Quality of recovery after general anesthesia with remimazolam in patients' undergoing urologic surgery: A randomized controlled trial comparing remimazolam with propofol

“CCI was a useful tool to identify patients with multiple chronic diseases.(17,18) The surgical Apgar score was a 10-point surgical outcomes score, based on the lowest HR, lowest MBP and estimated blood loss, which can well discriminate patients at high or low risk of major complications and death of operation.”

“CCI was a useful tool to identify patients with multiple chronic diseases.(17,18) The surgical Apgar score was a 10-point surgical outcomes score, based on the lowest HR, lowest MBP and estimated blood loss, which can well discriminate patients at high or low risk of major complications and death of operation.”

“However, a study evaluating the efficacy and safety of remimazolam versus propofol for general anesthesia showed a longer time to extubation in remimazolam group than propofol group.(9) Liu also found remimazolam may worsen elderly patients’ postoperative cognitive functions in upper gastrointestinal endoscopy.”

“Intraoperative awareness was assessed with modified Brice interview.(14,15) Somnolence was regarded as a state of sleepiness and falling asleep without stimulation.”

“However, it is worth noting that previous studies have proved the efficacy and safety of general anesthesia with remimazolam in ASA class III and elderly patients.(37,38) Even though the effect of age and ASA class was small on time to extubation with remimazolam anesthesia, lower doses of remimazolam were recommended…”

“Previous study revealed the minimal clinically important difference of global QoR-15 scores was 8, but the authors updated it to be 6 lately.(30) The paper was formally published Figure 2 The global QoR-15 scores of remimazolam group and propofol group at POD1 and POD3.”

“However, a recent study in day case surgery revealed that QoR-15 scores tested within 24h preoperatively may not represent a true baseline due to factors like fatigue, anxiety and others.(27) Thus, baseline for QoR-15 scale is controversial.”

“The Nursing Delirium Screening Scale (Nu-DESC) was used to screen patients with emergency delirium.(16) Patient demographic and clinical parameters including age, sex, BMI, education level, ASA physical status, duration of anesthesia and duration of operation were also collected.”

“However, patients’ postoperative recovery should be concerned in general anesthesia with remimazolam before it is widely promoted.(40) We demonstrated that general anesthesia with remimazolam temporarily impaired the quality of recovery in patients undergoing urologic surgery.”

“Even though the effect of age and ASA class was small on time to extubation with remimazolam anesthesia, lower doses of remimazolam were recommended for some fragile elderly patients.(10,39) Thus, further clinical data would help to understand the effect of general anesthesia with remimazolam on quality of recovery in…”

“Moreover, like other benzodiazepine, remimazolam can be antagonized by flumazenil.(7,8) These nearly perfect characteristics of remimazolam have greatly inspired scientists.”

“The surgical Apgar score was a 10-point surgical outcomes score, based on the lowest HR, lowest MBP and estimated blood loss, which can well discriminate patients at high or low risk of major complications and death of operation.(19) Statistical Analysis The sample size was calculated according to QoR-15 scores at POD…”

“Postoperative delirium is a mental problem puzzling anesthesiologist many years and use of benzodiazepines is associated with delirium.(34) Here, we used Nu-DESC to assess emergency delirium in PACU.”

“Even though the effect of age and ASA class was small on time to extubation with remimazolam anesthesia, lower doses of remimazolam were recommended for some fragile elderly patients.(10,39) Thus, further clinical data would help to understand the effect of general anesthesia with remimazolam on quality of recovery in…”

“However, it is worth noting that previous studies have proved the efficacy and safety of general anesthesia with remimazolam in ASA class III and elderly patients.(37,38) Even though the effect of age and ASA class was small on time to extubation with remimazolam anesthesia, lower doses of remimazolam were recommended…”

“Intraoperative awareness was assessed with modified Brice interview.(14,15) Somnolence was regarded as a state of sleepiness and falling asleep without stimulation.”

“Recently, it was recommended as an endpoint in comparative anesthesia studies.(26) Lots of studies have applied QoR-15 scale as their outcomes but the time points they tested varied.”

“When this trial was registered on January 11th 2021, we calculated the sample size referring to previous studies, which indicated the standard deviation (SD) of QoR-15 scale was 14.(12,21) Considering a dropout rate of 20%, a sample size of 166 could achieve a power of 90% with a type 1 error of 0.”

“The surgical Apgar score, unlike the obstetrical Apgar score, is calculated from the blood loss, lowest MBP, and lowest HR during the operation, which is strongly correlated with postoperative outcomes.(24,25) With the surgical Apgar score, we can quickly and objectively assess how well the operation has been done for…”

“Actually, many studies only tested it postoperatively and the timepoint of 24h after surgery was most commonly applied.(28,29) Chazapis M suggested a follow-up to 48h postoperatively, as most patients recovered 2 days after surgery.”

“The surgical Apgar score, unlike the obstetrical Apgar score, is calculated from the blood loss, lowest MBP, and lowest HR during the operation, which is strongly correlated with postoperative outcomes.(24,25) With the surgical Apgar score, we can quickly and objectively assess how well the operation has been done for…”

“Actually, many studies only tested it postoperatively and the timepoint of 24h after surgery was most commonly applied.(28,29) Chazapis M suggested a follow-up to 48h postoperatively, as most patients recovered 2 days after surgery.”

“Recently, a clinical trial to evaluate the effect of remimazolam compared with propofol on the incidence of delirium after cardiac surgery was registered.(35) Its results may answer this question more precisely.”

“Moreover, like other benzodiazepine, remimazolam can be antagonized by flumazenil.(7,8) These nearly perfect characteristics of remimazolam have greatly inspired scientists.”

“Liu also found remimazolam may worsen elderly patients’ postoperative cognitive functions in upper gastrointestinal endoscopy.(32) Like remifentanil, remimazolam, when doses at the top end of the response curve, might appear undesirable desensitization effects and rebound phenomenon once stopped, such as anxiety.”

“16 Patient Satisfaction : Remimazolam’s quick onset and offset, coupled with reduced side effects such as postoperative cognitive dysfunction, contribute to higher patient satisfaction.”

“Scores ranged from 0 to 150, with higher scores manifesting a more favorable health status [13].”

“Four trials with 277 patients measured HR changes (15,16,21,22).”

“Additionally, a study conducted by Mao et al. investigated the quality of recovery after use of remimazolam in comparison to propofol, where scores were significantly lower within the remimazolam cohort at postoperative day 1 and 3 [35].”

“There were no significant between-group differences in MMSE (PACU, P = 0.724; POD1, P = 0.117) or in PostopQRS scores (POD1, P = 0.072; POD14, P = 0.264) compared with baseline measurements (Table 3).”

“Mao et al evaluated patients’ recovery quality who were induced and maintained by general anesthesia with remimazolam.(17) The data showed that the score of remimazolam group on the first day after surgery was significantly lower than propofol group, especially the physical comfort and emotional state.”

“Mao et al. [17] found no statistically significant difference in the incidence of PONV after urological surgery according to whether remimazolam or propofol was used (10.9% vs. 4.7%).”

“In a prospective, double-blinded, randomized controlled trial, sufentanil and remifentanil were paired with either remimazolam or propofol for the induction and maintenance of general anesthesia during adult urologic surgery [11].”

“Further analysis revealed the reduction of postoperative recovery in the remimazolam group, which focused on the aspects of physical comfort and emotional state of the patient [20].”

“, 2021), or induction and maintenance of general anesthesia (Zhou et al., 2020; Mao et al., 2022).”

“Meanwhile, Qiu et al discovered that individuals receiving remimazolam had higher intraoperative blood pressure and recovered of brain function faster than those receiving propofol.(25,26) Propofol has been found have a significant myocardial depressant effect which reduces cardiac output, and causes peripheral vasodi…”

“…in patients undergoing urological surgery, compared with propofol, and the hemodynamics were more stable; however, it suggested that remima-zolam infusion resulted in more cases of postoperative delirium than did propofol infusion, although the difference was not statistically significant [18].”

“However, Mao et al. [33] found that patients undergoing urological surgery had lower QoR-15 scores 1 day after surgery in the remimazolam group than in the propofol group.”

“Physical independence and psychological support, two of the five QoR-15 domains, were also higher in the R group (8.5 [8 e 10] vs 8 [7 e 9], P ¼ 0.043; 17 [13 e 17] vs 12.5 [12 e 14], P < 0.001).”

“25,36 In a meta-analysis of patients with benzodiazepine intoxication, agitation and gastrointestinal symptoms were the most common adverse events in the flumazenil group, while supraventricular arrhythmia and convulsions were the most common severe adverse events.”

“In adults, both intermittent bolus doses and continuous infusions have been used as the sole agent during procedural sedation and as a supplement to volatile anesthetic agents during general anesthesia [26-28, 31-35].”

“We speculate that the laryngospasm is related to the mode of infusion, the low concentration of administration,(17,36) or the use of a neuromuscular blocking agent during general anesthesia.(37) Because our study used a bolus of 0.”

“17–20 Thus, remimazolam administered as a GA for nonoperating room anesthesia may also have a reduced incidence of hypotension.”

“Majority of the studies included patients with American Society of Anesthesiologists (ASA) physical status I–II, whereas four [33, 36, 38, 40] included patients with ASA III.”

“23,24 28 However, data regarding the use of remimazolam in outpatient gynecological surgeries, particularly in terms of patient satisfaction, are limited.”

“Some studies have reported no significant between-group differences [16, 17], whereas one study reported a decrease in postoperative QoR scores in the remimazolam-based TIVA group [35].”

“However, there were no residual complications until hospital discharge, as well as no significant differences in post-operative adverse events and length of hospital stay, between the two groups.”

“The sedative effects of anesthetic drugs, including remimazolam, are often assessed using the bispectral index (BIS) value via electroencephalogram (EEG) [9].”

“[25] reported that patients in the remima-zolam group experienced lower physical discomfort and emotional distress on postoperative days one and three compared to those in the propofol group (measured via patient-reported scores for physical comfort, emotional state, physical independence, pain,…”

“A total of four studies (27,28,30,32), involving a total of 321 patients, examined the incidence of bradycardia.”

“Remima - zolam had a mild effect on hemodynamics, thus improving postoperative cognitive function [ 43].”

“8,9 Ciprofol (HSK3486) is a promising alternative to propofol.”

“While most minimal clinically important differences (MCIDs) reported in various studies fell below 8 points for the total QoR-15 score [7,28], our observed 13-point difference could signify substantial clinical improvement in functional recovery beyond the MCID criteria [24].”

“For prolonged deep sedation, propofol may offer more predictable control [33].”

“This finding was consistent with a prior study [24] that the decrease in blood pressure was more moderate in the remimazolam group than in the propofol group during anesthesia.”

“However, propofol has adverse reactions such as inhibition of the respiratory and circulatory systems and impact on post-operative cognitive function, so it is not the most ideal anesthetic drug for day surgery anesthesia [22, 23].”

“Similarly, Mao et al. reported in their prospective, double-blinded, randomized controlled trial that the incidence of PONV was higher in the remimazolam group than in the propofol group in patients undergoing urological surgery [16].”

“While certain trials indicate a lower risk of POD associated with remimazolam [18, 24, 26], the majority of studies reveal comparable outcomes [15–17, 19–23, 25, 27–31].”

“…heart rate changes among the three groups after induction with different doses of remimazolam besylate, which was consistent with the results reported in the previous literature; Compared with propofol, remimazolam demonstrates favorable sedative effects and is more hemodynamically stable (11, 12).”

“In addition to its use for procedural sedation, remima-zolam has been used as a primary agent or as an adjunct to both volatile and intravenous anesthetic agents during general anesthesia [7-9].”

“A total of 20 studies (18, 19, 21, 24, 26–33, 35, 37–42, 44) comparing the delirium risk of Remimazolam and Propofol were included.”

“By targeting and blocking sensory nerves, this technique reduces the dose of general anesthetics, avoids dramatic circulatory fluctuations, and creates conditions for rapid postoperative awakening, to assess neurological function [7].”

“105,106 In either case, advances in monitoring, follow-up, and even arti fi cial intelligence (AI) may introduce novel ways to enhance postoperative patient care, much of which will hopefully be directly applicable to the ambulatory surgery patient population.”

“Another study evaluating the quality of recovery in urological surgery patients showed that MAP and HR were higher in remimazolam group compared to propofol group after the anesthesia induction [19].”

“Consistent with previous reports (17, 19, 27), remimazolam was associated with a longer time to loss of consciousness, extended extubation time, and a prolonged PACU stay.”

“19,20 Intraoperative hemodynamic parameters are comparable to a large extent, and at some points in time, blood pressure and heart rate only change very little.”

“A recent study evaluating the comparative recovery quality after general anesthesia with remimazolam vs. propofol indicated that remimazolam had a better score on the 15-item quality of recovery (QoR-15) scale compared to propofol [13].”

“In the combined use group, the sedation score, pain score and pain mediators of patients were significantly improved or reduced, indicating that remimazolam can enhance the sedative and analgesic effects (8).”

“This observed difference aligns with the findings of other studies comparing remimazolam-and propofol-based TIVA [22,29].”

“Similar to the study by Mao et al. we found that patients in Group R had lower QoR‐15 scores than those in the propofol group on the first postoperative day, possibly due to the effect of benzodiazepines on cognition and the rewarding effects of propofol [21].”

“Mao et al. found that remimazolam may lead to a temporary decrease in recovery quality compared to propofol for patients undergoing urologic surgery [16].”

“16 20 Moreover, these randomised controlled trials had strictly selected patients and small samples and were restricted to a specific dose or surgical type.”