Remimazolam: The New Star Sedative for Non-Intubated Thoracic Surgery?

Evolution in Thoracic Surgery: Less Invasive, More Efficient

Single-incision video-assisted thoracoscopic surgery (VATS) has revolutionized thoracic procedures by offering safer, less invasive options with fewer complications and shorter recovery times. When paired with non-intubated spontaneous breathing techniques, this method further reduces the risks and hastens recovery. Choosing the right sedative is crucial to achieving these outcomes.

Remimazolam vs. Propofol: A Game-Changer in NIVATS?

Remimazolam is an ultra-short-acting benzodiazepine, known for its rapid onset, offset, and minimal respiratory depression. This study from Taipei Veterans General Hospital investigated whether remimazolam could outperform the traditional propofol-dexmedetomidine combination in non-intubated VATS (NIVATS).

The retrospective cohort included 62 patients: 41 received propofol with dexmedetomidine, while 21 were sedated with remimazolam and dexmedetomidine. Outcomes were carefully balanced using propensity score matching to ensure fair comparisons.

Key Findings: Superior Respiratory Stability and Faster Recovery

• Better Respiratory Stability: Patients sedated with remimazolam had a significantly smaller increase in arterial carbon dioxide pressure (ΔPaCO2: 6.84 vs. 14.42 mmHg, p=0.0113), indicating superior respiratory stability during surgery.

• Shorter Surgeries and Hospital Stay: Remimazolam was associated with a shorter surgery duration (50.2 vs. 83.5 minutes) and a reduced postoperative hospital stay (1.38 vs. 1.83 days).

• Consistent Anesthesia Duration: Although anesthesia time trended shorter with remimazolam, the difference wasn't statistically significant.

• Flexible Pain Control: Subgroup analyses showed that remimazolam's benefits were consistent whether patients received thoracic epidural anesthesia (TEA) or a paravertebral block (PVB), allowing for personalized pain management strategies.

• No Need for Reversal: None of the patients in the remimazolam group required flumazenil, underscoring its predictability and safety.

Clinical Implications and Future Directions

The study demonstrates that remimazolam—combined with dexmedetomidine—delivers not only effective sedation but also enhanced respiratory safety and recovery for NIVATS patients. Its consistent performance across different pain management techniques provides anesthesiologists with greater flexibility.

As remimazolam is relatively new and this was a retrospective study with a moderate sample size, larger prospective studies are needed to confirm its advantages and determine optimal dosing in wider surgical settings. Nevertheless, these promising findings suggest remimazolam could soon become the preferred sedative for minimally invasive thoracic procedures.

Key Takeaways:

• Remimazolam ensures stable respiration and improved safety in non-intubated VATS.

• Patients experience shorter surgeries and faster hospital discharge with remimazolam.

• Suitable with both epidural and paravertebral pain management techniques.

• No need for reversal agents, indicating a reliable sedation profile.

Reference -

Huang P-Y, Ke H-H, Cheng H-W, Hsu P-K, Chang W-K, Ting C-K. Effect of remimazolam in non-intubated video-assisted thoracic surgery: a retrospective cohort study. BMC Anesthesiology. 2025;25:263. https://doi.org/10.1186/s12871-025-03131-w