Pieri M, D’Andria Ursoleo J, Di Prima AL, Bugo S, Barucco G, Licheri M, Losiggio R, Frau G, Monaco F; Collaborators. Remimazolam for anesthesia and sedation in pediatric patients: a scoping review. J Anesth. 2024 Oct;38(5):692-710. doi: 10.1007/s00540-024-03358-w. Epub 2024 Jun 7. PMID: 38844707.

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Anesthetic management of pediatric patients poses several challenges and the optimal anesthetic agent for use in this population is still a matter of debate. We systematically searched MEDLINE and Google Scholar from their inception for studies that investigated the role and potential applications of remimazolam, a novel ultra-short-acting benzodiazepine, in pediatric patients. Furthermore, in March 2024, an update of the literature search along with an additional post-hoc search on the EMBASE database were performed. A total of fourteen pertinent studies which spanned the 2021-2023 period explored remimazolam as either the primary or adjuvant hypnotic agent for inducing and/or maintaining general anesthesia or sedation. Preliminary evidence derived from these studies highlighted that remimazolam is a safe and effective option for both sedation and general anesthesia in pediatric patients, particularly those with concurrent mitochondrial disorders, myopathic diseases, or at risk for malignant hyperthermia. Moreover, the current evidence suggested that remimazolam may contribute to reducing preoperative anxiety and postoperative delirium in children. Its favorable pharmacodynamic and pharmacokinetic profile demonstrated potential safety, effectiveness, and ease-of-use in various perioperative pediatric contexts, making it suitable for integration into specific protocols, such as intraoperative monitoring of evoked potentials and management of difficult intubation. Notwithstanding these promising findings, further research is essential to determine optimal dosages, establish conclusive evidence of its superiority over other benzodiazepines, and elucidate the impact of genetic factors on drug metabolism.

Tobias JD. Clinical experience with remimazolam in pediatric anesthesiology: An educational focused review. Paediatr Anaesth. 2024 Nov;34(11):1095-1106. doi: 10.1111/pan.14970. Epub 2024 Jul 17. PMID: 39016217.

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Abstract
Remimazolam is a novel ultrashort-acting benzodiazepine, which like midazolam, results in sedation, anxiolysis, and amnesia through its agonistic effects on the gamma-amino butyric acid A receptor. As opposed to midazolam, its unique metabolism is via tissue esterases, which results in a rapid elimination with a limited context sensitive half-life and prompt dissipation of its effect when administration is discontinued. Remimazolam received FDA approval for use in adults in 2020. In preliminary and initial clinical trials, its efficacy and safety has been suggested in the adult population, both as a primary agent for procedural sedation or as an adjunct to general anesthesia. There are limited data regarding the use of remimazolam in infants and children and its use in this population remains off label as it does not hold FDA-approval in pediatric-aged patients. This narrative outlines the pharmacologic properties of this unique medication, reviews previous published reports of its role in pediatric-aged patients, and discusses dosing parameters and clinical use in this population.