The impact of remimazolam compared to propofol on postoperative delirium: a systematic review and meta-analysis

The administration of benzodiazepines has been linked to the occurrence of postoperative delirium (POD) among patients undergoing surgery. In this review, we aim to appraise the current controversy regarding the role of remimazolam in POD. A systematic review and meta-analysis of randomized controlled trials was conducted to examine the effects of remimazolam administration on postoperative delirium compared to propofol from inception to April 2024. We conducted a comprehensive search of PubMed, EMBASE, Cochrane Library, Web of Science, Wanfang, and ZhiWang Chinese databases. In the fixed-effects and random-effects statistical models, pooled risk ratios (RRs) or mean differences, 95% CIs, and P values were estimated for endpoints. The trial sequential analysis was used for sensitivity analysis. Among the 479 records screened, 11 randomized controlled trials with 1682 patients were eligible for inclusion. POD did not differ between groups (RR,0.82; 95% CI 0.53-1.26; P=0.36; df=10; I2=42%). There were no statistically significant differences between groups in the incidence of nausea and vomiting, hypoxemia, and length of stay. However, remimazolam had a lower incidence of hypotension and bradycardia than propofol. Analyses of subgroups did not reveal a difference in delirium based on the type of surgery, assessment timing, or definition of cognitive impairment. This result has been supported by the trial sequential analysis. Based on the available evidence, perioperative remimazolam administration is not associated with a significant rise in the incidence of POD.