Abstract
BACKGROUND: The choice of anesthetic drugs is crucial in ambulatory surgery. Esketamine has anesthetic, analgesic, and sedative effects, but it is associated with dose-dependent psychiatric symptoms. Benzodiazepines can alleviate these symptoms, but traditional drugs like midazolam may prolong the recovery time. Remimazolam tosilate as a novel benzodiazepine, has not been fully explored in terms of its effects when combined with esketamine and its impact on psychiatric symptoms. METHODS: A total of 249 patients undergoing elective laparoscopic surgery were enrolled. Randomly divided into the esketamine group (Group E), the esketamine plus midazolam group (Group EM), and the esketamine plus remimazolam tosilate group (Group ER). The primary outcome was the incidence of adverse reactions. The secondary outcomes included hemodynamics at different time points: at rest in the room (T0), immediately post-intubation (T1), immediately post-extubation (T2), 30 minutes following extubation (T3), and immediately after leaving the PACU (T4). Moreover, we also documented the Riker Sedation-Agitation Scale (SAS) scores at T2-4, as well as extubation time and PACU stay duration. RESULTS: Patients in Group ER had a significantly lower incidence of postoperative diplopia and blurry vision compared to Groups E and EM (p<0.05). Postoperative psychiatric symptoms were significantly lower in Groups EM and ER than in Group E (p<0.05). At the T1 time point, Groups EM and ER displayed significantly lower MAP and HR, compared to Group E (p<0.05). Groups E and ER displayed a shorter extubation time than Group EM (p<0.05); the PACU stay of Group ER was shorter than those of Groups E and EM (p<0.05). The SAS scores decreased from T2 to T4 in Groups EM and ER than in Group E (p<0.05). CONCLUSION: The combination of remimazolam tosilate and esketamine effectively reduces postoperative psychiatric symptoms, enhances hemodynamic stability, and improves recovery quality, making it a viable anesthetic strategy for ambulatory surgery.