Remimazolam: Bridging safety, stability, and recovery in contemporary anesthesia

Abstract

Remimazolam is a novel ultra-short-acting benzodiazepine increasingly used in procedural sedation and general anesthesia. Designed as an ester-based analog of midazolam, it combines rapid onset and recovery with predictable metabolism by tissue esterases. Compared with conventional sedative-hypnotic agents, such as propofol and midazolam, remimazolam demonstrates superior hemodynamic stability, limited respiratory depression, absence of injection pain, and pharmacological reversibility with flumazenil. Emerging evidence supports its use in gastrointestinal endoscopy, bronchoscopy, regional anesthesia sedation, and total intravenous anesthesia, particularly in elderly and hemodynamically unstable patients. Nevertheless, concerns remain regarding cost, electroencephalographic monitoring reliability, and limited long-term outcome data. This review summarises the pharmacology, clinical applications, advantages, limitations, and future perspectives of remimazolam in present anesthesia practice.