Intraoperative hypotension after remimazolam or propofol induction with sevoflurane maintenance in angiotensin II receptor blockers-treated patients: a randomized controlled trial

Robot-assisted laparoscopic prostatectomy (RALP) is associated with hemodynamic shifts; patients on angiotensin receptor blockers (ARBs) are especially susceptible to intraoperative hypotension. We investigated whether induction with remimazolam reduces the intraoperative hypotension incidence and severity compared with propofol in this population. Herein, 112 hypertensive patients undergoing RALP who continued ARB therapy received remimazolam (0.2 mg/kg) or propofol (1-1.5 mg/kg) for anesthetic induction. The primary endpoint was hypotension occurrence (mean arterial pressure [MAP] < 65 mmHg sustained for ≥ 1 min), assessed during the entire anesthesia and 15 min post-induction. Secondary endpoints included MAP < 55 mmHg sustained for ≥ 1 min, time-weighted average (TWA)-MAP < 65 mmHg or < 55 mmHg, duration of MAP < 65 mmHg, and required norepinephrine dose. The hypotension incidence did not differ significantly between groups during the entire anesthesia (87.5% vs. 89.3%, P > 0.999). During the entire anesthesia, no significant between-group differences were observed for MAP < 55 mmHg for ≥ 1 min, TWA-MAP < 65 mmHg or < 55 mmHg, duration of MAP < 65 mmHg, and required norepinephrine dose. Similarly, no significant between-group differences were observed during the 15 min after induction. Induction with remimazolam did not reduce intraoperative hypotension risk compared with low-dose propofol in patients undergoing RALP who continued ARB therapy.Clinical trial registration number: ClinicalTrials.gov (NCT06093971, 23/10/2023).