Comparison of Remimazolam Versus Dexmedetomidine on the Quality of Recovery in Functional Endoscopic Sinus Surgery ： A Randomized Clinical Trial

doi:10.21203/rs.3.rs-4298135/v1

Background: The quality of recovery (QoR) of remimazolam versus dexmedetomidine was compared as measured by QoR-40 scores in functional endoscopic sinus surgery (FESS).

Methods: 120 patients (18–65 years) scheduled for FESS were randomly allocated to the group R , group D or group C. Group R received remimazolam 0.075 mg/kg loading, 0.1mg/kg/h infusion.Group D received dexmedetomidine 1.0 µg/kg loading, 0.5 µg/kg/h infusion.Group C received the placebo equal to dexmedetomidine.The primary outcome was QoR-40 scores on the day before surgery and postoperative day 1 (POD1).Secondary outcomes were the time to awareness,the length of stay in the PACU,sedation score upon PACU arrival, pain, postoperative nausea and vomiting (PONV). Adverse effects were recorded.

Results: The total QoR-40 scores (median, IQR) on POD1 were decreased less(154.5, 152.0 to159.0) in the groups R and D (155.0, 154.8 to159.3)than in the group C (139.0, 136.8 to142.0) (P=0.000).The time to awareness and the length of stay in the PACU were significantly lower in the groups R and C than in the group D (P=0.000).The level of sedation upon PACU arrival (median, IQR) in the groups R (-2.0, -2.0 to -1.0) and D (-2.0, -3.0 to -2.0) was deeper than in the group C (1.0, 0.0 to 1.0)(P=0.000). Compared to the group C, the pain intensity was reduced inthe groups R and D (P=0.000). The incidence of PONV was lower in the groups R (6,15.0%) and D (8,20.0%) than in the group C (17,42.5%)(P=0.011).15 patients had bradycardia in the group D,while no bradycardia was noted in the groups R and C(P=0.000).

Conclusion: Administration of remimazolam could provided a similar QoR to dexmedetomidine. And remimazolam can be a promising option for improving the QoR in FESS.

Trial registration: ChiCTR2300076209. (Prospective registered). Initial registration date was 27/9/2023.

Remimazolam

Dexmedetomidine

Quality of recovery

Chronic rhinosinusitis

Functional endoscopic sinus surgery

Chronic rhinosinusitis (CRS) is a common disease affecting patients' quality of life [1]. Failure of medication is an indication for functional endoscopic sinus surgery (FESS),which can provide short-and long-term improvement in disease symptoms and quality of life[2, 3]. However, 37% patients underwent functional endoscopic sinus surgery (FESS) experienced mild to moderate pain on postoperative day 1(POD1)[4]. And pain influenced postoperative recovery. Currently, the quality of recovery (QoR) score is an objective measure of patient-centered general health status after surgery and anesthesia[5].QoR-40 questionnaire is characterized by time- efficiency and a high rate of response and completion [6], and it has been validated in patients undergoing various surgical procedures[7, 8].

Dexmedetomidine, a highly selective α-2 adrenergic agonist, was administrated to improve the QoR due to sedative,analgesic and sympathetic properties[9]. Nevertheless,dexmedetomidine has certain drawbacks, including hypotension and bradycardia[10]. If the benefit of dexmedetomidine in terms of the QoR could be replaced by another anesthetic adjuvant without the above-mentioned side effects, it would increase the available choices of postoperative recovery profiles.

Remimazolam, despite being a new ultra-short-acting benzodiazepine agent with hemodynamic stability and without considerable side effects, is becoming rapidly established in clinical practice as a sedative-anesthetic agent[11]. Notably, a previous study reported that midazolam-a classic benzodiazepine drug reduced the affective and motivational component of pain experience[12]. In additional, Choi et al[13].found that the QoR provided by remimazolam-based total intravenous anesthesia was not inferior to propofol-based total intravenous anesthesia, and remimazolam lowered pain intensity and analgesic consumption than propofol. However, the comparison of remimazolam versus dexmedetomidine on the QoR in FESS has not been evaluated.

Therefore, the aim of this study was to compare the effect of intravenous administration of remimazolam versus dexmedetomidine on the QoR in FESS.We hypothesized that intravenous administration of remimazolam is a promising option for improving the QoR.

Participants

This single-blind, randomized controlled clinical trial was prospectively registered at the Chinese Clinical Trial Registry(ChiCTR2300076209, registration date: 27/9/2023),which was conducted at Anqing medical center of Anhui Medical University (Anqing Municipal Hospital) from October 1, 2023 to February 29, 2024. The study protocol was approved by the Ethics Committee of Anqing medical center of Anhui Medical University.Written informed consent was obtained from each selected patient before surgery. Our study followed the Consolidated Standards and Regulations.

Following ethics approval and informed consent, CRS subjects were prospectively recruited following criteria:sinonasal symptoms present consistently for greater than 12 weeks, sinusitis evidenced by a sinus computerised tomography (CT) scan, age between 18 and 65 years,American Society of Anesthesiologists (ASA) physical status I-Ⅱ,and scheduled for elective FESS. Excluded criteria including patients with systemic diseases (including neuropsychiatric diseases, respiratory diseases, etc.), hypovolemia,bradycardia (HR<50 beats per minute or lower ), second or third degree atrioventricular blockage, BMI > 30kg / m², recent history of acute upper respiratory tract infection or pulmonary infection, use of any sedative before surgery, history of food and drug allergy, opioid medication misuse, and a refusal to participate in the study.

A total of 120 patients eligible for this study were randomised to the group R ,group D or group C with a 1:1:1 allocation. A blocked randomization was performed using computer- generated random table.Given the complete difference of infusion protocols between the three groups,the clinical trial was a single-blinded study.The medical care personnel,and researcher staff who performed the infusion protocols could not remain blind to the study group allocation. However, all eligible participants, data collectors and assessors of study outcomes were independent. Details of QoR-40 scale, visual analogue scale (VAS) and postoperative nausea or vomiting (PONV) intensity were explained to each patient on 1 day before surgery. The patients were not given any preoperative medication.

Study protocol

Standard monitoring including electrocardiogram (ECG),heart rate(HR), mean arterial pressure (MAP), and peripheral pulse oximeter value (SPO₂) were monitored throughout the procedure (Philips MX500, Boeblingen, Germany). In the group D,a loading dose of 1.0 µg/kg dexmedetomidine was infused over 10 min before anesthesia induction, followed by maintenance infusion at 0.5µg/kg per hour until the end of surgery. As described by Deng et al. [14], in the group R, a loading dose of 0.075 mg/kg for remimazolam was infused over 1 min before anesthesia induction, followed by a maintenance infusion at 0.1 mg/kg per hour until the end of surgery, and the infusion was stopped when severe arrhythmia (supraventricular or ventricular)and hypotension (MAP less than 60 mmHg) occurred.And patients in the group C were given the same amount of placebo equal to dexmedetomidine.Anesthesia was induced with propofol (3.0 mg/kg), sufentanil (0.5 µg/kg), and cisatracurium (1.5 mg/kg). After endotracheal intubation (ID:7.5 mm or 7.0 mm), anesthesia was maintained with propofol and remifentanil at the effect-site, followed by target-controlled infusion (TCIs) of propofol and remifentanil using TCI pump. The initial TCI levels of plasma propofol and remifentanil were set as 3.0 µ g/ml and 5.0 n g/ml, respectively. Mechanical ventilation was applied in volume-controlled mode with a tidal volume (VT) of 8–10 ml/kg at a respiratory rate (RR) of 10–12 beats per minute (bpm) to provide an end-tidal carbon dioxide concentration of 35–45 mm Hg. The inspired oxygen fraction (FiO₂) was 0.5 (balanced with air) throughout the anesthesia period. The depth of anesthesia was maintained at a BIS range between 45 and 60,as well as mean arterial pressure and heart rate within 20% of baseline values, by adjusting the TCIs concentration of plasma propofol and remifentanil during surgery[15]. Atropine 0.5 mg was intravenously injected to treat bradycardia. Cisatracurium 2.0 to 4.0 mg was intermittently used for muscle relaxation, and all surgeries were performed by the same team. The operating table was placed in 15-degree reverse Trendelenburg position during the surgery. To prevent PONV, ondansetron (4 mg) was administered intravenously 10 minute prior to the end of surgery. After surgery,all patients were transferred to the post-anesthesia care unit (PACU) with an endotracheal tube retained. The endotracheal tube was removed after full recovery of consciousness and spontaneous ventilation and the train-of-four ratio was ≥ 0.9. The discharge criteria from the PACU included stable vital signs, a pain score of 2 or less, absence of PONV,and a calm and alert patient[16].If the the score of visual analogue scale (VAS) exceeded 3, tramadol (50 mg) was administered intravenously.

Data collection

The main goal of this study was assessed using the global QoR-40 score on the day before surgery, and postoperative day 1(POD1), which includes five dimensions: emotional state (9 items), physical comfort (12 items), physical independence (5 items), psychological support (7 items), and pain (7 items)[7]. Each item is rated on a 5-point numerical scale.The score of QoR-40 ranges from 40 to 200.The recovery state is proportional to the score (40 = extremely poorest recovery quality, 200 = best recovery quality)[8].Demographic variables such as gender,age, height, weight and ASA were recorded.Hemodynamic parameters, including MAP and HR, were measured and recorded before anesthesia induction (T0),before intubation (T1), immediately after intubation (T2), at the end of surgery (T3),immediately after extubation (T4),and upon PACU arrival (T5). The duration of anesthesia and surgery was recorded. The cumulative consumption of remifentanil during surgery was recorded. The time to awareness, which was calculated from the time of stopping narcotic agent infusion until sustained eye opening (for > 5 s), and the length of stay at the PACU were documented.The time to first rescue analgesia was recorded. The maximal VAS pain scores at the PACU and ward were measured with the VAS scale,this 10-point scale ranges from 0 ( no pain) to 10 (the most pain imaginable)[17]. The level of sedation upon PACU arrival was documented using a 10-point Richmond Agitation Sedation Scale (+ 4 = combative, -5 = unarousable)[18].Adverse effects such as severe arrhythmia, bradycardia, hypotension, PONV, need for vasopressors,and prolonged respiratory support were recorded.

Statistical analysis

As Hu et al.[19] described, the calculation of sample size was based on the quality of recovery on the day before surgery and postoperative day 1.The allowable error was 0.05, and each group needed 36 patients (assuming a power of 80%).Forty patients were included per group, allowing for a 10% dropout rate. Data analysis was performed using SPSS version 23.0 (SPSS Inc., Chicago,IL). Shapiro-Wilk test was used to evaluate the normal distribution of data.Continuous variables are presented as the mean (standard deviation, SD). Normally distributed variables were compared using Student’s t-test. Nonnormally distributed variables are presented as the median, inter-quartile range [M (IQR)], and compared using the Kruskal-Wallis H test. Qualitative data are presented as numbers or percentages and were compared using the chi-square test. P values of less than 0.05 were statistically significant.

The study assessed 132 patients for eligibility. 8 patients did not meet the inclusion criteria, and 4 patients refused to participate in the present study. Therefore, 120 subjects were enrolled for follow-up. The details are shown in Fig. 1. The baseline general characteristics of patients, including age, height, weight, ASA physical status, duration of surgery and anaesthesia, were not significantly different (Table 1).Compared with the group C, the cumulative consumption of remifentanil was significantly reduced in groups R and D (P=0.000) (Table 1). As shown in Table 1,the time to awareness and the length of stay at the PACU were significantly lower in groups R and C than in the group D (P=0.001) and (P=0.000),respectively.

The QoR-40 scores were shown in Table 2. At POD1, the total score of the QoR-40 (median, IQR) was reduced less in groups R (154.5,152.0 to159.0) and D (155.0,154.8 to159.3) than in the group C (139.0,136.8 to142.0) (P=0.000). There was no significant difference in the total QoR-40 score in the both groups R and D.The scores of the emotional state, physical comfort and pain dimensions were reduced lower in the groups R and D than in the group C on POD1(P﹤0.005).

As shown in Table 3, the time to first required rescue analgesia (mean, SD) was longer in the groups R (9.9 h, 1.2 h) and D (9.7 h, 1.4h) than in the group C (5.6 h, 0.8h) (P=0.000). The number of patients requiring rescue analgesia was less in the groups R (7/40, 17.5%) and D (6/40, 15.0%) than in the group C (18/40, 45.0%) (P=0.003). As detailed in Table 3, 15 patients (15/40, 37.5%) had bradycardia in the group D during surgery. After intravenous atropine 0.5mg, the heart rate of these patients gradually recovered to between 60 and 70 beats/minute,but no patients had bradycardia in groups R and C (P=0.000).The incidence of PONV in the groups R (7/40,17.5%) and D (6/40, 15.0%) was less than in the group C (17/40, 42.5%) (P=0.016). Hypotension, need for vasopressors or prolonged respiratory support was not observed.

As detailed in Table 4,the maximal VAS pain score was lower at the PACU and ward in the groups R and D than in the group C (P=0.000). And the RASS score was lower upon PACU arrival in the groups R and D than in the group C (P=0.000).

As detailed in Figure 2, compared with the baseline values, the fluctuation in the MAP values in the groups R and D were lower at T2 and T4. However, the fluctuation in the HR values in groups R and C were lower than in group D at T2,T3 and T4(P<0.05).

The results of the study demonstrated that the total QoR-40 scores decreased less on POD1 in patients following FESS who received remimazolam or dexmedetomidine than received placebo. Treatment with remimazolam or dexmedetomidine also reduced the cumulative consumption of remifentanil, lowered the pain intensity and the incidence of PONV. Additionally, compared with the group D, the time to awareness and the length of stay in the PACU were lower in groups R and C. At the dose selected in the study, bradycardia was noted in 15 patients in the group D, but no bradycardia was recorded in the groups R and C.

Previous studies have validated the effectiveness and reliability of QoR-40 in general surgery patients[8].Furthermore,a study showed that total intravenous anesthesia was more beneficial to physical comfort and physical independence, out of five dimensions of the QoR-40 questionnaires than inhalation anesthesia[20]. Another study also reported that remimazolam-based anesthesia was more effective than sevoflurane-based anesthesia on preventing PONV and improving quality of recovery in cervical spine surgery[21].Additionally,Matsumoto et al. has compared the effect on PONV using remimazolam and propofol,and the result showed that there was not significant difference in the incidence of PONV[22].Similarly to these results, the incidence of PONV in the groups R and D was lower than in the group C. Despite the fact that otolaryngological procedures without prophylactic antiemetics is considered risk factors for PONV[23], but only 6 and 8 patients had PONV in the groups R and D,respectively. Moreover, intraoperative opioid use has a positive relationship with PONV[24]. In the present study,the cumulative consumption of remifentanil was decreased in the groups R and D than in the group C.Another study parallels to our study. Zhang et al.[25]reported that dexmedetomidine could decrease the occurrence of PONV in adult patients under general anaesthesia and promote recovery. Hence,the main reason of inhibition of PONV may be opioid-sparing effect of remimazolam and dexmedetomidine in the study [12, 26].

Besides, Erskine et al.[27]found that mood disturbance is a highly prevalent in patients with CRS,which negatively impacts on patients’quality of life.Recent studies reported that emotion was regulated by remimazolam and dexmedetomidine[28, 29].Our finding showed that the scores of the emotional state were higher in the groups R and D than in the group C,these results suggested that remimazolam and dexmedetomidine improved patients' emotional state.Given potential anti- depressant properties of remimazolam or dexmedetomidine, the total score of QoR-40 was decreased less in the groups R and D than in the group C.Nevertheless,the current findings were contradicted the results from a recent study.In their study, the scores of physical comfort and emotional state were lower in the remimazolam group than in the propofol group,an undesirable desensitization-like effect at the top end of the response curve and a rebound phenomenon upon the termination of the agent contributed to the reason[30].whereas a low dose infusion of remimazolam was used as a narcotic adjunct in the study, no significant difference was observed in the groups R and D.

Variety of factors such as gender,age, concurrent turbinectomy, or number of sinuses addressed might be associated with increased POD1 pain scores[13].But the aforementioned risk factors were not statistically different in the study,which were not assessed to predict higher POD1 scores. FESS is commonly used in clinical practice associated with a better tolerated procedure, greater symptom improvement, and fewer complications than the traditional open approach[2]. Notably, patient underwent FESS experienced mile to moderate postoperative pain on POD1, and remained a lack of specific pain management[4].Many nociceptive, inflammatory, and neuropathic pathway contribute to perioperative pain and delay patient recovery after surgical procedures[31]. A recent study demonstrated that neuropathic pain induced by injected with complete freund’s adjuvant in rats was alleviated by remimazolam through regulating bradykinin receptor B1and autophagy[32].Additionally,another study also showed that remimazolam attenuated myocardial ischemia-reperfusion injury by inhibiting the NF-qB pathway of macrophage inflammation[33]. Furthermore, a study reported that dexmedetomidine relieved neuropathic pain and inflammation response[34]. Therefore, appropriate management of postoperative pain is known to improve the recovery of patients.The results of our study showed that the pain intensity and analgesic consumption were significantly reduced in the groups R and D than in the group C.The explanation maybe linked to analgesic potency of dexmedetomidine or remimazolam.

Moreover,the half-life of dexmedetomidine is 2–3 h[9],while that of remimazolam is 1–2 h [11],and remimazolam has its own antagonist, flumazenil. Thus,the duration of awakening and the length of stay in the PACU in group R were significantly lower than in the group D. Intravenous infusion of high doses of both agents might lead to adverse effects such as delayed recovery and respiratory or cardiovascular depression[35, 36].However, no patient required postoperative respiratory support, and no serious cardiovascular or other adverse reactions occurred in the groups R and D,suggesting that the infusion dose selected for dexmedetomidine or remimazolam in this study was safe.

There were several limitations in this study. Firstly, the focus of the study was only to evaluate the short-term recovery of patients after surgery, and the long-term recovery after surgery were not analyzed.Secondly,the relationship between the severity of chronic sinusitis and the quality of recovery was not analyzed. Thirdly, the number of patients enrolled was small,the study was a single-center clinical study, and the conclusion was further supported by large-sample and multi-center studies. Therefore, the results of this study were limited to generalize.

Administration of remimazolam and dexmedetomidine could enhance the quality of recovery, alleviate the intensity of pain after FESS.Compared with dexmedetomidine,the efficacy and safety of remimazolam were not inferior.

CRS

Chronic Rhinosinusitis

CT

Computerised Tomography

QoR

Quality of Recovery

FESS

Functional Endoscopic Sinus Surgery

ASA

American Society of Anesthesiologists

POD

Postoperative Day

PACU

Postanesthesia Care Unit

PONV

Postoperative Nausea or Vomiting

MAP

Mean Arterial Pressure

HR

Heart Rate

ECG

Electrocardiogram

SPO₂

Peripheral Pulse Oximeter

VT

Tidal Volume

RR

Respiratory Rate

FiO₂

Inspired Oxygen Fraction

Ce

Effect -Site Concentration

BIS

Bispectral Index

VAS

Visual Analogue Scale

SD

Standard Deviation

ANOVA

One-way analysis of variance

IQR

Inter- quartile Range.

Acknowledgments

Not applicable.

Authors’ contributions

SHH, QYT and YQL conceived the study design and drafted the study protocol. SHH, QYT, YQL, FFG,HZ,QQG and SBW all participated in the study design and coordination. YQL,FFG,HZ and QQG contributed to data collection. SHH, and QYT were the principal investigator and has overall responsibility for this study. SHH and YQL performed the statistical analysis for the study protocol. SHH YQL and QYT drafted and revised the manuscript. SHH, YQL and QYT critically revised the manuscript. All authors have read and approved the final manuscript.

Funding

This research received no external funding.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding authors on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Medical Ethics Committee of Anqing Medical Center of Anhui Medical University. Written informed consent was obtained from all subjects before surgery. This study was prospective registered in the Chinese Clinical Trial Registry (ChiCTR2300076209). Initial registration date was 27/9/2023.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Author details

¹Department of Anesthesiology, Anqing Medical Center of Anhui Medical University, No.87 Tianzhushan Road,Yixiu District, Anqing 246003,China.

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Table 1 Baseline demographic and clinical characteristics

Variables	group R (n=40)	group D (n=40)	group C (n=40)	P-value
Age (years)	40.7±14.6	42.4±13.2	41.3±12.4	0.834
Height(cm)	171.1±8.1	168.8±8.2	167.7±10.1	0.448
Weight (kg)	66.5±11.4	64.9±10.1	65.9±13.2	0.905
Gender (male/female)	11/29	14/26	12/28	0.762
ASA physical status (I/II)	25/15	28/12	24/16	0.627
Duration of surgery(min)	100.2±8.7	100.3±10.7	123.4±16.6	0.000
Duration of anesthesia (min)	119.6±12.5^*	119.4±13.9^*	136.4±17.5	0.001
Time to awareness (min)	20.6±5.4^†	25.9±2.3	22.2±4.1^†	0.000
Length of PACU stay (min)	48.8±7.9^†	53.2±5.8	37.2±7.8^†	0.000
Cumulative consumption of remifentanil (µg)	1188.9±207.9^*	1093.0±172.5^*	1379.5±244.5	0.000

Values were presented as the mean±SD (standard deviation) or number.group R: iv. remimazolam; group D: iv. dexmedetomidine; group C:iv. placebo.Time to awareness:the time of stopping narcotic agent infusion until sustained eye opening (for >5 s). ASA: American Society of Anesthesiologists; PACU: post- anesthesia care unit.^*p < 0.05 vs. group C;^†p < 0.05 vs. group D.

Table 2 Preoperative and POD1 global QoR-40 Score

	group R（n=40）	group D（n=40）	group C（n=40）	P-value
Preoperative
Total QoR-40 Score	161.0 (158.0 to164.0)	162.0 (159.0 to 163.0)	162.0 (158.3 to163.8)	0.928
POD1
Emotional state	35.0 (33.8 to 36.3)^*	34.5 (33.8 to 36.0)^*	29.5 (28.8 to 31.0)	0.000
Physical comfort	42.5 (42.0 to 44.3)^*	42.0 (40.0 to 43.3)^*	40.0 (38.0 to 41.3)	0.004
Physical independence	22.0 (21.0 to 22.0)	22.0 (20.8 to 22.0)	20.5 (20.0 to 22.0)	0.219
Psychological support	28.0 (26.8 to 29.0)	28.0 (26.0 to 29.0)	27.0 (26.0 to 28.0)	0.475
Pain	29.0 (28.0 to 30.3)^*	30.0 (28.0 to 30.3)^*	25.5 (24.8 to 27.0)	0.000
Total QoR-40 Score	154.5 (152.0 to159.0)^*	155.0 (154.8 to159.3)^*	139.0 (136.8 to142.0)	0.000

Values were presented as the median[ inter-quartile range]. group R: iv. remimazolam; group D: iv. dexmedetomidine; group C: iv.placebo. POD1:postoperative day 1;QoR-40:quality of recovery 40. ^*p < 0.05 vs. group C.

Table 3 Recovery profiles after surgery

Variables	group R （n=40）	group D （n=40）	group C （n=40）	P -value
Time to first require rescue analgesia (h)	9.7±1.4^*	9.9±1.2^*	5.6±0.8	0.000
Number of patients requiring analgesia(n,%)	7 (17.5%)^*	6 (15.0%)^*	18 (45.0%)	0.000
Bradycardia(n,%)	0 (0.0)^†	15(37.5)	0 (0.0)^†	0.000
Incidence of PONV(n,%)	6 (15.0%)^*	8 (20.0%)^*	17 (42.5%)	0.011

Values were presented as the mean±SD or number (proportion).group R: iv. remimazolam; group D: iv. dexmedetomidine; group C: iv.placebo. PONV:postoperative nausea or vomiting. ^*p < 0.05 vs. group C;^†p < 0.05 vs. group D.

Table 4 Maximal VAS score at the PACU or ward and RASS score upon PACU arrival

Variables	group R (n=40)	group D (n=40)	group C(n=40)	P -value
Maximal VAS score ( at PACU)	3.0 (2.0 to 3.0)^*	3.0 (2.0 to 3.0)^*	3.0 (3.0 to 4.0)	0.000
Maximal VAS score (at ward)	4.0 (3.8 to 4.3)^*	4.0 (3.0 to 4.0)^*	4.5 (4.0 to 5.0)	0.000
RASS score(upon PACU arrival)	-2.0 (-2.0 to -1.0)^*	-2.0 (-3.0 to -2.0)^*	1.0 (0.0 to 1.0)	0.000

Values were presented as the the median[inter-quartile range].group R: iv. remimazolam; group D: iv. dexmedetomidine; group C: iv. placebo.VAS: visual analogue scale; PACU: post- anesthesia care unit;RASS:Richmond Agitation Sedation Scale.^*p < 0.05 vs. group C.

No competing interests reported.

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Comparison of Remimazolam Versus Dexmedetomidine on the Quality of Recovery in Functional Endoscopic Sinus Surgery ： A Randomized Clinical Trial

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