Remimazolam in pediatric sedation and anesthesia: current perspectives and clinical considerations

Remimazolam is a novel, short-acting benzodiazepine that acts as a high-affinity selective ligand for the GABA-A receptor. Since its approval, growing evidence has demonstrated its safety and efficacy for sedation and anesthesia in adult patients. Recently, increasing interest has emerged regarding the utility of remimazolam in pediatric patients due to its favorable characteristics, including its limited suppressive effect on respiration and circulation in comparison to other sedatives. However, its clinical use in pediatric patients requires special consideration despite the overall safety profile of remimazolam. Because of differences in body composition and dynamic physiological changes during growth and development, the pharmacokinetic and pharmacodynamic properties of remimazolam in children may differ from those in adults. Therefore, a clear understanding of its pharmacological properties, potential indications, limitations, and reverse options is essential for clinical use. Previous studies have suggested that higher doses relative to body size may be required in pediatric patients than in adult patients for adequate sedation and anesthesia. While body weight-based dosing regimens are straightforward, age-related differences in pharmacokinetics and pharmacodynamics may increase the risk of under- or overdosing. The use of concentration prediction models may assist in dose and infusion rate adjustments. Advances in electroencephalogram monitoring during sedation and anesthesia may also provide valuable guidance, although age-dependent EEG differences and the distinct effects of remimazolam in comparison to other sedatives require further investigation. Despite its short-acting nature and low risk of accumulation, the combination of relatively high dose requirements and potentially reduced clearance in children raises a theoretical concern regarding rebound effects in this population. Therefore, careful dose titration, appropriate monitoring, and judicious reversal are necessary to ensure safe administration in pediatric practice.