Objective To investigate the effects of remimazolam tosilate on the hemodynamics and safety of elderly patients during endoscopic ultrasonography. Methods A total of 84 elderly patients who underwent endoscopic ultrasonography in the Affiliated Hospital of Qingdao University from June to October 2021 were selected. According to the random number table method, they were divided into two groups (n=42): a control group (group C) and an experimental group (group R). All the patients were administered with sufentanil. Then, patients in group C were given propofol for sedation, whereas those in group R received remimazolam. Their heart rate, blood pressure, respiratory rate (RR), pulse oxygen saturation (SpO2), bispectral index (BIS) and the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores were recorded at the time of admission into the operating room (T0), at the end of sedative administration (T1), at the time of inserting the endoscopy (T2), 5 min after entering the endoscope (T3), at the time of retracting the endoscope (T4) and 30 min after retracting the endoscope (T5). The operation time, emergence time and the time of recovery of orientation in the two groups were recorded. The incidences of intraoperative injection pain, hypotension, bradycardia, respiratory depression and intraoperative awareness were recorded. The incidences of postoperative nausea and vomiting, agitation, dizziness and satisfaction were recorded. Results There was no statistical difference in blood pressure, heart rate, SpO2 and BIS between the two groups at T0. Blood pressure and HR in group R were higher than those in group C at T1, T2, T3, T4 and T5 (P<0.05). SpO2 and BIS in group R were higher than those in group C at T1, T2, T3 and T4 (P<0.05). Compared with group C, group H showed prolonged onset time of sedation (P<0.05), and shortened emergence time and time of recovery of orientation (P<0.05). Compared with group C, group R showed decreased incidences of intraoperative injection pain, hypotension, respiratory depression and bradycardia (P<0.05). No intraoperative awareness occurred in both groups. There was no statistical difference in the incidences of postoperative nausea and vomiting, agitation, dizziness and satisfaction between the two groups (P>0.05). Conclusions Remimazolam is beneficial for elderly patients for ultrasonic gastroscopy, with stable hemodynamics, high safety, quick recovery and few adverse reactions.