Author: Megan Rolfzen, MD
IARS and SOCCA 2026 Annual Meeting coverage
Anesthesiologists continue to reconsider both established medications and newer agents designed to improve hemodynamic stability, recovery, and patient comfort. At the 2026 IARS and SOCCA Annual Meeting, experts reviewed nitrous oxide, remimazolam, and ciprofol, emphasizing that no single anesthetic is ideal for every patient or clinical setting.
Chanhung Lee, MD, PhD, examined the continuing role of nitrous oxide. Despite being one of the oldest anesthetic agents, nitrous oxide remains controversial because of its environmental effects and association with postoperative nausea and vomiting.
The ENIGMA-II trial, which included more than 7,000 patients undergoing major noncardiac surgery, supported the drug’s overall safety but reinforced concerns about its emetogenic effects.
Nitrous oxide may have renewed value in functional neurosurgery. Because it produces relatively little cortical suppression, it can be used as an adjunct during asleep microelectrode recording for deep-brain stimulation procedures. This may allow clinicians to identify target nuclei while maintaining adequate anesthesia.
Olivier Duranteau, MD, PhD, MSc, discussed remimazolam, a rapidly metabolized benzodiazepine engineered from the midazolam structure. The addition of a carboxylic ester allows tissue esterases to convert the medication quickly into an inactive metabolite.
Unlike midazolam, remimazolam does not depend heavily on hepatic cytochrome P450 metabolism. Its context-sensitive half-time remains approximately seven to eight minutes, even after prolonged administration, reducing the risk of drug accumulation.
Potential advantages include:
- Rapid onset and recovery
- Limited accumulation during prolonged infusions
- Reduced postoperative nausea and vomiting
- Greater hemodynamic stability
- Availability of flumazenil for reversal
- Potential usefulness in patients susceptible to malignant hyperthermia
In the United States, remimazolam is approved for procedural sedation lasting less than 30 minutes, although it is used for general anesthesia in some other countries. Meta-analyses suggest that remimazolam-based total intravenous anesthesia may produce faster emergence and less postoperative nausea and vomiting than sevoflurane.
Important limitations remain. Remimazolam may precipitate when administered with Ringer’s solution or Plasma-Lyte, its cost may restrict widespread use, and additional Phase 3 evidence is needed before it becomes a routine general anesthetic in the United States.
Felix Borngaesser, MD, presented ciprofol, also known as HSK3486. Ciprofol is an R-enantiomer with approximately four to five times the potency of propofol. It was developed to maintain propofol’s rapid hypnotic effects while reducing injection pain, hypotension, and respiratory depression.
A randomized, double-blind Phase 3 trial involving 255 adults found that ciprofol was noninferior to propofol for induction of general anesthesia. Patients receiving ciprofol experienced less injection-site pain, and available studies suggest fewer hypotensive events and less respiratory depression.
However, ciprofol remains in the early stages of international adoption. Much of the available evidence comes from research conducted within a single country, and broader international Phase 2 and Phase 3 trials are still needed.
Propofol therefore remains the standard in many settings, particularly where cost is important or established protocols rely on Bispectral Index-guided titration.
Key Takeaways
Nitrous oxide remains clinically useful despite its age and environmental concerns. Its limited cortical suppression may provide a specialized role during neurosurgical mapping and deep-brain stimulation procedures.
Remimazolam offers rapid, organ-independent metabolism and greater hemodynamic stability. It may be particularly useful for procedural sedation in medically fragile patients or those susceptible to malignant hyperthermia.
Ciprofol may preserve propofol’s rapid hypnotic effect while producing less injection pain, hypotension, and respiratory depression. More international research is required before it can replace propofol in routine practice.
Propofol continues to provide predictable, rapid induction at relatively low cost and remains the preferred agent in many clinical environments.
The best medication depends on the patient’s cardiovascular condition, procedure, recovery goals, available monitoring, drug cost, and institutional experience. These emerging options expand the anesthesiologist’s ability to tailor care rather than identify a single universal replacement for established drugs.
Thank you to IARS and SOCCA for allowing us to summarize this important coverage from the 2026 Annual Meeting.