Remimazolam Versus Propofol for Anesthesia Induction and Maintenance in Adult Cardiac Surgical Patients: A PRISMA-Compliant Systematic Review and Meta-analysis.

OBJECTIVES: To compare remimazolam-based with propofol-based anesthesia for induction and maintenance in adult cardiac surgery. DESIGN: Systematic review and meta-analysis of randomized controlled trials. SETTING: Cardiovascular centers. PARTICIPANTS: Adults undergoing cardiac surgery. INTERVENTIONS: Remimazolam-based versus propofol-based general anesthesia for induction and maintenance. MEASUREMENTS AND MAIN RESULTS: Fourteen reports describing randomized trials, including three theses, contributed 1,773 reported participants to the primary synthesis. All were conducted in China, and no key pooled result was supported exclusively by results at low risk of bias. One terminated European registry-results trial (23 treated patients) was included as supplementary sensitivity evidence. Data on major postoperative morbidity and mortality were too sparse to pool. Remimazolam was associated with fewer trial-defined intraoperative hypotension events (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.20-0.47; p < 0.001; I² = 0%) and fewer bradycardia events (OR, 0.20; 95% CI, 0.12-0.34; p < 0.001; I² = 0%). It was also associated with shorter mechanical ventilation duration (mean difference [MD], -1.84 hours; 95% CI, -2.34 to -1.35 hours; p < 0.001; I² = 71%). Hospital length of stay crossed the line of no effect (MD, -0.48 days; 95% CI, -0.99 to 0.02 days; p = 0.06; I² = 37%). Certainty of evidence was very low for the hemodynamic and mechanical ventilation findings. CONCLUSIONS: Across the cardiac surgical populations represented in the included trials, remimazolam was associated with fewer trial-defined intraoperative hypotension and bradycardia events and shorter mechanical ventilation duration. The certainty of evidence for these associations was very low. The evidence does not establish improved major morbidity or mortality. Future multicenter confirmation is required.