Title : Evaluating remimazolam IV sedation via infusion pump in special care dentistry: A retrospective review
Abstract:
Background: Remimazolam is a short-acting benzodiazepine with rapid onset, predictable titration, and a favourable recovery profile. In dentistry, intravenous sedation has traditionally relied on intermittent bolus administration of midazolam, which can be associated with variable sedation depth, limited flexibility during prolonged procedures, and unpredictable recovery. Delivering remimazolam via an infusion pump allows continuous administration and real-time dose adjustment, potentially improving sedation stability and clinical workflow. Evidence describing infusion-based remimazolam in dental settings remains limited. This study evaluates its use in Special Care Dentistry, focusing on clinical outcomes and practical benefits and limitations.
Methods: A retrospective review was conducted of 80 intravenous sedation cases using remimazolam delivered via infusion pump in the Special Care Dental Department at the Royal London Hospital. Data collected included patient demographics, ASA classification, Body Mass Index (BMI), infusion flow rates, bolus doses, sedation model (single operator-sedationist or separate sedationist), recovery time, and sedation outcome. Sedation success was defined as completion of the planned treatment without the need for flumazenil reversal or the occurrence of significant adverse events. Descriptive analysis was performed to explore trends across age groups, ASA grades, and BMI.
Results: Sedation was successful in 72 of 80 cases (90%). Patients represented a wide range of ages, ASA classifications, and BMIs, with a mean BMI of 27.6. BMI did not appear to significantly influence sedation success or recovery time. The average infusion flow rate for patients aged under 65 years was 21.1 mg/hr, compared with 17.3 mg/hr for patients aged 65 years and over, suggesting lower infusion requirements in older patients.
A wide range of dental procedures was completed, including implant placement, dental extractions, restorative treatment, endodontic procedures, and scaling. The duration of continuous infusion during which patients remained sedated ranged from 6 to 88 minutes, demonstrating the adaptability of the infusion technique for both short and prolonged procedures. The infusion pump allowed real-time adjustment of sedation depth in response to patient cooperation, oxygen saturation, and procedural stimulation. Both operator-sedationist and separate sedationist–operator models were used successfully. Mean recovery time was 20.1 minutes, demonstrating rapid and predictable emergence following cessation of the infusion.
No cases required flumazenil reversal, and no significant respiratory or cardiovascular adverse events were recorded. Despite infusion durations of up to 88 minutes, recovery times remained predictable. Continuous infusion reduced the need for repeated clinician intervention, contributing to smoother workflow and improved operating conditions in behaviourally and medically complex patients.
Conclusion: Remimazolam administered via infusion pump appears to be an effective and flexible sedation technique for patients undergoing dental treatment in Special Care Dentistry. High sedation success rates were achieved across a broad spectrum of patient characteristics, including age, ASA grade, and BMI. Infusion-based delivery enabled individualised titration, stable sedation without pronounced peaks and troughs, and smooth recovery profiles. This technique also supported both single operator-sedationist and two-clinician sedation models, offering potential benefits for service delivery and staffing efficiency. Further prospective studies are warranted to strengthen the evidence base and explore optimisation of infusion protocols.
