The pooled incidence of following remimazolam administration was 5%.
Patients classified as ASA III-IV had a delirium rate of 19%, in contrast to 1% for ASA I-II patients.
Children exhibited the highest delirium rate at 11%, followed by elderly patients at 8%, while adults had a rate of 1%.
Oncologic surgeries were associated with the highest delirium incidence at 16%, and orthopedic surgeries at 12%, whereas gastrointestinal and endoscopic procedures showed 0%.
Higher doses of remimazolam were linked to a lower incidence of delirium compared to moderate doses.
Surgery type was identified as a primary predictor of delirium incidence, with orthopedic surgery presenting the greatest risk.
Simplified
BACKGROUND: is a significant and common complication in surgical patients, particularly in vulnerable populations such as the elderly. Remimazolam, a novel benzodiazepine, has been introduced as an anesthetic agent with a favorable pharmacokinetic profile. However, its potential association with postoperative delirium remains unclear. This study aims to systematically synthesize available evidence on the incidence of delirium following remimazolam administration in surgical patients. We sought to identify significant moderators of delirium incidence and to explore predictors of delirium through meta-regression analysis.
METHODS: A comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar, up to May 20, 2024. The search was updated on Feb 2nd, 2025. Randomized trials were selected based on predefined criteria, and data on patient characteristics, surgical details, and delirium incidence were extracted. A meta-analysis was performed to calculate the pooled incidence rate of delirium, and subgroup and meta-regression analyses were conducted to identify incidence rate moderators.
RESULTS: A total of 29 RCTs, including 2,435 patients, were analyzed. The pooled incidence of postoperative delirium following remimazolam administration was 5% (95%CI: 3-7%). ASA III-IV patients had a delirium rate of 19% (95%CI: 15-23%) compared to 1% (95%CI: 0-1%) for ASA I-II. Age was a key factor, with children showing the highest rate (11%, 95%CI: 3-19%), followed by elderly patients (8%, 95%CI: 4-13%), while adults had the lowest (1%, 95%CI: 0-2%). Delirium incidence was highest in oncologic (16%, 95%CI: 0-34%) and orthopedic surgeries (12%, 95%CI: 9-14%), and lowest in gastrointestinal and endoscopic procedures (0%, 95%CI: 0-1%). High-dose remimazolam was linked to the lowest delirium incidence, while moderate doses had higher rates. Meta-regression identified surgery type as the primary predictor, with orthopedic surgery having the highest risk compared to laparoscopic and abdominal procedures (coefficient = 0.081, p = 0.03).
CONCLUSIONS: Postoperative delirium occurs in 5% of surgical patients following remimazolam administration. Key moderators include , age, surgery type, and anesthetic dosing. Remimazolam may be safely used in surgical patients, particularly when higher doses are administered, but caution is warranted in high-risk populations such as elderly patients and those undergoing complex surgical procedures.
Key numbers
5%
Pooled Delirium Incidence
Calculated from 29 RCTs involving 2,435 patients.
19%
Delirium Rate in ASA III-IV Patients
Compared to 1% in ASA I-II patients.
11% (children), 8% (elderly), 1% (adults)
Delirium Rate by Age Group
Rates reflect findings from multiple studies.
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Declarations. Ethics approval and consent to participate: Given the nature of this research which involved pooling of data from already published studies, there was no need for patient consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.
