Frontiers in medicine · 2026
Remimazolam is associated with superior cerebral and pulmonary protection over propofol in elderly thoracic surgery: a real-world study validated by propensity score matching.
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Zhang Jingjing, Zhang Xiaoyan, Cao Na, Cai Yichao, Zhao Caixia, Tang Chunying, Ma Zhenhua, Zhang Yan
Аннотация
BACKGROUND: Selecting the optimal anesthetic regimen to mitigate postoperative cognitive decline and pulmonary complications in elderly patients undergoing thoracic surgery remains a clinical challenge. While propofol is widely used, remimazolam offers potential advantages due to its hemodynamic stability and rapid clearance. This study employed rigorous propensity score matching (PSM) to compare the real-world outcomes of these two intravenous anesthetics in a high-risk surgical cohort.
METHODS: We conducted a retrospective cohort study of patients aged ≥65 years undergoing elective VATS lobectomy (2020-2023). Patients received either remimazolam- or propofol-based total intravenous anesthesia under a standardized, driving pressure-guided individualized PEEP protocol. To address significant baseline imbalances and confounding by indication, we performed 1:1 propensity score matching using a multivariable logistic regression model incorporating 13 pre-specified covariates (e.g., age, comorbidities, pulmonary/cognitive function). Balance was assessed via standardized mean differences. The matched cohort was used for all outcome analyses.
RESULTS: From 342 eligible patients, PSM created 122 well-balanced pairs (n = 244). The matched cohort demonstrated excellent covariate balance (all SMDs < 0.1). Compared to the propofol group, the remimazolam group exhibited: (1) Superior cognitive recovery across the early and short-term postoperative period, with higher MMSE scores at 24 h (mean difference 3.6 points, 95% CI 2.8-4.4, p < 0.001), 72 h (2.7 points, 95% CI 2.0-3.4, p < 0.001), postoperative day 4 (2.1 points, 95% CI 1.4-2.8, p < 0.001), day 7 (1.3 points, 95% CI 0.7-1.9, p < 0.001), and day 30 (0.6 points, 95% CI 0.1-1.1, p = 0.021); (2) Better pulmonary function at 72 h, including higher FEV₁% predicted (6.9%, 4.3-9.5, p < 0.001) and lower lung ultrasound scores (-2.0, -2.4 to -1.6, p < 0.001); (3) Enhanced hemodynamic and cerebral oxygen stability, with higher time-weighted mean arterial pressure (5.7 mmHg, 3.9-7.5, p < 0.001) and cerebral oxygen saturation nadir during one-lung ventilation (4.3%, 2.9-5.7, p < 0.001); and (4) Reduced postoperative morbidity, including lower incidence of delirium (9.0% vs. 23.0%, OR 0.33, 95% CI 0.16-0.69) and pulmonary complications (11.5% vs. 22.1%, OR 0.46, 0.23-0.92).
CONCLUSION: Using robust propensity score matching to emulate a randomized comparison, this study provides real-world evidence that a remimazolam-based anesthetic strategy, integrated with lung-protective ventilation, is associated with significantly better cerebral oxygenation, accelerated neurocognitive and pulmonary recovery, and lower rates of key postoperative complications compared to propofol in elderly patients undergoing VATS lobectomy. These findings highlight the clinical value of remimazolam within enhanced recovery pathways for geriatric thoracic surgery.
METHODS: We conducted a retrospective cohort study of patients aged ≥65 years undergoing elective VATS lobectomy (2020-2023). Patients received either remimazolam- or propofol-based total intravenous anesthesia under a standardized, driving pressure-guided individualized PEEP protocol. To address significant baseline imbalances and confounding by indication, we performed 1:1 propensity score matching using a multivariable logistic regression model incorporating 13 pre-specified covariates (e.g., age, comorbidities, pulmonary/cognitive function). Balance was assessed via standardized mean differences. The matched cohort was used for all outcome analyses.
RESULTS: From 342 eligible patients, PSM created 122 well-balanced pairs (n = 244). The matched cohort demonstrated excellent covariate balance (all SMDs < 0.1). Compared to the propofol group, the remimazolam group exhibited: (1) Superior cognitive recovery across the early and short-term postoperative period, with higher MMSE scores at 24 h (mean difference 3.6 points, 95% CI 2.8-4.4, p < 0.001), 72 h (2.7 points, 95% CI 2.0-3.4, p < 0.001), postoperative day 4 (2.1 points, 95% CI 1.4-2.8, p < 0.001), day 7 (1.3 points, 95% CI 0.7-1.9, p < 0.001), and day 30 (0.6 points, 95% CI 0.1-1.1, p = 0.021); (2) Better pulmonary function at 72 h, including higher FEV₁% predicted (6.9%, 4.3-9.5, p < 0.001) and lower lung ultrasound scores (-2.0, -2.4 to -1.6, p < 0.001); (3) Enhanced hemodynamic and cerebral oxygen stability, with higher time-weighted mean arterial pressure (5.7 mmHg, 3.9-7.5, p < 0.001) and cerebral oxygen saturation nadir during one-lung ventilation (4.3%, 2.9-5.7, p < 0.001); and (4) Reduced postoperative morbidity, including lower incidence of delirium (9.0% vs. 23.0%, OR 0.33, 95% CI 0.16-0.69) and pulmonary complications (11.5% vs. 22.1%, OR 0.46, 0.23-0.92).
CONCLUSION: Using robust propensity score matching to emulate a randomized comparison, this study provides real-world evidence that a remimazolam-based anesthetic strategy, integrated with lung-protective ventilation, is associated with significantly better cerebral oxygenation, accelerated neurocognitive and pulmonary recovery, and lower rates of key postoperative complications compared to propofol in elderly patients undergoing VATS lobectomy. These findings highlight the clinical value of remimazolam within enhanced recovery pathways for geriatric thoracic surgery.