Enhanced Sedation Strategies: Implications of Remimazolam-Propofol Combination for Extubation Timing

Combining remimazolam with propofol shortens extubation timing compared with propofol alone and matches remimazolam alone, according to the Hamamatsu University Hospital study. This finding shifts perioperative expectations and directly informs extubation planning when remimazolam-based maintenance is used.

Although clinicians often assume propofol dose dictates emergence speed, the reported data show a remimazolam–plus–propofol maintenance strategy produces extubation timing equivalent to remimazolam alone. Framed this way, the practical question the study answers is whether adding propofol alters time to extubation under remimazolam-based anesthesia — and the answer is no.

A single-center, propensity-score analysis compared remimazolam alone, propofol alone, and the remimazolam–propofol combination, using extubation time as the primary endpoint and time-weighted average hypotension as the key safety metric. After matching, remimazolam alone and the combination had shorter extubation intervals than propofol alone: medians of 9.0 minutes for the remimazolam and combination groups versus 13.0 minutes for propofol. The remimazolam group also recorded a lower time-weighted average hypotension than propofol (0.74 mmHg vs 2.03 mmHg). The matched-cohort design and adjustment for operative and patient factors support the comparative claim while limiting confounding; overall, the data indicate that adding propofol to remimazolam preserves remimazolam’s faster emergence without reproducing propofol’s slower extubation timing.

How will earlier extubation readiness affect monitoring and ICU planning? Shorter time to readiness can reduce projected PACU observation duration and may shorten ED-to-ward handovers, while still requiring standard respiratory and neurologic endpoints for safe extubation. Monitoring should document sustained spontaneous respiratory drive, RASS levels consistent with airway protection, and acceptable end-tidal CO2 or arterial CO2 trends before considering extubation. Accounting for earlier readiness can streamline post-anesthesia workflows without relaxing essential physiologic checks.

Hemodynamic outcomes showed a lower time-weighted average hypotension with remimazolam compared with propofol, indicating a reduced intraoperative blood-pressure burden for remimazolam-based maintenance. The remimazolam–propofol combination maintained the faster emergence profile without reproducing the higher hypotension signal seen with propofol alone, and postoperative nausea and vomiting incidence did not differ significantly between groups. Perioperative hemodynamic preparedness and antiemetic planning should therefore reflect a lower hypotension signal with remimazolam while recognizing that combination regimens preserve emergence benefits.

• What’s new: The remimazolam–propofol approach preserves remimazolam-level extubation timing while avoiding the longer emergence observed with propofol alone.
• Who’s affected: Adult noncardiac surgical patients managed with remimazolam-based maintenance or a remimazolam–propofol mix are the population directly impacted by the timing and hemodynamic differences reported.
• What changes next: Local post-anesthesia observation windows and handover checklists can be adjusted to reflect earlier extubation readiness under remimazolam-containing regimens as an operational consideration.