Remimazolam-Nalbuphine Infusion Minimizes Visceral Traction Response in Cesarean Delivery, study finds

Seventy-two parturients scheduled for elective cesarean delivery under spinal anesthesia were randomly assigned to receive either remimazolam (0.05 mg/kg) plus nalbuphine (0.1 mg/kg) after cord clamping or placebo. The primary outcome was the incidence of positive visceral traction response (VTR), defined as moderate to severe discomfort or pain during abdominal exploration and suturing.

Key Findings: Dramatic Reduction in VTR and Adverse Events

Incidence of VTR dropped from 41.7% (placebo) to just 5.6% in the remimazolam-nalbuphine group (absolute risk reduction: 36.1%, p < 0.001).

Maternal satisfaction scores were higher (mean 9.6 vs. 7.1, p < 0.001) with the combination regimen.

Adverse events (including nausea, chest tightness, and gastric spasm) were significantly less frequent with remimazolam-nalbuphine (total adverse event rate: 33.3% vs. 77.8%, p < 0.001).

Hemodynamic stability (mean arterial pressure and heart rate) was maintained in both groups, with no difference in hypotension, bradycardia, or hypoxemia.

Sedation quality was optimal (Ramsay score 4) during visceral manipulation, without respiratory depression or interference with maternal-infant bonding.

Clinical Relevance: A Safe, Effective Adjunct for Cesarean Delivery

The results position remimazolam-nalbuphine as a valuable adjunct for managing VTR under spinal anesthesia. Unlike intrathecal opioids, which increase the risk of respiratory depression, or agents like ketamine and dexmedetomidine, which can induce undesirable cardiovascular or psychotomimetic effects, this combination provides strong visceral analgesia and sedation with a reassuring safety profile. Effective VTR control can enhance maternal satisfaction, reduce intraoperative nausea, and potentially lower the risk of negative psychological sequelae after childbirth.

Limitations and Future Directions

While these findings are compelling, the study was single-center and did not evaluate long-term neonatal outcomes. The absence of arms testing remimazolam or nalbuphine alone precludes precise attribution of effect. Larger, multicenter trials and systematic neonatal evaluations are warranted to confirm these safety and efficacy results.

Conclusion

For anesthesiologists and obstetric teams, remimazolam-nalbuphine offers an evidence-based approach to reducing intraoperative discomfort and improving the cesarean delivery experience. Adopting this adjunct may result in smoother surgeries and greater patient satisfaction without compromising hemodynamic or respiratory safety.

Key points

Remimazolam-nalbuphine infusion reduced VTR incidence from 41.7% to 5.6% during cesarean delivery under spinal anesthesia.

Maternal satisfaction and sedation quality were significantly improved with this regimen.

The intervention group experienced fewer adverse events (notably, less nausea and chest tightness).

Hemodynamic and respiratory safety were maintained throughout the procedure.

This regimen is a promising, safe adjunct for intraoperative comfort in cesarean delivery; further studies should confirm neonatal outcomes.

Citation:

Meng J, Deng X, Han R, Jiang S, Zou YC, Zou T, Gong JG, Bao HM, Wang ST, Bhandari S, Feng B, Cheng LM. Intraoperative remimazolam-nalbuphine infusion reduces visceral traction response during cesarean delivery: a randomised trial. BMC Anesthesiology. 2026. https://doi.org/10.1186/s12871-026-03909-6