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).