Neurological sedative indicators during general anesthesia with remimazolam

Background: The bispectral index (BIS) value during general anesthesia with the newly developed anesthetic remimazolam is reported to be relatively high; however, the reason for this and the appropriate indicator for assessing the sedation level during remimazolam anesthesia have not been determined. In this study, the level of sedation during general anesthesia with remimazolam was evaluated using several different indicators. Methods: Thirty patients who underwent breast surgery under general anesthesia with remimazolam were included. BIS®, Sedline® and the pupil resting diameters were measured simultaneously. The intraoperative dose of remimazolam was adjusted to obtain a BIS in the range of 40–60; if a BIS < 60 could not be achieved, the intraoperative dose was increased up to the maximal dose of 2 mg/kg/h. Results: The mean intraoperative BIS and patient state index (PSI) in all patients was 50.6 ± 9.1 and 43.0 ± 11.8, respectively. Five patients showed a mean intraoperative BIS > 60 and eight patients showed mean intraoperative PSI > 50. The mean intraoperative spectral edge frequency (SEF) of BIS® or Sedline® was 15.3 ± 2.5 Hz or 10.6 ± 3.0 Hz, each. The mean intraoperative resting pupil diameter was 1.7 ± 0.2 mm. There were no patients with awareness during anesthesia. Conclusions: Processed electroencephalograms (BIS and PSI), and SEF of BIS® were relatively high during anesthesia with remimazolam, but SEF of Sedline® or pupillary diameter could be a supportive indicator to confirm sedation level during remimazolam anesthesia.