Remimazolam for Postoperative Sleep in Elderly Patients

General Hospital of Ningxia Medical University84 enrolled

Overview

Postoperative sleep disturbance (PSD) is highly prevalent in elderly patients undergoing laparoscopic radical resection of colorectal cancer. Although remimazolam has shown favorable sedative properties and may alleviate perioperative stress, its effects on postoperative sleep architecture remain poorly understood. Polysomnography (PSG), the gold standard for objective sleep assessment, has not been widely used to evaluate these effects in this population. Therefore, this study employs a randomized controlled trial design to verify whether remimazolam is superior to propofol in preserving postoperative sleep quality, thereby offering more evidence-based options for anesthetic management in elderly patients undergoing laparoscopic colorectal cancer surgery.

Laparoscopic radical resection of colorectal cancer is the most commonly used surgical approach for colorectal cancer in elderly patients. Although this technique is less invasive than traditional open surgery, more than 60% of elderly patients still experience significant sleep fragmentation and disturbance in the early postoperative period, making effective sleep preservation a key component of enhanced recovery after surgery (ERAS). Sedative agents play a critical role in modulating perioperative sleep patterns. Remimazolam, a novel ultra-short-acting benzodiazepine, is considered a promising anesthetic for elderly patients due to its favorable pharmacokinetic profile and minimal dependence on hepatic and renal function. However, its impact on objective sleep architecture remains unclear. Propofol, the most widely used sedative in general anesthesia, has been reported to disrupt sleep cycles in the postoperative period, with inconsistent effects on slow-wave sleep and rapid eye movement (REM) sleep. Polysomnography (PSG) is the gold standard for assessing sleep architecture, including total sleep time, sleep efficiency, sleep stage distribution, and arousals. Previous studies have demonstrated that remimazolam is associated with improvements in subjective sleep outcomes in surgical patients. However, current research on remimazolam's effects on postoperative sleep after laparoscopic colorectal cancer surgery remains limited, particularly lacking high-quality, prospective, randomized controlled studies using objective PSG measurements to verify whether remimazolam can achieve superior sleep outcomes compared with propofol. Therefore, this study adopts a randomized controlled trial design to verify whether remimazolam is superior to propofol in preserving postoperative sleep quality, providing more evidence-based options for anesthetic management in elderly patients undergoing laparoscopic radical resection of colorectal cancer.

Interventions

RemimazolamDRUG

In the remimazolam group, anesthesia was induced with remimazolam 0.2 mg/kg, sufentanil 0.3-0.5 μg/kg, and rocuronium 0.6-0.8 mg/kg. After 3 minutes of preoxygenation, tracheal intubation was performed, and mechanical ventilation was initiated to maintain PETCO₂ at 30-40 mmHg. Anesthesia was maintained with continuous infusions of remimazolam and remifentanil, guided by anesthetic depth monitoring. Rocuronium was supplemented intermittently and discontinued 30 minutes before the end of surgery.Polysomnography (PSG) was performed both preoperatively and postoperatively to measure total sleep time and sleep architecture. Subjective sleep quality was assessed using validated questionnaires during postoperative follow-up.

propofolDRUG

In the propofol group, anesthesia was induced with propofol 1.0-1.5 mg/kg, sufentanil 0.3-0.5 μg/kg, and rocuronium 0.6-0.8 mg/kg. Anesthesia was maintained with continuous infusions of propofol and remifentanil. All other procedural details were identical to those in the remimazolam group.

Eligibility

Sex: ALLMin age: 65 YearsMax age: 80 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Aged between 65 and 80 years. * Scheduled for elective laparoscopic radical resection of colorectal cancer. * American Society of Anesthesiologists (ASA) physical status class II-III. * Able to understand the study protocol and provide written informed consent. Exclusion Criteria: * Known allergy to any study medications. * Preoperative sleep disorder (Pittsburgh Sleep Quality Index \[PSQI\] score \> 10). * Regular use of sedatives, antipsychotics or hormonal drugs within the past month. * Preoperative cognitive impairment, screened using the education-adjusted Mini-Mental State Examination (MMSE). * Preoperative history of neurological or psychiatric disorders, including Alzheimer's disease, Parkinson's disease, depression and anxiety disorders. * Severe preoperative comorbidities involving the cardiovascular, cerebrovascular, respiratory, hepatic or renal systems, as follows:New York Heart Association (NYHA) functional class IV; current or recent (within 2 months) congestive heart failure; myocardial infarction or coronary stent implantation within the preceding 3 months; Uncontrolled frequent ventricular premature beats (\>5 beats per minute), couplets, triplets, paired ventricular arrhythmias, multifocal ventricular premature beats, or R-on-T phenomenon; Second-degree atrioventricular block (Mobitz II type), third-degree atrioventricular block or sick sinus syndrome without pacemaker implantation; Stroke or transient ischemic attack within the preceding 3 months; Severe hypertension (blood pressure ≥ 180/110 mmHg); Severe respiratory tract infection (including common cold), or maximal voluntary ventilation (MMV) \< 30% of the predicted value; Severe hepatic dysfunction (Child-Pugh score \> 9); Acute or chronic renal failure without renal replacement therapy: Acute kidney injury was defined as an absolute increase in serum creatinine ≥ 0.3 mg/dL (≥26.5 μmol/L) or a relative increase ≥ 50% from baseline, or urine output \< 0.5 mL/(kg·h) for more than 6 consecutive hours. Chronic renal failure or uremia was defined as serum creatinine \> 451 μmol/L and estimated glomerular filtration rate (eGFR) \< 30 mL/min/1.73 m². * Severe coagulation disorders. * Refusal to participate in the trial. * Anticipated postoperative admission to the intensive care unit (ICU).

Outcomes

Primary Outcomes

Total sleep time (TST) on the first postoperative night

Polysomnography (PSG) was used to assess total sleep time on the first postoperative night in both groups.

Time frame: On the first postoperative night

Secondary Outcomes

Richards-Campbell Sleep Questionnaire (RCSQ) Score

Subjective sleep quality assessed via the Richards-Campbell Sleep Questionnaire (RCSQ), ranging from 0 to 100 points, with a higher score indicating better sleep quality. Result interpretation: A total score \< 50 indicates poor sleep quality; 50 - 69 points indicate average sleep quality; ≥ 70 points indicate good sleep quality.

Time frame: Postoperative Day 1, Postoperative Day 2, Postoperative Day 3, Postoperative Day 7

Pittsburgh Sleep Quality Index (PSQI) Score

Subjective sleep quality assessed via the Pittsburgh Sleep Quality Index (PSQI). Scores range from 0 to 21; higher scores indicate worse sleep quality.

Time frame: 1 month postoperatively

Resting Visual Analogue Scale (VAS) Pain Score

Pain at rest was measured in both groups preoperatively and at 1, 2, and 3 days postoperatively using the Visual Analogue Scale (VAS). Scores range from 0 to 10; higher scores indicate greater pain intensity.

Time frame: at 1, 2, and 3 days postoperatively

The incidence of postoperative delirium

The incidence of postoperative delirium was evaluated in both groups at 1, 2, and 3 days postoperatively using the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM).

Time frame: at 1, 2, and 3 days postoperatively

Postoperative cognitive function

Cognitive function was assessed preoperatively, at 7 days postoperatively, and at 1 month postoperatively using the Mini-Mental State Examination (MMSE). Scores range from 0 to 30; higher scores indicate better cognitive function.

Time frame: at 7 days postoperatively and at 1 month postoperatively

Sleep efficiency assessed by polysomnography (PSG)

Sleep efficiency measured by polysomnography (PSG). It is defined as the percentage of sleep time relative to total time spent in bed.

Time frame: Postoperative Night 1

Number of awakenings after sleep onset assessed by polysomnography (PSG)

Number of awakenings after sleep onset measured by polysomnography (PSG).

Time frame: Postoperative Night 1

Total wake time assessed by polysomnography (PSG)

Total duration of awakenings during sleep measured by polysomnography (PSG).

Time frame: Postoperative Night 1

Proportion of each sleep stage assessed by polysomnography (PSG)

Proportion of each sleep stage measured by polysomnography (PSG), including N1,N2,N3 and REM.

Time frame: Postoperative Night 1

Serum levels of cortisol

Serum levels of cortisol were measured preoperatively and on the morning of postoperative day 1 and compared between the two groups.

Time frame: on the morning of postoperative day 1

Movement Visual Analogue Scale (VAS) Pain Score

Postoperative pain during movement assessed via the Visual Analogue Scale (VAS). Scores range from 0 to 10; higher scores indicate greater pain intensity.

Time frame: Postoperative Day 1, Postoperative Day 2, Postoperative Day 3

Serum C-reactive protein (CRP) level

Serum concentration of C-reactive protein (CRP).

Time frame: Morning of postoperative day 1

Serum interleukin-6 (IL-6) level

Serum concentration of interleukin-6 (IL-6).

Time frame: Morning of postoperative day 1

Remimazolam for Postoperative Sleep in Elderly Patients

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes

Central Contacts