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In this phase 3 randomised controlled trial, we compared the anaesthetic efficacy and the incidence of postinduction hypotension during total intravenous anaesthesia with remimazolam vs. propofol. A total of 365 patients (ASA physical status 3 or 4) scheduled for elective surgery were assigned randomly to receive total intravenous anaesthesia with remimazolam (n\u2009=\u2009270) or propofol (n\u2009=\u200995). Primary outcome was anaesthetic effect, quantified as the percentage of time with Narcotrend\u00ae Index values \u2264\u200960, during surgery (skin incision to last skin suture), with a non\u2010inferiority margin of \u201010%. Secondary outcome was the incidence of postinduction hypotensive events. Mean (SD) percentage of time with Narcotrend Index values \u2264\u200960 during surgery across all patients receiving remimazolam (93% (20.7)) was non\u2010inferior to propofol (99% (4.2)), mean difference (97.5%CI) \u20106.28% (\u20108.89\u2013infinite); p\u2009=\u20090.003. Mean (SD) number of postinduction hypotension events was 62 (38.1) and 71 (41.1) for patients allocated to the remimazolam and propofol groups, respectively; p\u2009=\u20090.015. Noradrenaline administration events (requirement for a bolus and\/or infusion) were also lower in patients allocated to remimazolam compared with propofol (14 (13.5) vs. 20 (14.6), respectively; p\u2009&lt;\u20090.001). In conclusion, in patients who were ASA physical status 3 or 4, the anaesthetic effect of remimazolam was non\u2010inferior to propofol.<\/jats:p>","DOI":"10.1111\/anae.16205","type":"journal-article","created":{"date-parts":[[2024,1,14]],"date-time":"2024-01-14T22:40:04Z","timestamp":1705272004000},"page":"410-422","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":86,"title":["Anaesthetic efficacy and postinduction hypotension with remimazolam compared with propofol: a multicentre randomised controlled trial"],"prefix":"10.1111","volume":"79","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8713-9114","authenticated-orcid":false,"given":"J.","family":"Fechner","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9912-717X","authenticated-orcid":false,"given":"K.","family":"El\u2010Boghdadly","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4782-183X","authenticated-orcid":false,"given":"D. 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