关键词: 胸腔镜下肺叶切除术, 瑞马唑仑, 丙泊酚, 老年患者, 肝功能, 术后恢复质量

Abstract:

Objective To compare the effects of remimazolam versus propofol for general anesthesia maintenance on postoperative liver function， quality of recovery， and perioperative safety in elderly patients undergoing video-assisted thoracoscopic lobectomy （VATS）. Methods A total of 117 patients aged ≥ 65 years scheduled for VATS lobectomy were enrolled and randomly assigned to two groups using a random number table： the propofol group （Group P， n = 59） and the remimazolam group （Group R， n = 58）. For anesthesia induction， Group P received propofol 2 mg/kg and Group R received remimazolam 0.25 mg/kg. For anesthesia maintenance， Group P received a continuous infusion of propofol at 8 mg/（kg·h）， and Group R received a continuous infusion of remimazolam at 1.2 mg/（kg·h）. Both groups were combined with target-controlled infusion （TCI） of remifentanil for analgesia. Anesthesia depth was monitored using SedLine to maintain the Patient State Index （PSI） between 25 and 50. Postoperative analgesia was provided via standardized patient-controlled intravenous analgesia （PCIA）. Patient demographics were recorded. The primary outcome was the change in alanine aminotransferase from baseline on postoperative day 1 （ΔALT）. Secondary outcomes included the changes in aspartate aminotransferase （ΔAST） and total bilirubin （ΔTBIL） from baseline on postoperative days 1 and 3， as well as the levels of ALT， AST， and TBIL assessed preoperatively and on postoperative days 1 and 3， and the Quality of Recovery-15 （QoR-15） scores at the same time points.Mean arterial pressure （MAP）， heart rate （HR）， and PSI were recorded at the following time points： before induction （T₁）， when PSI reached 50 （T₂）， during tracheal intubation （T₃）， at skin incision （T₄）， during irrigation （T₅）， during skin suturing （T₆）， and during extubation （T₇）. Postoperative extubation time， post-anesthesia care unit （PACU） stay duration， and the incidences of nausea and vomiting， hypoxemia， and hypotension within 72 hours postoperatively were recorded. Results There were no statistically significant differences in preoperative levels of ALT， AST， and TBIL between the two groups （P > 0.05）. The primary outcome， ΔALT， showed no significant difference between the groups. No significant differences were observed in ΔAST and ΔTBIL on postoperative days 1 and 3 between the two groups （all P > 0.05）. Compared with preoperative values， ALT， AST， and TBIL levels were significantly elevated on postoperative day 1 in both groups （P < 0.05）， with a gradual decrease by postoperative day 3， suggesting a transient elevation of liver function indicators induced by surgical stress. Compared with Group P， Group R had significantly higher QoR-15 scores on postoperative day 3， significantly higher MAP at T₂ and T₃， and significantly higher HR at T₃ （P < 0.05）. Postoperative extubation time and PACU stay duration were significantly shorter in Group R compared with Group P （P < 0.05）. There were no statistically significant differences between the two groups in baseline characteristics （age， sex， ASA grade， BMI）， intraoperative parameters （operation time， anesthesia time， blood loss， urine output， fluid infusion volume， remifentanil consumption）， PSI values at different time points， or the incidence of postoperative nausea and vomiting， hypoxemia， and hypotension （all P > 0.05）. Conclusions In elderly patients undergoing VATS lobectomy with potential risk of liver injury， remimazolam and propofol for general anesthesia maintenance have no significant difference in their overall impact on postoperative liver function. However， remimazolam can improve intraoperative hemodynamic stability， shorten recovery time， and enhance the quality of postoperative recovery.

Key words: remimazolam, propofol, elderly patients, video-assisted thoracoscopic lobectomy, liver function, postoperative quality of recovery