Weight-Scaled Dose Optimization of Intravenous Anesthetics in Patients with Obesity: General Anesthesia and Procedural Sedation.

Obesity alters the pharmacokinetics and pharmacodynamics of intravenous anesthetics, complicating weight-based dose selection. This narrative review examines weight-scaling strategies and effective-dose estimates (ED50/ED95) for propofol, ciprofol, and remimazolam in patients with obesity undergoing general anesthesia or procedural sedation. Targeted searches of PubMed/MEDLINE were supplemented by DOI and title searches in Europe PMC and publisher records. Evidence was selected purposively according to clinical relevance, study design, population, dosing phase, and outcome, prioritizing obesity-specific studies. General pharmacological evidence was considered separately to contextualize findings and evidence gaps. The evidence supporting dose optimization is broader for propofol than for ciprofol or remimazolam. Propofol studies support weight-informed initial dosing followed by individualized adjustment, although no single weight scalar is appropriate across all settings. Obesity-specific induction and dose-finding studies of ciprofol and remimazolam provide preliminary information, but limited study numbers and population diversity restrict generalizability. Their maintenance dosing in patients with obesity remains insufficiently characterized. ED50/ED95 values reflect responses under specific study conditions and should not be interpreted as routine clinical dosing recommendations. For procedural sedation, dose selection requires consideration of the intended sedation depth, concomitant medications, and respiratory risk. Weight-based calculations provide initial dose estimates, while titration guided by clinical response and appropriate pharmacodynamic monitoring remains essential. The proposed dosing framework distinguishes approaches supported by broader clinical evidence from preliminary findings and suggestions based on pharmacological reasoning. The latter require further validation before routine adoption. Adequately powered, multicenter comparative trials should address maintenance dosing, extreme obesity, and clinically meaningful safety and recovery outcomes.