Comparison of Remimazolam and Dexmedetomidine on Postoperative Delirium and Emergence Agitation in Elderly Patients Undergoing Thoracoscopic Surgery: A Randomized, Double-Blind, Non-Inferiority Trial

Xi Chen,1,2 Wei Zhao,1 Beibei Yu,1 Yuge Liu,1 Yan Ma,1 Chi Tang,1 Yibo Huang,1 Ming Yan1,2 1Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China; 2Jiangsu Provincial Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of ChinaCorrespondence: Ming Yan, Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China, Tel +8618052268329, Email [email protected] and Aim: Postoperative delirium (POD) and emergence agitation (EA) are common complications in older patients undergoing video-assisted thoracoscopic surgery (VATS), significantly impacting recovery. This study was designed to examine whether remimazolam is noninferior to dexmedetomidine for preventing POD and EA in elderly patients following VATS.Patients and Methods: A total of 176 elderly patients scheduled for VATS due to lung cancer were randomly assigned to receive either dexmedetomidine (Group D, n = 88) or remimazolam (Group R, n = 88). Group D received dexmedetomidine at 0.5 μg/kg/h starting 3 minutes before anesthesia induction until surgery completion. Group R received remimazolam at 0.5 mg/kg/h over the same period. The primary outcomes were the incidence of EA and POD within 5 days after surgery. Secondary outcomes included Quality of Recovery-15 (QoR-15) score, Athens Insomnia Scale (AIS), and numeric rating scale (NRS) for pain. Correlations among hypotension, EA, and POD were also analyzed.Results: The incidence of POD and EA in Group R was non-inferior to that in Group D (non-inferiority P < 0.01), with overall rates of 20.73% vs 18.75% and 10.98% vs 8.75%, respectively. No significant differences were observed in QoR-15 or NRS scores between groups, though Group D had lower AIS scores on postoperative day 1. Group R demonstrated more stable intraoperative hemodynamics with reduced requirements for opioids and vasopressors, and shorter extubation times. Hypotension and EA were significantly correlated with POD.Conclusion: Remimazolam was non-inferior to dexmedetomidine in preventing POD and EA in elderly patients undergoing VATS while providing improved hemodynamic stability and reducing the need for intraoperative opioids and vasopressors.Keywords: remimazolam, postoperative delirium, emergence agitation, thoracoscopic surgery