Advantages of Remimazolam in Pediatric Anesthesia: A Narrative Review

Remimazolam is an ultra-short-acting benzodiazepine developed according to the "soft drug" concept and characterized by rapid onset, predictable offset, organ-independent metabolism, and the availability of a specific antagonist. Due to these pharmacological features, this drug represents a particularly attractive option for pediatric anesthesia and sedation, a field in which traditional agents are often limited by hemodynamic instability, prolonged recovery, and adverse respiratory effects. This narrative review summarizes and discusses the current evidence regarding the use of remimazolam in pediatric patients, focusing on pharmacokinetics, pharmacodynamics, clinical applications, and safety. Available data indicate that remimazolam provides effective sedation and anesthesia in children across multiple settings, including induction of general anesthesia, non-operating room anesthesia, and intensive care unit sedation. Compared with propofol and midazolam, remimazolam is generally associated with greater hemodynamic stability, rapid recovery, reduced emergence delirium, and a favorable respiratory profile, while maintaining comparable efficacy. Intranasal administration has also shown promise as a premedication strategy for reducing preoperative anxiety, although it may occasionally be associated with pain. Even if remimazolam lacks intrinsic analgesic properties, its use appears to indirectly improve postoperative comfort by attenuating stress responses and emergence agitation. Despite encouraging results, pediatric use of remimazolam remains off-label in many countries, and evidence is still limited by small sample sizes and heterogeneous protocols. Further large-scale randomized controlled trials are needed to define optimal dosing strategies, long-term safety, and their definitive role in pediatric anesthetic and sedative practice.