Effect of remimazolam in non-intubated video-assisted thoracic surgery: a retrospective cohort study.

Background: Single-incision video-assisted thoracoscopic surgery (VATS) is safer, more efficient, and less invasive, with fewer complications and shorter hospital stays. When combined with non-intubated spontaneous breathing, it enhances recovery by reducing complications, operating time, and anesthesia duration. Remimazolam, an ultrashort-acting benzodiazepine, provides rapid onset and offset with minimal respiratory depression, making it promising for non-intubated VATS (NIVATS).

Methods: This retrospective study was conducted at Taipei Veterans General Hospital, Taiwan, and included 62 patients who underwent single-port NIVATS. Of these, 41 patients received propofol with dexmedetomidine (August 2019-December 2021), and 21 patients received remimazolam with dexmedetomidine (January 2023-December 2023). The primary outcome was the change in arterial carbon dioxide pressure (ΔPaCO2), while secondary outcomes included anesthesia duration, surgery duration, and postoperative hospital stay. Propensity score matching controlled for confounders, and subgroup analyses compared thoracic epidural anesthesia (TEA) with paravertebral block (PVB).

Results: The patients in the remimazolam group showed a smaller PaCO2 increase (6.84 ± 6.01 mmHg vs. 14.42 ± 11.55 mmHg; p = 0.0113), shorter surgery duration (50.19 ± 26.12 min vs. 83.54 ± 24.86 min; p < 0.0001), and shorter postoperative hospital stay compared with those in the propofol group. No significant between-group differences were found with regard to anesthesia duration. Subgroup analysis showed consistent outcomes between TEA and PVB groups, supporting the flexibility of remimazolam-based sedation. None of the patients required flumazenil reversal.

Conclusions: This study demonstrated effective sedation and superior respiratory stability with the use of remimazolam-dexmedetomidine combination in NIVATS, suggesting it to be a viable alternative. Further studies are needed to confirm these findings in diverse surgical settings.