BACKGROUND AND STUDY OBJECTIVE: Delirium is an organic mental syndrome significantly associated with long-term cognitive decline, increased hospital stays and higher mortality. This systematic review of randomised controlled trials (RCTs) with meta-analysis assesses the association of remimazolam with postoperative cognitive function and delirium compared with non-benzodiazepine hypnotics. DESIGN: Systematic review of RCTs with meta-analysis. DATA SOURCES: PubMed, Embase, Cochrane Library and Web of Science databases up to 27 April 2024. ELIGIBILITY CRITERIA: Adult patients undergoing general anaesthesia or sedation procedures
use of remimazolam as the primary hypnotic or as an adjunct, administered via intermittent bolus or continuous infusion
comparison with other hypnotics or sedatives
evaluation of cognitive function or delirium. MAIN RESULTS: Twenty-three RCTs with 3598 patients were included. The incidence of delirium was not significantly different between remimazolam and other sedatives in general anaesthesia and sedation procedures [ n = 3261
odds ratio (OR) = 1.2, 95% confidence interval (CI), 0.76 to 1.91
P = 0.378843
I2 = 17%]. Regarding cognitive function evaluation, remimazolam showed no difference compared with the control group in Mini-Mental State Examination (MMSE) scores on the first postoperative day ( n = 263
mean difference = 0.60, 95% CI, -1.46 to 2.66
P = 0.5684
I2 = 90%) or on the third postoperative day ( n = 163
mean difference = 1.33, 95% CI, -0.72 to 3.38
P = 0.2028
I2 = 93%). Remimazolam exhibited superiority over the control group in MMSE scores on the seventh postoperative day ( n = 247
mean difference = 0.53, 95% CI, 0.30 to 0.75
P <
0.0002
I2 = 28%). CONCLUSION: Remimazolam does not increase the incidence of delirium or cognitive impairments compared with non-benzodiazepine hypnotics. However, the analysis showed that the type of surgery significantly influenced the incidence of delirium. Additionally, remimazolam was associated with better short-term postoperative cognitive function. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42024532751.