Sevoflurane or remimazolam anaesthesia and emergence agitation after nasal surgery in adults

BACKGROUND Emergence agitation is common after nasal surgery under general anaesthesia. Remimazolam, a novel ultra-short-acting benzodiazepine, allows haemodynamic stability and prompt postoperative recovery, but the specific impact of remimazolam on emergence agitation is not well understood. OBJECTIVES The primary aim of this study was to compare the effects of remimazolam-based total intravenous anaesthesia (TIVA) and sevoflurane-based volatile induction and maintenance of anaesthesia (VIMA) on the occurrence of emergence agitation. DESIGN A prospective, randomised, assessor-blinded clinical trial. SETTING A single-centre study in a university-affiliated tertiary hospital. PARTICIPANTS Ninety-eight adults undergoing nasal surgery under general anaesthesia. INTERVENTIONS Patients were randomised into two groups. The Sevoflurane group ( n = 49) received VIMA with sevoflurane and nitrous oxide, while the Remimazolam group ( n = 49) received TIVA with remimazolam and remifentanil. MAIN OUTCOME MEASURES The primary outcome was the occurrence of emergence agitation, which was evaluated using the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale. The secondary outcomes were immediate complications after extubation and postoperative pain, and the interval between discontinuation of anaesthesia and extubation. RESULTS Emergence agitation, as measured by the Richmond Agitation-Sedation Scale, occurred in six of 49 patients (12.2%) in the Sevoflurane group and none (0.0%) in the Remimazolam group. The risk difference was 12.2 (95% CI, 3.0 to 21.4, P = 0.008). The occurrence measured by the Riker Sedation-Agitation Scale was identical to that with the Richmond Agitation-Sedation Scale. Coughing was more frequent in the Sevoflurane group, 53.1 vs. 12.2%, risk difference = 40.8 (95% CI, 24.0 to 57.5, P < 0.001). In addition, the interval between discontinuation of anaesthesia and extubation was lower in the Remimazolam group than the Sevoflurane group (9.00 ± 4.25 min vs. 12.18 ± 4.18 min, respectively, P < 0.001) CONCLUSION The occurrence of emergence agitation in adult patients after nasal surgery under general anaesthesia can be significantly reduced using remimazolam-based TIVA. TRIAL REGISTRATION Clinical Research Information Service (KCT0007387).