The promise of precision
Exploring the role of remimazolam in paediatric anaesthesia
British Journal of Anaesthesia
Submitted August 2025 by Dr Ayaka Omori
Read by 3 Journal Watch subscribers
This narrative review serves as an update on the use of remimazolam in paediatric population.
The introduction of remimazolam is a notable development in hypnotics in the past two decades.
Remimazolam has advantages because of its predictable pharmacokinetics due to rapid onset (1-2 mins), short duration (5-20 mins), predictable metabolism (elimination half-life 5-10 mins) with minimal accumulation (context-sensitive half-life likely short and stable).
It also promises a remakrable safety profile, with the absence of adverse events such as hypotention, respiratory depression, or bradycardia. It has already established antagonist flumazenil.
Remimazolam could be a safer alternative in high risk population where haemodynamic and respiratory stability is paramount.
With these advantages and despite its growing use in adult anaesthesia and sedation, clinical data and experience with remimazolam in the paediatric population remains limited, especially in neonates and infants. Recently, Cai et al. provided dosing estimates for children, reporting the ED₅₀ and ED₉₅ values. Based on their findings, the recommended dosing range is 0.45–0.60 mg/kg for children aged 1–6 years and 0.35–0.45 mg/kg for those aged 6–12 years.
However, the authors describe several gaps remain in our understanding of remimazolam use in children, and outline the following priorities for further research:
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Safety, efficacy and cost-effectiveness are yet to be evaluated in the broader paediatric population. Potential heterogeneity has been reported in remimazolam metabolism due to variability of carboxylesterase 1 activity, which plays a key role in the drug metabolism. Safety for vulnerable cohorts such as neonates also need to be examined.
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Comparative trials against commonly used agents such as propofol and midazolam will be necessary to establish clinical superiority or equivalence.
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The development of a robust target-controlled infusion (TCI) model for paediatric use, along with a deeper understanding of remimazolam’s interactions with opioids and neuromuscular blocking agents, would further bolster remimazolam's utility in the clinical sphere.
