Association Between American Society of Anesthesiologists Physical Status Classification System and Remimazolam Sedation Outcomes

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Abstract
Background: Remimazolam (RM) is an ultrashort‐acting benzodiazepine with pharmacodynamic properties ideal for procedural sedation in emergency departments (EDs). This study evaluated the safety of RM when used for procedural sedation of American Society of Anesthesiologists (ASA) I–III patients in the ED. Aims: To compare the occurrence of no or mild/moderate respiratory complications during procedural sedation in patients with ASA scores I, II, and III. Secondarily, to compare clinical characteristics of RM sedations between the ASA groups. Methods: This qualitative improvement study was conducted in 2024 and 2025 at a Danish Level 1 trauma center. RM was administered to ASA I–III patients ≥ 12 years of age as procedural sedation by emergency medicine physicians or nurses educated in airway management, RM sedation, and adverse events. Safety was measured by the occurrence of respiratory problems graded as none, mild, moderate, or severe. Results: Of the 540 patients sedated with RM, 95%–100% in ASA I–III had no or mild/moderate respiratory complications, with ASA I and III being the safest groups ( p < 0.014). ASA III patients had the most potential airway risks, but still experienced fewer severe respiratory complications than ASA II patients (4.7% vs. 1.3%, p = 0.014). The RM dose was found to be age‐, gender‐ and ASA score‐dependent. Conclusions: RM showed great potential for procedural sedation and was safe for procedural sedation of ASA I–III patients in the ED, with few serious respiratory complications, even in high doses and with high‐risk profiles.

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