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Remimazolam as an Alternative to Propofol in Oral Surgeries

Anesthesia Progress – Propofol has been a widely used intravenous sedative for oral and maxillofacial surgeries because of advantages like less postoperative nausea and vomiting (PONV), no air pollution issues, a fast, clean emergence profile, and less emergence delirium. However, propofol has some significant downsides, including cardiovascular depression, injection pain, high fat content, and not being water-soluble. Recently, remimazolam has been suggested as an alternative to propofol in dental procedures because it does not contain similar fat, does not cause injection pain, and does not have cardiovascular depression potential. But is remimazolam as safe and effective as propofol?

To answer these questions and determine if remimazolam is a viable substitute, researchers from Tsurumi University in Yokohama, Japan, recently published a study in the current issue of Anesthesia Progress. Lead author Yoshio Hayakawa, DDS, PhD, and colleagues lay out their primary objectives: “The main objective of this study was to compare remimazolam and propofol used for general anesthesia by assessing cardiovascular stability and anesthetic depth as determined by EEG. Secondary objectives included time to loss of consciousness, time to extubation, administered opioid dosing, surgical and anesthetic times, local anesthetic totals, and the incidence of side effects.”

A total of 100 participants with comparable sociodemographic characteristics were divided into two 50-patient groups. Both the propofol and remimazolam groups were further divided by half, 25 in the bispectral index (BIS) and 25 in the patient state index (PSI) groups. Of note, five patients of the remimazolam group were excluded, so the final group only contained 45 patients. Hayakawa et al. evaluated the following: “Blood pressure, heart rate, and BIS/PSI values were compared at fixed time points perioperatively. Time to loss of consciousness and total opioid doses were also compared across groups. Other items that were compared included intraoperative arousal and postoperative nausea and vomiting.”

The researchers found that blood pressure and heart rate differed insignificantly at baseline, but there were decreases in both in the propofol group during the procedures. In the propofol group, hypotension and bradycardia were observed in 11 patients, requiring intervention with all responses being positive; only two patients were hypotensive in the remimazolam group with no bradycardia. BSI and PSI values did not significantly differ between groups. Time to loss of consciousness was longer in the propofol group, and no difference was seen for time to extubation. Higher total opioid doses were observed in the remimazolam for both fentanyl and remifentanil. In the remimazolam group, two patients experienced PONV, and two had shivers. Excessive movement was seen by only one patient in each group.

The results of this study show that remimazolam could be considered a suitable alternative to propofol. Hayakawa et al. did find limitations in this study and recommended that “future studies should consider increased surgical procedure homogeneity to better ensure consistency between groups.” They go on to note that “remimazolam appears to be a safe alternative to propofol for providing intubated general anesthesia for oral and maxillofacial surgery procedures.”

Full text of the article, ““Comparison of Remimazolam and Propofol for Intubated General Anesthesia for Oral and Maxillofacial Surgery,” Anesthesia Progress, Vol. 70, No. 4, 2023, is now available at  https://doi.org/10.2344/523398

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About Anesthesia Progress

Anesthesia Progress is the official publication of the American Dental Society of Anesthesiology (ADSA). The quarterly journal is dedicated to providing a better understanding of the advances being made in the science of pain and anxiety control in dentistry. The journal invites submissions of review articles, reports on clinical techniques, case reports, and conference summaries. To learn more about the ADSA, visit: http://www.adsahome.org/.

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