary event) compared with sevoflurane [risk ratio (RR) 0.38, 95% confidence interval (CI) 0.25 to 0.57; P < 0.001]. Mean arterial pressure (MAP) was higher with remimazolam at 30 min after start of surgery (mean difference 6.05 mmHg, P < 0.03). Heart rate (HR) was consistently higher with remimazolam at 30 min ( P = 0.04), at the end of surgery ( P < 0.01) and in the postanaesthesia care unit ( P < 0.01). Analyses suggested a reduction in PONV incidence up to 24 h with remimazolam [RR 0.65 (95% CI, 0.47 to 0.90); P = 0.01] and 72 h [RR 0.66 (95% CI, 0.50 to 0.89)]. TSA just confirmed favouring remimazolam in reducing intraoperative hypotension. CONCLUSIONS Remimazolam was associated with a lower incidence of intraoperative hypotension compared with sevoflurane, while differences in MAP and HR were limited to specific time points. Sensitivity analyses suggested a potential reduction in PONV; however, these findings were not statistically significant in the primary analysis and should be interpreted with caution.
BACKGROUND Postoperative pain relief after laparoscopic appendicectomy in children provided by transversus abdominis plane (TAP) block and local anaesthesia wound infiltration (LAWI) of trocar insertion sites has never been compared. OBJECTIVE To investigate whether TAP block could decrease postoperative opioid requirements after laparoscopic appendicectomy in children compared with LAWI. DESIGN Multicentre, double-blind, phase III randomised trial. SETTING Two tertiary paediatric surgery centres. PATIENTS Children aged 3 to 15 years admitted for laparoscopic appendicectomy. MAIN OUTCOME MEASURES The primary outcome was the total dose of nalbuphine delivered within 24 h after surgery. Secondary outcomes were the Face Legs Activity Cry Consolability (FLACC) scale values at 1, 2, 6, 12 and 24 h, the time from levobupivacaine injection to the first dose of nalbuphine, and the time from the end of surgery to the first mobilisation. Patients received either ultrasound-guided TAP block (TAP group) or LAWI of trocar insertion sites (infiltration group) with 0.6 ml kg −1 of levobupivacaine 2.5 mg ml −1 , combined with standardised systemic multimodal analgesia including paracetamol, ketoprofen, phloroglucinol and nalbuphine. RESULTS Forty-six and 50 patients were analysed in the TAP and infiltration groups, respectively [age: 10 [7 to 12] versus 10 [8 to 12] years; females: 16 (35%) versus 25 (50%); duration of surgery: 71 [64 to 90] versus 69 [56 to 89] min]. The primary outcome (total nalbuphine dose) was 0.2 [0.0 to 0.2] and 0.2 [0.0 to 0.2] mg kg −1 in the TAP and infiltration groups, respectively ( P = 0.95). FLACC scale values did not significantly differ between the two groups ( P = 0.78). Time to the first dose of nalbuphine or to first mobilisation was not significantly different between groups ( P value for log-rank test = 0.095 and 0.18, respectively). CONCLUSION TAP block does not appear to provide a greater opioid-sparing effect than LAWI of trocar insertion sites after laparoscopic appendicectomy in children, when combined with systemic multimodal analgesia including nonsteroidal anti-inflammatory drugs. TRIAL REGISTRATION ClinicalTrials.gov NCT04969133.
