Remimazolam versus propofol for sedation in mechanically ventilated ICU patients: A systematic review and meta-analysis of randomized controlled trials
In brief
Remimazolam matches propofol for time in target sedation range
In six randomized trials involving 705 mechanically ventilated ICU patients, remimazolam and propofol showed no meaningful difference in the time patients spent within their target sedation range. Other measures, including mortality, ventilation duration and adverse effects, also showed no significant differences, but estimates were imprecise; larger trials are needed to clarify clinical and safety outcomes.
- Journal
- Journal of critical care (Q1)
- Published
- 4 November 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Shun Nakahara, Ana-Alicia Velarde-Pineda, Christian A Romero Bonifaz, Maria Júlia Hallack Moura, David Abraham Batista da Hora, Ryota Sato
- PMID
- 42981695
- DOI
- 10.1016/j.jcrc.2026.155798
Why clinicians should know about it
- Picked for Critical Care and Intensive Care Medicine (top studies of the week, 8 November 2026): Compares sedation options in mechanically ventilated ICU patients
Abstract
BACKGROUND: Propofol is widely used for sedation in the intensive care unit (ICU), but its use may be limited by cardiovascular depression, hypertriglyceridemia, and propofol infusion syndrome. Remimazolam has emerged as a potential alternative to propofol, with rapid metabolism, predictable recovery, and flumazenil reversibility. However, evidence regarding its use in mechanically ventilated ICU patients remains limited. METHODS: PubMed, Embase, Cochrane, and ClinicalTrial.gov databases were reviewed for randomized controlled trials (RCTs) comparing remimazolam with propofol in mechanically ventilated ICU patients. The primary outcome was percentage of time within the target sedation range. Secondary outcomes included sedation success rate, 28-day mortality, ICU mortality, length of ICU stay, and duration of mechanical ventilation. Safety outcomes including adverse events leading to dose reduction, hypotension, and delirium were evaluated. Continuous endpoints were reported using mean differences (MDs), and dichotomous outcomes were analyzed using risk ratios (RRs), with 95% confidence intervals (CIs). RESULTS: Six RCTs including 705 patients were analyzed. No statistically significant difference was detected in the percentage of time within the target sedation range (MD, -0.45%; 95% CI, -2.46 to 1.55; p = 0.56; I2 = 0%). No significant differences were detected in sedation success rate, 28-day mortality, ICU mortality, ICU length of stay, and duration of mechanical ventilation, or safety outcomes, although several estimates were imprecise. CONCLUSION: Remimazolam probably results in little to no difference in sedation efficacy compared with propofol in mechanically ventilated ICU patients. However, uncertainty remains regarding clinical and safety outcomes. Larger multinational RCTs are warranted to clarify these effects.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.