Comparative analysis of esketamine versus remimazolam in adult and pediatric surgical patients: a multimodal monitoring evaluation.

To evaluate the anesthetic effects of esketamine and remimazolam across different age groups, optimizing personalized anesthesia strategies. This retrospective study analyzed 264 surgical patients (esketamine n = 135, remimazolam n = 129) stratified by age (adults n = 141, children n = 123). Seventeen key perioperative parameters were assessed. Two-way analysis of variance (ANOVA) was performed to examine drug-specific, population-dependent, and interaction effects, while point-biserial correlation analysis was employed to assess relationships between parameters. Remimazolam demonstrated superior pharmacokinetic profiles, with a shorter time to sedation target, shorter recovery time, and lower dosage requirements compared to esketamine (all P < 0.001). However, it was associated with more pronounced respiratory depression, a higher incidence of intraoperative body movements, and hemodynamic suppression. Conversely, esketamine provided greater hemodynamic stability, minimal respiratory impact, and a significantly lower incidence of postoperative restlessness (P < 0.001). Pediatric patients showed a higher incidence of postoperative nausea and vomiting (PONV) with both agents. Significant drug-population interactions (P < 0.05) were observed for sedation onset, respiratory depression, and recovery time. Remimazolam offers faster onset and recovery but carries higher cardiorespiratory risks. Esketamine provides superior hemodynamic stability and is associated with less restlessness. The anesthetic effects show significant age-dependent variations, necessitating individualized drug selection based on patient age, physiological status, and surgical type.