Remimazolam vs propofol for postoperative delirium in adults undergoing general anesthesia: A meta-analysis

Postoperative delirium (POD) is a prevalent and serious complication in adults undergoing surgery with general anesthesia. Remimazolam, an innovative ultra-short-acting benzodiazepine, has been identified as a potential alternative to propofol due to its advantageous pharmacological properties. However, its impact on POD remains uncertain. This study conducted a systematic review and meta-analysis following PRISMA guidelines. A comprehensive search of the PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang databases was performed up to March 29, 2025. Randomized controlled trials (RCTs) comparing remimazolam and propofol in adult surgical patients under general anesthesia, specifically reporting on POD incidence, were included. A random-effects model was utilized to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs), accounting for heterogeneity. The analysis included seventeen RCTs encompassing 3,133 patients. Overall, remimazolam significantly decreased the risk of POD compared to propofol (OR: 0.71, 95% CI: 0.52-0.97, p = 0.03; I² = 36%). Sensitivity analyses, which involved excluding one study at a time, yielded consistent results, reinforcing the robustness of the findings. Subgroup analyses revealed uniform effects across different study designs (single-blind vs. double-blind; OR: 0.73 vs. 0.64; p = 0.71) and age groups (adults vs. elderly; OR: 0.64 vs. 0.72; p = 0.79). A trend toward greater benefit was observed in studies with longer follow-up periods (7 days: OR: 0.42) and in those employing the CAM or CAM-ICU for POD diagnosis, although subgroup differences were not statistically significant. In conclusion, remimazolam is associated with a significantly reduced risk of POD compared to propofol in adults undergoing general anesthesia.