Remimazolam versus Sevoflurane for Paediatric Circumcision: A Randomised Controlled Trial Evaluating Emergence...

Area of Science:

• Anesthesiology
• Pediatric Anesthesia
• Pharmacology

Background:

• Emergence delirium affects up to 40% of pediatric sevoflurane anesthetics.
• Remimazolam, an ultra-short-acting benzodiazepine, offers rapid, predictable recovery via esterase metabolism.
• Investigating remimazolam as a volatile-free alternative to reduce emergence delirium in children.

Purpose of the Study:

• To evaluate remimazolam monotherapy as a volatile-free anesthetic alternative.
• To compare the incidence of emergence delirium between remimazolam and sevoflurane.
• To assess induction and emergence times, and patient/guardian experience.

Main Methods:

• Prospective, randomized, assessor-blinded trial in 100 children (3-12 years) undergoing circumcision.
• Randomized 1:1 to remimazolam or sevoflurane anesthesia, both with penile nerve block.
• Co-primary outcomes: induction and emergence times; Key secondary outcome: emergence delirium (PAED score ≥12).

Main Results:

• Remimazolam group had significantly lower emergence delirium (12% vs. 36%, P=0.009) and shorter PACU stay (33.4 vs. 40.7 min, P<0.001).
• Emergence was faster with remimazolam (10.7 vs. 13.5 min, P<0.001), while induction was slower (80.8 vs. 52.3 s, P<0.001).
• Transient hypotension occurred more in the remimazolam group (12% vs. 2%, P=0.11), but was fluid-responsive. Guardian anxiety was threefold reduced.

Conclusions:

• Remimazolam monotherapy effectively reduces emergence delirium by 67% compared to sevoflurane.
• It provides faster recovery and an improved family experience in pediatric anesthesia.
• Further multicenter trials are recommended to confirm safety and broader applicability, with attention to preoperative fluid management.