Remimazolam for anesthesia in cardiac and noncardiac surgery. A narrative literature review and synthesis

Despite decades of advancements in anesthetic techniques, a novel hypnotic agent combining rapid onset and offset, hemodynamic stability, and predictable effects has remained elusive. The recent approval of remimazolam, a short-acting benzodiazepine, represents a potential breakthrough in fulfilling these criteria. Since its first approval, growing evidence highlights its benefits, including superior hemodynamic stability, rapid emergence from anesthesia, and minimal respiratory depression compared to widely used agents such as propofol. These attributes have been demonstrated across various surgical contexts and patient populations. However, existing studies have limitations that challenge the generalizability of such findings. This review evaluates the literature on remimazolam in both the cardiac and noncardiac perioperative surgical contexts. A systematic search of PubMed/MEDLINE, EMBASE, and Google Scholar databases identified studies published from 2020 to 2024, with an emphasis on randomized controlled trials and observational studies. By analyzing the limitations inherent in the retrieved studies, we aimed to provide practicing anesthesiologists with an overview of remimazolam's potential benefits and inherent challenges, while identifying current knowledge gaps that warrant future research.