Effects of Remimazolam on Perioperative Inflammatory Response and Neurocognitive Disorders in Elderly Patients Undergoing Video-Assisted Thoracic Surgery: A Randomized Controlled Trial

Juan Hu,1,* Yu Huang,1,* Junjie Li,1,* Jinqiu Yang,1 Pengfei Pan,2 Su Xiang,3 Yucheng Ding,3 Ping Yang,1 Chun Liu1 1Department of Anesthesiology, Chongqing University Three Gorges Hospital, Chongqing, Wanzhou, People’s Republic of China; 2Department of Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, Wanzhou, People’s Republic of China; 3Department of Thoracic Surgery, Chongqing University Three Gorges Hospital, Chongqing, Wanzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Chun Liu, Department of Anesthesiology, Chongqing University Three Gorges Hospital, Chongqing, Wanzhou, People’s Republic of China, Email [email protected] Ping Yang, Department of Anesthesiology, Chongqing University Three Gorges Hospital, Chongqing, Wanzhou, People’s Republic of China, Email [email protected]: The systemic inflammatory response triggered by video-assisted thoracic surgery (VATS) is associated with the risk of perioperative neurocognitive disorders (PND). Remimazolam, a newer benzodiazepine anesthetic, has unknown anti-inflammatory properties and uncertain effects on elderly patients. This study investigated the effects of remimazolam on postoperative inflammation and neurocognitive disorders in elderly patients undergoing VATS.Patients and Methods: Ninety-two patients aged 60 years or older scheduled for VATS were randomized to receive either remimazolam (induction: 0.25 mg/kg; maintenance: 0.5– 1.5 mg/kg/h) or propofol (induction: 2 mg/kg; maintenance: 4– 6 mg/kg/h). The primary outcome was the serum C-reactive protein concentration at 24 h postoperatively. Secondary outcomes included the incidence of PND, assessed using the 3-Minute Diagnostic Confusion Assessment Method and the Mini-Mental State Examination on postoperative days 1, 3, 5, and 7. Exploratory outcomes included inflammatory cells (leucocytes and neutrophil counts), cytokines (IL-6, TNF-α, S100β), stress markers, and the systemic inflammatory response index. Other measures comprised hemodynamic parameters, anesthesia parameters, and potential adverse events.Results: All 92 patients completed the intention-to-treat analysis. At 24h postoperation, the remimazolam group showed significantly higher CRP, IL-6, leukocyte counts, neutrophil counts, and systemic inflammatory response index than the propofol group. No differences were found in TNF-α, S100β, or PND incidence (8.7% vs 6.5%). Stress marker levels were comparable between groups at all time points. Additionally, the remimazolam group demonstrated shorter anesthesia awakening time (P< 0.001), with reduced incidence of hypotension (P < 0.001) and injection pain (P = 0.015).Conclusion: Although remimazolam is less effective than propofol in suppressing the early postoperative inflammatory response in elderly patients undergoing VATS, it did not increase the risk of PND or infection. It has significant advantages in hemodynamic stability, facilitates faster recovery, and reduces injection pain, establishing it as a preferred anesthetic option for geriatric VATS, though its inflammatory mechanisms require clarification.Keywords: remimazolam, propofol, elderly, inflammatory, neurocognitive disorders, thoracic surgery