Ciprofol Versus Remimazolam TIVA and PONV After Lap Chole
Nausea and vomiting after laparoscopic cholecystectomy is still one of the most common complaints I hear about in recovery. Even with dexamethasone and ondansetron on board, a fair number of patients feel miserable for the first few hours. A randomized trial published September 28, 2026 in Drug Design, Development and Therapy compared two newer intravenous agents for total intravenous anesthesia, ciprofol and remimazolam, with PONV as the main outcome.
The study
This was a single center, assessor blinded trial from Wuxi, China. 146 adults having laparoscopic cholecystectomy were split evenly between ciprofol based and remimazolam based TIVA. Everyone got dexamethasone and ondansetron for prophylaxis and the same analgesic plan, so the main thing that differed was the hypnotic.
PONV in the first 24 hours was 31.5% with ciprofol and 58.9% with remimazolam (RR 0.53, 95% CI 0.36 to 0.79). The difference held up after adjusting for known PONV risk factors. Vomiting was 19.2% versus 50.7%, and rescue antiemetics were needed in 9.6% versus 34.2%. Most of the gap showed up in the first two hours. Pain scores, QoR-15 recovery scores, adverse events, and vasopressor use were similar between the groups.
Why it makes sense
Ciprofol is a propofol derivative, and propofol TIVA has a long track record of less PONV than volatile anesthesia. Remimazolam is an ultra short acting benzodiazepine. It has real strengths, like quick offset and stable hemodynamics, but there is no good reason to expect it to protect against nausea the way propofol does. So the result lines up with what we would predict. The authors also point out that the trial was not powered to show the two drugs are equivalent on the secondary and safety outcomes.
What it means for practice here
Ciprofol so far has been used mainly in China, and in the United States remimazolam is labeled for procedural sedation, so this exact comparison is not one most American anesthesiologists face every day. The broader point still carries over. Choosing TIVA does not automatically mean lower PONV. The benefit seems to come with propofol and drugs like it, not from the intravenous route by itself. If someone switches a high risk patient to a remimazolam based technique and expects the same antiemetic benefit as propofol, this study suggests they may not get it.
For my own high risk patients, propofol based anesthesia is still a core part of the plan, along with multimodal prophylaxis and keeping opioids as low as is reasonable. This was one center and one procedure, and the authors call for multicenter trials, which I agree with. It is a useful reminder that the specific drug matters, not just the delivery method.
Source
- Zeng J, Ye Y, Li Z, Yang S, Jian J, Huang D. Effects of ciprofol- versus remimazolam-based total intravenous anesthesia on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial. Drug Design, Development and Therapy. 2026;20. Published September 28, 2026. Article (Dove Medical Press)
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.