Remimazolam Versus Propofol for Early Recovery After Cytoreductive Surgery

Effect of Remimazolam Versus Propofol on Early Postoperative Quality of Recovery in Patients Undergoing Cytoreductive Surgery for Peritoneal Surface Malignancies: A Randomized Controlled Trial

The REPAIR Trial is a single-center, prospective, randomized, parallel-group superiority trial enrolling 320 adults scheduled for elective cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC). Participants will be assigned 1:1 to bispectral index-guided remimazolam- or propofol-based general anesthesia under standardized perioperative care. The primary objective is to determine whether remimazolam improves patient-reported recovery 48 ± 4 hours after surgery, measured by the Chinese 15-item Quality of Recovery score (QoR-15; range, 0 to 150; higher scores indicate better recovery). The investigators hypothesize that remimazolam will produce a higher 48-hour QoR-15 score than propofol. Secondary outcomes will characterize recovery at 24 and 72 hours, intraoperative hypotension burden and vasopressor use, acute kidney injury, infection, delirium, respiratory complications, other safety events, and 30-day mortality.

Inclusion Criteria

1.Age 18 to 75 years. 2.American Society of Anesthesiologists physical status class II or III. 3.Pathologically confirmed primary peritoneal surface malignancy or peritoneal metastasis from colorectal, gastric, ovarian, or appendiceal malignancy.

4.Scheduled for elective cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy under general anesthesia.

5.Expected surgical duration of at least 2 hours and planned postoperative admission to the intensive care unit.

6.Able to understand and independently complete the Chinese Quality of Recovery-15 questionnaire.

7.Willing to participate and able to provide written informed consent. Exclusion Criteria

1. Emergency surgery.
2. Uncontrolled bacterial, fungal, or viral infection requiring systemic anti-infective treatment within 14 days before surgery, or temperature of 38.0 °C or higher at post-consent eligibility confirmation with corresponding clinical, imaging, microbiological, or laboratory evidence. Perioperative antimicrobial prophylaxis is not an exclusion.
3. Child-Pugh class C, total bilirubin greater than 3 times the upper limit of normal, or alanine or aspartate aminotransferase greater than 5 times the upper limit of normal.
4. Estimated glomerular filtration rate below 30 mL/min/1.73 m² or maintenance renal replacement therapy.
5. Known allergy to remimazolam, benzodiazepines, propofol, or their excipients, or a contraindication to either study drug.
6. Continuous or near-daily opioid use for at least 90 days before surgery, or benzodiazepine or Z-drug use on at least 5 days per week for at least 4 weeks.
7. Severe cognitive, psychiatric, hearing, speech, or language impairment that prevents understanding and independent completion of the QoR-15 after standardized explanation.
8. Pregnancy or breastfeeding.
9. A preoperative plan for continuous epidural analgesia or another continuous regional analgesic technique that is incompatible with the study's standardized intravenous analgesia pathway.
10. A specific clinical condition that, in the investigator's judgment, would make participation pose an unacceptable risk.