{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T07:00:21Z","timestamp":1780470021742,"version":"3.54.1"},"reference-count":26,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T00:00:00Z","timestamp":1780444800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Selecting the optimal anesthetic regimen to mitigate postoperative cognitive decline and pulmonary complications in elderly patients undergoing thoracic surgery remains a clinical challenge. While propofol is widely used, remimazolam offers potential advantages due to its hemodynamic stability and rapid clearance. This study employed rigorous propensity score matching (PSM) to compare the real-world outcomes of these two intravenous anesthetics in a high-risk surgical cohort.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective cohort study of patients aged \u226565\u202fyears undergoing elective VATS lobectomy (2020\u20132023). Patients received either remimazolam- or propofol-based total intravenous anesthesia under a standardized, driving pressure-guided individualized PEEP protocol. To address significant baseline imbalances and confounding by indication, we performed 1:1 propensity score matching using a multivariable logistic regression model incorporating 13 pre-specified covariates (e.g., age, comorbidities, pulmonary\/cognitive function). Balance was assessed via standardized mean differences. The matched cohort was used for all outcome analyses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      From 342 eligible patients, PSM created 122 well-balanced pairs (\n                      <jats:italic>n<\/jats:italic>\n                      \u202f=\u202f244). The matched cohort demonstrated excellent covariate balance (all SMDs &amp;lt; 0.1). Compared to the propofol group, the remimazolam group exhibited: (1) Superior cognitive recovery across the early and short-term postoperative period, with higher MMSE scores at 24\u202fh (mean difference 3.6 points, 95% CI 2.8\u20134.4,\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt;\u202f0.001), 72\u202fh (2.7 points, 95% CI 2.0\u20133.4,\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt;\u202f0.001), postoperative day 4 (2.1 points, 95% CI 1.4\u20132.8,\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt;\u202f0.001), day 7 (1.3 points, 95% CI 0.7\u20131.9,\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt;\u202f0.001), and day 30 (0.6 points, 95% CI 0.1\u20131.1,\n                      <jats:italic>p<\/jats:italic>\n                      =\u202f0.021); (2) Better pulmonary function at 72\u202fh, including higher FEV\u2081% predicted (6.9%, 4.3\u20139.5,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001) and lower lung ultrasound scores (\u22122.0, \u22122.4 to \u22121.6,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001); (3) Enhanced hemodynamic and cerebral oxygen stability, with higher time-weighted mean arterial pressure (5.7\u202fmmHg, 3.9\u20137.5,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001) and cerebral oxygen saturation nadir during one-lung ventilation (4.3%, 2.9\u20135.7,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001); and (4) Reduced postoperative morbidity, including lower incidence of delirium (9.0% vs. 23.0%, OR 0.33, 95% CI 0.16\u20130.69) and pulmonary complications (11.5% vs. 22.1%, OR 0.46, 0.23\u20130.92).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Using robust propensity score matching to emulate a randomized comparison, this study provides real-world evidence that a remimazolam-based anesthetic strategy, integrated with lung-protective ventilation, is associated with significantly better cerebral oxygenation, accelerated neurocognitive and pulmonary recovery, and lower rates of key postoperative complications compared to propofol in elderly patients undergoing VATS lobectomy. These findings highlight the clinical value of remimazolam within enhanced recovery pathways for geriatric thoracic surgery.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1805497","type":"journal-article","created":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T06:00:56Z","timestamp":1780466456000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Remimazolam is associated with superior cerebral and pulmonary protection over propofol in elderly thoracic surgery: a real-world study validated by propensity score matching"],"prefix":"10.3389","volume":"13","author":[{"given":"Jingjing","family":"Zhang","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaoyan","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Na","family":"Cao","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yichao","family":"Cai","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caixia","family":"Zhao","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chunying","family":"Tang","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhenhua","family":"Ma","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yan","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Zhangjiakou First Hospital","place":["Zhangjiakou, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,6,3]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"e061535","DOI":"10.1136\/bmjopen-2022-061535","article-title":"Effects of subanaesthetic S-ketamine on postoperative delirium and cognitive function in elderly patients undergoing non-cardiac thoracic surgery: a protocol for a randomized, double-blinded, placebo-controlled and positive-controlled, non-inferiority trial (SKED 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iron and glucose metabolism","volume":"13","author":"Ge","year":"2021","journal-title":"Aging (Albany NY)"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"59","DOI":"10.1017\/S0265021506001025","article-title":"Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study","volume":"24","author":"Casati","year":"2007","journal-title":"Eur J Anaesthesiol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"e33148","DOI":"10.1097\/MD.0000000000033148","article-title":"Effects of EEG burst suppression on cerebral oxygen metabolism and postoperative cognitive function in elderly surgical patients: a randomized clinical trial","volume":"102","author":"Liu","year":"2023","journal-title":"Medicine (Baltimore)"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"793","DOI":"10.1016\/j.resinv.2023.08.009","article-title":"Transcutaneous gas monitoring is a useful tool to detect respiratory depression during bronchoscopy performed under propofol sedation","volume":"61","author":"Yazawa","year":"2023","journal-title":"Respir Investig"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"1150045","DOI":"10.3389\/fphar.2023.1150045","article-title":"Efficacy and safety analysis of midazolam combined with dezocine sedation and analgesia colonoscopy in patients with inflammatory bowel disease: a prospective single-center open study","volume":"14","author":"Chen","year":"2023","journal-title":"Front Pharmacol"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/02648725.2023.2193047","article-title":"Study on the combination of remazolam besylate and sufentanil in elderly patients with percutaneous vertebroplasty","volume":"23","author":"Liu","year":"2023","journal-title":"Biotechnol Genet Eng Rev"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"e34731","DOI":"10.1097\/MD.0000000000034731","article-title":"The study of different dosages of remazolam combined with sufentanil and propofol on painless gastroscopy: a randomized controlled trial","volume":"102","author":"Wu","year":"2023","journal-title":"Medicine (Baltimore)"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"1073","DOI":"10.23736\/S0375-9393.21.15517-8","article-title":"Safety and efficacy of remimazolam compared with propofol in induction of general anesthesia","volume":"87","author":"Dai","year":"2021","journal-title":"Minerva Anestesiol"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"1996","DOI":"10.1053\/j.jvca.2023.06.027","article-title":"Propofol versus Remimazolam on cognitive function, hemodynamics, and oxygenation during one-lung ventilation in older patients undergoing pulmonary lobectomy: a randomized controlled trial","volume":"37","author":"Kuang","year":"2023","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"543","DOI":"10.1007\/s00540-020-02788-6","article-title":"Efficacy and safety of remimazolam versus propofol for general anesthesia: a multicenter, single-blind, randomized, parallel-group, phase IIb\/III trial","volume":"34","author":"Doi","year":"2020","journal-title":"J Anesth"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1409495","DOI":"10.3389\/fmed.2025.1409495","article-title":"Comparison of the safety of remimazolam and propofol during general anesthesia in elderly patients: systematic review and meta-analysis","volume":"12","author":"Liu","year":"2025","journal-title":"Front Med (Lausanne)"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"524","DOI":"10.4097\/kja.25376","article-title":"Comparison of remimazolam and sevoflurane on arterial oxygenation during one-lung ventilation in thoracoscopic surgery: a randomized controlled trial","volume":"78","author":"Shon","year":"2025","journal-title":"Korean J Anesthesiol"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"11951","DOI":"10.2147\/DDDT.S565045","article-title":"Effects of Remimazolam on perioperative inflammatory response and neurocognitive disorders in elderly patients undergoing video-assisted thoracic surgery: a randomized controlled trial","volume":"19","author":"Hu","year":"2025","journal-title":"Drug Des Devel Ther"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1186\/s12871-023-01974-9","article-title":"Comparison of hemodynamics during induction of general anesthesia with remimazolam and target-controlled propofol in middle-aged and elderly patients: a single-center, randomized, controlled trial","volume":"23","author":"Sekiguchi","year":"2023","journal-title":"BMC Anesthesiol"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1186\/s12871-023-02095-z","article-title":"Effect of remimazolam versus propofol for the induction of general anesthesia on cerebral blood flow and oxygen saturation in elderly patients undergoing carotid endarterectomy","volume":"23","author":"Gao","year":"2023","journal-title":"BMC Anesthesiol"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"49","DOI":"10.1016\/j.bja.2022.02.040","article-title":"Pharmacodynamic analysis of intravenous bolus remimazolam for loss of consciousness in patients undergoing general anaesthesia: a randomized, prospective, double-blind study","volume":"129","author":"Chae","year":"2022","journal-title":"Br J Anaesth"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"143","DOI":"10.2147\/DDDT.S392569","article-title":"Effect of remimazolam on postoperative delirium in older adult patients undergoing orthopedic surgery: a prospective randomized controlled clinical trial","volume":"17","author":"Yang","year":"2023","journal-title":"Drug Des Devel 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a meta-analysis of randomized controlled trials","volume":"78","author":"Park","year":"2025","journal-title":"Korean J Anesthesiol"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"1567794","DOI":"10.3389\/fmed.2025.1567794","article-title":"Association of remimazolam with delirium and cognitive function in elderly patients undergoing general anesthesia or procedural sedation: a meta-analysis of randomized controlled trials","volume":"12","author":"Wang","year":"2025","journal-title":"Front Med (Lausanne)"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"e12994","DOI":"10.1111\/ijn.12994","article-title":"Feasibility, safety, and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery","volume":"28","author":"Liu","year":"2022","journal-title":"Int J Nurs Pract"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"1456827","DOI":"10.3389\/fsurg.2025.1456827","article-title":"Remimazolam mitigates oxidative stress response in patients undergoing one-lung ventilation","volume":"12","author":"Li","year":"2025","journal-title":"Front Surg"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1805497\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T06:00:57Z","timestamp":1780466457000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1805497\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,3]]},"references-count":26,"alternative-id":["10.3389\/fmed.2026.1805497"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1805497","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,3]]},"article-number":"1805497"}}