Remimazolam-based anesthesia in sepsis patients: a retrospective cohort study of hemodynamic stability and...

Patients with abdominal sepsis or septic shock undergoing urgent source-control surgery are highly susceptible to anesthetic-induced hypotension, often requiring vasopressors that may stabilize mean arterial pressure (MAP) but worsen microcirculatory perfusion. This retrospective single-center study evaluated whether remimazolam-based general anesthesia reduces perioperative vasopressor burden and improves hemodynamic stability and postoperative outcomes compared with propofol induction followed by volatile maintenance.

In this study, 220 consecutive Sepsis-3-defined patients who underwent abdominal surgery between January 2021 and June 2025 were analyzed, using a prospectively maintained database. Patients were categorized as propofol/volatile anesthesia (Group C, n = 116) or remimazolam induction and maintenance (Group R, n = 104). The primary outcome was the Vasopressor-Inotrope Score (VIS) at postoperative intensive care unit (ICU) admission; secondary outcomes included intraoperative hemodynamics across six time points, change in Sequential Organ Failure Assessment at 24 h, ICU/hospital length of stay (LOS), mortality, and complications.

In a matched cohort (87 per group), VIS at ICU admission was lower with remimazolam (P = 0.006), accompanied by shorter ICU LOS (P = 0.008) and hospital LOS (P = 0.012), lower in-hospital mortality (P = 0.007), and fewer hospital-acquired infections (P = 0.048), with no differences in mechanical ventilation duration, 30-day mortality, acute kidney injury, acute respiratory distress syndrome, delirium, major complications, or ICU readmission. Mixed-effects models showed more favorable intraoperative systolic blood pressure/MAP and heart-rate trajectories with remimazolam (significant group-by-time interactions).

Remimazolam-based anesthesia was associated with greater hemodynamic stability and reduced postoperative vasopressor needs, translating to lower resource utilization and in-hospital mortality in septic surgical patients undergoing surgery, supporting prospective trials to test causality.