目的 比较瑞马唑仑和丙泊酚全麻维持对拟行胸腔镜肺叶切除术老年患者术后肝功能、恢复质量以及围术期安全性的影响。 方法 纳入胸腔镜肺叶切除术患者117例，年龄 ≥ 65岁，按随机数字表法将患者分为丙泊酚组（P组，n = 59）和瑞马唑仑组（R组，n = 58）。麻醉诱导：P组给予2 mg/kg 丙泊酚，R组给予 0.25 mg/kg 瑞马唑仑；麻醉维持：P组泵注8 mg/（kg·h） 丙泊酚，R组泵注1.2 mg/（kg·h）瑞马唑仑；两组均联合瑞芬太尼靶控输注镇痛，术中采用SedLine监测并维持患者状态指数（PSI）于25 ~ 50。术后均采用标准化静脉自控镇痛（PCIA）。收集并记录患者一般资料，主要观察指标为术后第1天丙氨酸氨基转移酶的变化值（ΔALT）；次要观察指标包括术后第1、3天的天门冬氨酸氨基转移酶的变化值（ΔAST）、总胆红素的变化值（ΔTBIL），以及术前、术后第1天、第3天的ALT、AST、TBIL以及QoR-15 恢复质量评分；记录麻醉诱导前（T₁）、PSI = 50（T₂）、气管插管时（T₃）、切皮时（T₄）、冲洗时（T₅）、缝皮时（T₆）、拔管时（T₇）的平均动脉压（MAP）、心率（HR）和 PSI 值。记录术后拔管时间、PACU停留时间及72 h内恶心呕吐、低氧血症、低血压发生率。 结果 两组患者术前 ALT、AST、TBIL 水平差异无统计学意义（P > 0.05）；主要观察指标ΔALT两组间差异无统计学意义；两组术后第1、3天的 ΔAST、ΔTBIL 比较，差异均无统计学意义（P > 0.05）；与术前相比，两组术后第1天 ALT、AST、TBIL 均术前显著升高，差异有统计学意义（P < 0.05），术后第3天逐渐回落。提示手术应激可导致一过性肝功能指标升高；与P组相比，R组术后第3天 QoR-15恢复质量评分、术中T₂、T₃时刻的MAP以及T₃时刻的HR显著高于P组；术后拔管时间、PACU停留时间明显缩短（P < 0.05）。两组基线资料（年龄、性别、ASA分级、BMI）及术中手术时间、麻醉时间、出血量、尿量、补液量及瑞芬太尼用量、不同时间点PSI值，两组术后恶心呕吐、低氧血症、低血压的发生率差异均无统计学意义（P > 0.05）。 结论 对于可能存在潜在肝脏损伤风险的老年胸腔镜肺叶切除术的患者，瑞马唑仑和丙泊酚全麻维持对整体肝功能影响无明显差异，瑞马唑仑能改善术中血流动力学的稳定性、缩短苏醒时间、提升患者术后恢复质量。

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.