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Clinical outcomes of a remimazolam-based sedation regimen in patients receiving ECMO: a retrospective comparative
Dalong Zhang1, Ying Liu1, Tongrui Zhang1
1Department of Critical Care Medicine, The Fifth Clinical Medical College of Henan University of Chinese Medicine (Zhengzhou People's Hospital), Zhengzhou, Henan, China.
Objective:
Recent meta-analyses have established the overall safety of remimazolam in general surgical populations, but evidence in high-risk subgroups such as patients requiring extracorporeal membrane oxygenation (ECMO) remains absent. This study aimed to compare the sedative effects of remimazolam-based vs. midazolam-based sedation regimens in adults requiring ECMO, with a focus on the incidence of delirium.
Methods:
This single-center retrospective study included patients receiving ECMO from January 2023 to October 2025. The primary analysis cohort comprised patients receiving veno-arterial ECMO (VA-ECMO, n = 44), divided into a remimazolam group (Group R, n = 22) or a midazolam group (Group M, n = 22). The primary outcome was delirium incidence assessed by the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).
Results:
For the primary outcome, delirium occurred in 0/22 (0%) patients in Group R vs. 6/22 (27.3%) in Group M (risk difference -27.3%, 95% CI -45.9% to -8.7%, p = 0.021 by Fisher's exact test). Due to zero events in Group R, Firth's penalized likelihood regression adjusting for Acute Physiology and Chronic Health Evaluation II (APACHE-II) yielded an odds ratio of 0.06 (95% CI 0.00 to 0.56, p = 0.009), and multivariable and propensity score adjustments produced consistent results. E-value analysis (point estimate 2.0, lower CI bound 1.3) indicated that a relatively modest unmeasured confounder could potentially shift the confidence interval to include the null. For secondary outcomes, Group R had shorter recovery time after decannulation (24.90 ± 3.36 h vs. 29.84 ± 4.53 h, p < 0.001), better-preserved muscle strength (median MRC grade 1 vs. 0, p < 0.001), and lower incidences of hypotension and bradycardia (both p < 0.05).
Conclusion:
In this retrospective exploratory study, a remimazolam-based sedation regimen was associated with lower delirium incidence, faster recovery, and better-preserved muscle strength compared with a midazolam-based regimen. These findings reflect a comparison of two distinct sedation regimens rather than a head-to-head drug comparison of remimazolam vs. midazolam. These hypothesis-generating findings warrant further validation in prospective studies.
Insights
Remimazolam-based sedation showed lower delirium rates in extracorporeal membrane oxygenation (ECMO) patients compared to midazolam. This approach also led to faster recovery and better muscle strength, warranting further investigation.
Area of Science:
- Critical Care Medicine
- Pharmacology
- Anesthesiology
Background:
- Limited data exists on remimazolam safety in high-risk populations like extracorporeal membrane oxygenation (ECMO) patients.
- Previous meta-analyses confirm remimazolam's safety in general surgical settings.
Purpose of the Study:
- To compare the sedative efficacy and delirium incidence of remimazolam-based versus midazolam-based sedation in adult ECMO patients.
- To evaluate secondary outcomes including recovery time and muscle strength.
Main Methods:
- A single-center retrospective study involving adult veno-arterial ECMO (VA-ECMO) patients from January 2023 to October 2025.
- Patients were divided into remimazolam (Group R, n=22) and midazolam (Group M, n=22) groups.
- Delirium incidence was the primary outcome, assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).
Main Results:
- Delirium incidence was significantly lower in the remimazolam group (0%) compared to the midazolam group (27.3%, p=0.021).
- Remimazolam group showed shorter recovery time post-decannulation (24.90 ± 3.36 h vs. 29.84 ± 4.53 h, p < 0.001).
- Better preserved muscle strength (MRC grade 1 vs. 0, p < 0.001) and lower rates of hypotension/bradycardia were observed with remimazolam.
Conclusions:
- Remimazolam-based sedation may be associated with reduced delirium incidence in ECMO patients.
- Faster recovery and improved muscle strength were noted with remimazolam compared to midazolam.
- These findings are hypothesis-generating and require validation in prospective studies.
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