Skip to main content
Download PDF

Effects of balanced opioid-free anesthesia on post-operative nausea and vomiting in patients undergoing video-assisted thoracic surgery: a randomized trial

BMC Anesthesiology volume 25, Article number: 62 (2025) Cite this article

Abstract

Objectives

Postoperative nausea and vomiting (PONV) is common after video-assisted thoracic surgery, which may be associated with the use of intraoperative opioids. We tested the hypothesis that balanced opioid-free anesthesia (OFA) might reduce the incidence of PONV after video-assisted thoracic surgery.

Methods

One hundred and sixty-eight adults undergoing video-assisted thoracic assisted surgery were randomly assigned to receive balanced opioid-free anesthesia or balanced opioid-based anesthesia (OBA). The primary outcome was the incidence of PONV, which was assessed with the Myles’s simplified PONV impact scale during the initial 24 h after surgery.

Results

Compared with OBA group, the overall incidence of PONV in OFA group was significant reduced (14.6% vs. 30.1%, P = 0.017), and OFA reduced the risk of PONV events within 24 h of surgery (HR, 0.44; 95%CI: 0.22–0.87, P = 0.018). The incidence of other postoperative complications in OFA group was lower than that in OBA group (19.5% vs. 33.7%, P = 0.039). The quality of recovery, distance of 6-minute walk test, pain scores, and 36-item short form survey were comparable at each time points.

Conclusion

In patients undergoing video-assisted thoracic surgery, the use of balanced OFA anesthesia can help reduce the incidence of PONV events. This anesthetic regimen has shown good feasibility without significantly increasing the patient’s pain score and complications.

Clinical trial registration number

Clinicaltrials.gov, Identifier: NCT05411159. First posted date: 9 Jun, 2022.

Peer Review reports

Introduction

Postoperative nausea and vomiting (PONV) is a common complication, with an incidence of 30%~40% in video-assisted thoracic surgery under general anesthesia [1,2,3]. Severe PONV can affect the early recovery of patients, leading to prolonged post-anesthesia care, increased costs, and increased staffing burden [4,5,6,7]. Given the significant population of such patients, reducing the incidence of PONV in patients receiving video-assisted thoracic surgery after anesthesia would have important clinical implications.

Opioids is one of the predictive factors for PONV [8]. Opioids contribute to PONV through various mechanisms, including direct stimulation of opioid receptors, delayed gastric emptying, sensitization of the vestibular system, and triggered release of histamine [9]. Other concerns of opioids use include ventilation disturbances, hyperalgesia, and the potential for addiction [10]. Therefore, the concept of opioid-sparing or opioid-free anesthesia (OFA) is thus gaining attention as a potential strategy to reduce opioid-related side effects and complications [11,12,13].

The OFA usually involves utilizing alternative analgesic techniques to provide comprehensive pain relief [14,15,16,17]. Previous studies suggested that avoiding opioids during video-assisted thoracic surgery could be a viable approach without reported anesthesia-related adverse events [18]. An et al. [19] and Yan et al. [3] in their RCT focused on the effects of OFA on perioperative pain control, and also observed that it was associated with a potential reduction of PONV. In contrast to previous studies, this study applied a widely used standardized scale to evaluate the incidence of PONV as well as the severity of PONV. This approach enhanced the generalizability of the conclusions drawn from this trial. We therefore tested the primary hypothesis that OFA may reduce the incidence of PONV within the initial 24 h after video-assisted thoracic surgery in adult patients.

Methods

This blinded, randomized, parallel-group trial was conducted at the Beijing Chao-Yang Hospital of Capital Medical University, a tertiary hospital. This study was approved by the Institutional Review Board (No. 2022-ke-19) and written informed consent was obtained from all subjects participating in the trial. The trial was registered prior to patient enrollment at clinicaltrials.gov (NCT05411159). This trial was conducted in accordance with the Declaration of Helsinki principles and followed the Consolidated Standards of Reporting Trials guidelines. The full protocol has been published [20].

Participants

Patients aged 18–65 years with lung space-occupying lesions who were scheduled for video-assisted video-assisted thoracic surgery under general anesthesia were screened for eligibility. Those who met any of the following criteria were excluded: (1) ASA) ≥ IV, (2) BMI > 35 kg/m2; (3) unable to communicate before surgery; (4) received radiation therapy, chemotherapy, opioids or hormonal drugs within 14 days before surgery; (5) intolerant of the anesthesia protocol, such as nerve block contraindications, allergies to medication; (6) expected to experience prolonged mechanical ventilation usage after surgery; or (7) declined to participate.

Randomization and masking

Eligible patients were randomized to OFA group (opioid-free anesthesia) or OBA group (opioid-based anesthesia) with a 1:1 ratio. The randomization sequence with a block size of 4 or 6 was generated by an independent researcher. The generated random results were sealed in sequentially numbered opaque envelopes and kept by a research assistant. After participants entered the operating room, the randomized envelopes were opened according to the recruitment sequence by an attending anesthesiologist, who then prepared the study medications accordingly. The research assistant was not involved in anesthesia management, perioperative care, and postoperative follow-up. Patients, surgeons, nurses, and the investigator performing follow-up assessments were blinded to the allocation.

Anesthesia, perioperative care, and intervention

Intraoperative monitoring included electrocardiogram, peripheral oxygen saturation, invasive blood pressure, end-tidal carbon dioxide tension, end-tidal anesthetic concentration, and wavelet index (WLi), which was calculated from the changes in EEG signals by multifunction combination monitor [2]. The WLi ranges from 0 to 100, with 0 indicating the disappearance of EEG while 100 indicating awake status.

Dexamethasone (5 mg) and atropine (0.25 mg) were administered before anesthesia induction for prevention of PONV and reduction of bronchial secretions. All participants received flurbiprofen (50 mg, twice) as adjunctive analgesics before induction and skin closure. A single thoracic paravertebral block (20 ml of 0.5% ropivacaine) was performed at T5 level on the surgical side before incision to reduce pain during incision.

Anesthesia was induced with intravenous propofol (2–3 mg/kg), rocuronium (0.6–0.8 mg/kg) in both groups. Participants in the OFA group received dexmedetomidine (0.5 ug/kg for 15 min) before induction, lidocaine (1.5 mg/kg) intravenous for induction, and followed by dexmedetomidine (0.5 ug/kg/h) and lidocaine (1.5 mg/kg/h) infusion during surgery. While participants in the OBA group received sufentanil (0.3–0.4 ug/kg) intravenous for induction, and followed by remifentanil (0.1–0.2 ug/kg/min) infusion during surgery. The anesthesia was maintained with desflurane (0.5–1.0 MAC) in both groups. Continuous or intermittent additions of propofol were allowed to maintain a reasonable depth of sedation (WLi between 40 and 60) [19]. All participants received a double-lumen endobronchial tube intubation to facilitate lung isolation. During anesthesia, the vasoactive drugs were used to maintain the heart rate and blood pressure within 25% of baseline.

After surgery, patients in both groups received the same multimodal analgesia regimen, including ibuprofen orally at a dosage of 0.2 g every 8 h for 48 h, and patient-controlled analgesia pump with sufentanil (1 µg/h background, 2 µg bolus, and a 10-minute lock-out). Medications available for the treatment of PONV included ondansetron, metoclopramide, and dexamethasone.

Measurements

Baseline data included patients’ characteristics, preoperative comorbidities, current diagnosis, smoking and alcohol consumption, and pulmonary function measures. All participants finished lung CT, pulmonary function test, 6-minute walk test (6-MWT), and PONV risk assessment one day before surgery [5]. Intraoperative data included surgical type, medications during anesthesia, fluid infusion, blood loss and transfusion, and the length of anesthesia and surgery.

PONV and pain severity were assessed at 24 and 48 h after surgery. The severity of PONV was assessed with the Myles’s simplified PONV impact scale [21]. According to this scale, the frequency of vomiting/retching (Once, Twice, three or more times) and the duration of nausea (Sometimes, Often or most of the time, All of the time.) directly contribute to the score, with a maximum of 6 points. A total score of 3 or higher indicates severe PONV. The time to first PONV after surgery was also recorded. Postoperative pain at rest and with movement were assessed with the Numerical Rating Scale score (NRS, 0–10 points, higher score represents worse). Postoperative quality of recovery was assessed through the Quality of Recovery 15-item scale (QoR-15, 0–150 points, higher point indicates better) at 24 h after surgery [22]. The 6-MWT (farther distance is better) was tested on the 48 h after surgery [23]. The 36-item short form survey (SF-36) was performed at 180 days after surgery.

Study endpoints

The primary outcome was the cumulative incidence of PONV (Myles’s simplified PONV impact scale ≥ 1) during the first 24 h after surgery [21]. The secondary outcomes included the severity of PONV within 24 h after surgery, the score of QoR-15 at 24 h after surgery, the pain severity at rest and with movement at 24 and 48 h after surgery, the 6-MWT at 48 h after surgery, the length of hospital and PACU stay, and the score of SF-36 at 180 days after surgery. Perioperative complications were recorded as newly occurring adverse conditions that required therapeutic interventions, and the severity of complications were classified by the ClassIntra [24] and Clavien-Dindo [25] surgical complication categories from interventions to 48 h after surgery.

Safety outcomes included intraoperative, postoperative complications, and mortality. Intraoperative complications included the occurrence of hypotension, bradycardia, newly occurred arrhythmias, delayed awakening, and desaturation. The occurrence of local anesthetic toxicity and hematoma due to nerve block puncture were also recorded. Postoperative complications of interest within 2 days after surgery included hypoxemia, hypotension, pulmonary embolism based on lung imaging, pruritus, drowsy, dizziness, fatigue, constipation, and uroschesis.

Statistics

Outcome analyses were mainly conducted in the modified intention-to-treat population, that was, all subjects who were randomized and received surgery under general anesthesia without withdrawing consent. For the primary outcome, a per-protocol analysis was planned after excluding patients with major protocol deviations.

Baseline characteristics were described with mean [standard deviation (SD)], median [inter-quartile range (IQR)], or number (percentage). For perioperative data, normally distributed continuous variables were described by mean (SD) and compared by Student’s t-test, while skewed distributed continuous variables were described by median (IQR) and compared by Mann-Whitney U test. Categorical variables were reported as number (percentage) and compared by χ [2] test or Fisher’s test.

For the primary outcome, log-binomial model was applied to calculate the relative risk (RR) with 95% confidence interval (CI). The time to the first PONV after surgery was represented by Kaplan-Meier curve, and compared by log-rank test between groups as sensitivity analysis. The hazard ratio and 95% CI were calculated from cox regression. Secondary and exploratory outcomes were analyzed by χ [2] test, Student t-tests, or Mann-Whitney U test as appropriate. Between groups, the median differences (MD) with 95% CIs were calculated for normal or skewed continuous variables by Hodges-Lehman Estimation. Safety outcomes were evaluated with χ [2] tests or Fisher’s exact tests. No imputation was performed for missing data. Predefined subgroup analyses (sex, smoker, history of PONV/motion sickness, and the length of anesthesia) were conducted. Two-sided P < 0.05 was considered statistically significant. Statistical analyses were conducted with SAS 9.4 (SAS Inc., Cary, NC, USA).

Sample size estimation

Sample size estimation was based on previous publications [26, 27], and our pilot results, the incidence of PONV within the first day among patients after VATs was about 40%. And we assumed that there would be a 50% reduction in the OFA group. Therefore, a total of 168 subjects (84 per group) were required to provide 80% power at a two-sided alpha level of 0.05 with a dropout rate of 5%.

Results

One hundred ninety-six patients were assessed for eligibility, and 168 were enrolled and randomized to OFA or OBA group. Finally, 165 subjects were included in the modified intention-to-treat analysis. During the operation, no major protocol deviations were observed in all cases, so the modified intention-to-treat and per-protocol population were identical (Fig. 1).

Fig. 1
figure 1

Flowchart. ASA, American Society of Anesthesiologists

Full size image

The baseline characteristics were reported in Table 1. For participants assigned to OBA group, the median dosage of sufentanil and remifentanil during surgery were 20 ug (IQR: 20, 25) and 1080 ug (IQR: 800,1600) ug, respectively. No significant differences were observed in the dose and infusion rate of sufentanil, or other medications between groups postoperatively (Table 2).

Table 1 Baseline characteristics
Full size table

Primary outcome

The incidence of PONV within 24 h after surgery was 14.6% in OFA group and 30.1% in OBA group (RR, 0.49; 95%CI: 0.26 to 0.90, P = 0.017; Table 3; Fig. 2). And the OFA group showed significant lower the risk of PONV within 24 h of surgery (HR, 0.44; 95%CI: 0.22 to 0.87, P = 0.018; Fig. 3).

Fig. 2
figure 2

Distribution of PONV severity score during 24h after surgery. PONV, postoperative nausea and vomiting. OFA, opioid-free anesthesia. OBA, opioid-based anesthesia

Full size image
Fig. 3
figure 3

The Kaplan-Meier curve of time to first postoperative nausea and vomiting. OBA, opioid-based anesthesia; OFA, opioid-free anesthesia

Full size image
Table 2 Perioperative data
Full size table

Secondary outcomes

The median score of PONV severity was lower in the OFA group than in the OBA group (0 vs. 0, MD 0, 95%CI 0 to 0; P = 0.018; Table 3; Fig. 2). The quality of recovery 15-item scale at 24 h after surgery were comparable (median 113 vs. 112, MD 1.00, 95CI%: −3.11 to 5.11, P = 0.358; Table 3). The distance of 6-minute walk test of patients in the two groups was also similar (median 305 vs. 298 m, MD 5.00, 95 CI%: −37.65 to 47.65, P = 0.545; Table 3). The scores of each dimension of SF-36 at 180 days were comparable between groups (Table 3). Subjects randomized to OFA group did not have more intraoperative complications than those in the OBA group (7.3% vs. 3.6%, P = 0.328). In subgroup analyses, patients without history of PONV or motion sickness in OFA group had lower incidence of PONV (6.9% vs. 24%, P = 0.022; Supplementary Table 1). The incidence of postoperative complications within 2 days in OFA group was lower than that in OBA group (19.5% vs. 33.7%, P = 0.039; Supplementary Table 2).

Table 3 Primary outcomes and secondary outcomes
Full size table

Discussion

In this prospective randomized controlled trial, we examined the effect of OFA on the PONV with 24 h after video-assisted thoracic surgery. Compared to opioid-based analgesia, the OFA reduced the overall incidence of postoperative nausea and vomiting, and it also delayed the time to first PONV occurrence. However, OFA showed no significant benefits in terms of quality of recovery or mobility after video-assisted thoracic surgery.

In this trial, we observed that the overall incidence of PONV was lower in patients received OFA compared to the OBA group. Previous studies on whether opioid-free anesthesia could reduce the incidence of postoperative nausea and vomiting had inconsistent conclusions [18, 19, 29]. A randomized controlled study of the effects of OFA on PONV hadn’t found a significant reduction in the incidence of serious PONV events in patients after gynecological laparoscopy (10.5% vs. 8.1%, P = 0.57) [28]. However, given the design of the study, which included only female patients, the conclusions are difficult to generalize to patients undergoing video-assisted thoracic surgery. In thoracic surgery patients, a propensity score study observed the incidence of PONV was 9% in the OFA group and 2% in the control group, but no significant statistical difference could be confirmed due to the small sample size [18]. In this study, we used a randomized controlled study design to include a larger sample size to demonstrate the effect of OFA in reducing the incidence of PONV. We further adjusted the feasibility of opioid-free regimens compared to previous studies [14], and compared the overall incidence and time to first occurrence of PONV, which are consistent with the conclusions of a recent randomized controlled study [29]. The results of this study suggested that OFA are useful in the prevention of PONV.

Severity of PONV is significant correlated with the quality of recovery in patients after non-cardiothoracic surgery, reducing the severity of PONV may have potential benefits [21]. However, few studies reported on the effect of OFA on the quality of recovery of patients after pulmonary surgery [3, 19, 29]. So, we pre-defined quality of recovery at 24 h, mobility at 48 h, and health status at 180 days after surgery as secondary outcomes. These patient-centered outcomes reflect both subjective feeling and objective mobility, and helped clinicians evaluate the quality of recovery [22, 23]. In this study, OFA didn’t show a clinically meaningful advantage over OBA in terms of quality of recovery, mobility, and long-term health status. In addition, the median difference of estimated effect sizes for secondary outcomes between groups did not reach the minimum clinically important difference as we predefined. Therefore, our result is insufficient to support the use of OFA to improve the quality of recovery in patients undergoing video-assisted thoracic surgery. In another small randomized controlled trial, OFA also did not show significant improvement in postoperative recovery quality compared to the OBA group [17]. As we have observed, the occurrence of PONV is mostly concentrated within 24 h, and with the popularization of PONV prevention, the median difference in the quality of recovery at 24 h after surgery is only 1 ponits, which is much lower than the clinically meaningful 6 points. Similarly, a similar conclusion was reached in another multicenter study in patients undergoing major non-cardiac surgery [30].

Opioids are the common choice for intraoperative pain control, but withdraw-induced hyperalgesia of opioids has been observed in certain clinical scenarios [31]. In our results, the median differences in pain scores between groups did not meet our pre-defined clinically meaningful minimum difference for both at rest and with movement at 24 and 48 h, suggesting that the use of OFA could not result in a significant difference in the management of early postoperative pain among patients after video-assisted thoracic surgery. The effect of opioid-free regimens on postoperative pain had been conclusively concluded in different studies. Devine et, al., observed that OFA resulted in similar postoperative pain scores and morphine consumption compared with opioid-based anesthesia at 0, 1 and 24 h after lung cancer resection [32]. Jean et, al., found that patients who received OFA not only reduced the median of cumulative morphine consumption at 24 h (−28.50 mg) and 48 h (−27.67 mg), but also had lower pain scores at the same time points (−1.40 and − 1.87 of 10-point scales) [18]. On the contrary, Yan et, al., demonstrated that compared with opioid-based anesthesia, the OFA group had higher rates of acute pain at 24 h after video-assisted thoracic surgery, but lower rates of mild chronic pain at 3 and 6 month [3]. In general, the multimodal analgesic regimen has met the analgesic needs of most patients after thoracoscopy surgery, and the minimization of opioid dosage has become a trend.

Since the largest trial of OFA (The POFA trial) to date was terminated prematurely for safety reasons, the optimal protocol for implementing OFA remains unclear [14]. Previous trials applied a diverse range of non-opioids analgesics, including dexmedetomidine, ketamine, nonsteroidal anti-inflammatory drugs, lidocaine, and regional blocks.14 32 33 We applied OFA protocol comprised intraoperative IV flurbiprofen, dexmedetomidine, lidocaine, and a single injection video-assisted thoracic paravertebral nerve block before incision. No serious adverse events occurred during the operation, and the type of intraoperative complications of interest was comparable between groups. Our study offers evidence into the feasibility and versatility of our OFA regimen.

There are some limitations of our study. First, the attending anesthesiologists in the operating room were not blinded to the treatment allocation. Blinding the sedative and analgesic drugs used during anesthesia could pose challenges for anesthesiologists and potentially compromise patient safety [14]. To minimize information bias in the study, they were not involved in the following procedures, and both the subjects and the follow-up investigators responsible for collecting endpoint events were unaware of the group allocation. Second, the optimal protocol for OFA in video-assisted thoracic surgery remains unclear [13], and our protocol was based on a combination of previous literature and the experience of clinical practice [2, 32]. No serious adverse events were observed with this protocol, providing valuable insights for the practice of OFA. Third, we only enrolled adult participants aged between 18 and 65 years in the present trial. The generalizability of our results to elderly patients may be limited.

Conclusions

The OFA regimen reduced the overall incidence of PONV and reduced the risk of developing first postoperative PONV compared to standard opioid-based general anesthesia. Meanwhile, this opioid-free procedure was not only safe and feasible in video-assisted thoracic surgery, but also did not observe an increase in pain scores in patients at rest or with movement after surgery. Opioid-free anesthesia regimens can help reduce the risk of postoperative PONV and is a potential way to prevent postoperative PONV.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

6-MWT:

6-minute walk test

ASA:

American Society of Anesthesiologist

BMI:

Body mass index

IQR:

Inter-quartile range

MD:

Median differences

NRS:

Numerical Rating Scale

OBA:

Opioid-based anesthesia

OFA:

Opioid-free anesthesia

PONV:

Postoperative nausea and vomiting

QoR-15:

Quality of Recovery 15-item scale

RR:

Relative risk

SD:

Standard deviation

SF-36:

36-item short form survey

WLi:

Wavelet index

References

  1. Gao X, Zhao T, Xu G, et al. The efficacy and safety of ultrasound-guided, bi-level, erector spinae plane block with different doses of dexmedetomidine for patients undergoing video-assisted thoracic surgery: a randomized controlled trial. Front Med (Lausanne). 2021;8:577885.

    Article  PubMed  Google Scholar 

  2. Dhawan R, Daubenspeck D, Wroblewski KE, et al. Intrathecal morphine for analgesia in minimally invasive cardiac surgery: a randomized, placebo-controlled, double-blinded clinical trial. Anesthesiology. 2021;135(5):864–76.

    Article  CAS  PubMed  Google Scholar 

  3. Yan H, Chen W, Chen Y, et al. Opioid-free versus opioid-based anesthesia on postoperative pain after thoracoscopic surgery: the use of intravenous and epidural esketamine. Anesth Analg. 2023;137(2):399–408.

    CAS  PubMed  Google Scholar 

  4. Goldson KV, Brennan E, Burton BN, et al. Does management of postoperative nausea and vomiting differ by patient demographics? An evaluation of perioperative anesthetic management - An observational study. Anesthesiology. 2025. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/ALN.0000000000005367. Published online January 9, 2025.

  5. Apfel CC, Laara E, Koivuranta M, et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693–700.

    Article  CAS  PubMed  Google Scholar 

  6. Gan TJ, Belani KG, Bergese S, et al. Fourth Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020;131(2):411–48.

    Article  PubMed  Google Scholar 

  7. Gress K, Urits I, Viswanath O, et al. Clinical and economic burden of postoperative nausea and vomiting: analysis of existing cost data. Best Pract Res Clin Anaesthesiol. 2020;34(4):681–6.

    Article  PubMed  Google Scholar 

  8. Apfel CC, Heidrich FM, Jukar-Rao S, et al. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth. 2012;109(5):742–53.

    Article  CAS  PubMed  Google Scholar 

  9. Imam MZ, Kuo A, Ghassabian S, et al. Progress in understanding mechanisms of opioid-induced gastrointestinal adverse effects and respiratory depression. Neuropharmacology. 2018;131:238–55.

    Article  CAS  PubMed  Google Scholar 

  10. Levy N, Quinlan J, El-Boghdadly K, et al. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia. 2021;76(4):520–36.

    Article  CAS  PubMed  Google Scholar 

  11. Wu CL, King AB, Geiger TM, et al. American Society for enhanced recovery and perioperative quality initiative joint consensus statement on perioperative opioid minimization in opioid-naive patients. Anesth Analg. 2019;129(2):567–77.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Shanthanna H, Ladha KS, Kehlet H, et al. Perioperative opioid administration. Anesthesiology. 2021;134(4):645–59.

    Article  CAS  PubMed  Google Scholar 

  13. Shanthanna H, Beloeil H, Joshi GP. Opioid-free anesthesia in research and practice: so near yet so far! Can J Anaesth. 2024;71(11):1447–52.

    Article  PubMed  Google Scholar 

  14. Beloeil H, Garot M, Lebuffe G, et al. Balanced opioid-free anesthesia with dexmedetomidine versus balanced anesthesia with remifentanil for major or intermediate noncardiac surgery. Anesthesiology. 2021;134(4):541–51.

    Article  CAS  PubMed  Google Scholar 

  15. Forget P. Opioid-free anaesthesia. Why and how? A contextual analysis. Anaesth Crit Care Pain Med. 2019;38(2):169–72.

    Article  PubMed  Google Scholar 

  16. Ziemann-Gimmel P, Goldfarb AA, Koppman J, et al. Opioid-free total intravenous anaesthesia reduces postoperative nausea and vomiting in bariatric surgery beyond triple prophylaxis. Br J Anaesth. 2014;112(5):906–11.

    Article  CAS  PubMed  Google Scholar 

  17. Choi H, Huh J, Kim M et al. Opioid-free using ketamine versus opioid-sparing anesthesia during the intraoperative period in video-assisted thoracoscopic surgery: a randomized controlled trial. J Pers Med. 2024;14(8):881. https://doiorg.publicaciones.saludcastillayleon.es/10.3390/jpm14080881.

  18. Selim J, Jarlier X, Clavier T, et al. Impact of opioid-free Anesthesia after Video-assisted thoracic surgery: a propensity score study. Ann Thorac Surg. 2022;114(1):218–24.

    Article  PubMed  Google Scholar 

  19. An G, Zhang Y, Chen N, et al. Opioid-free anesthesia compared to opioid anesthesia for lung cancer patients undergoing video-assisted thoracoscopic surgery: a randomized controlled study. PLoS ONE. 2021;16(9): e0257279.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Yan X, Liang C, Jiang J, et al. Effects of opioid-free anaesthesia on postoperative nausea and vomiting in patients undergoing video-assisted thoracoscopic surgery (OFA-PONV trial): study protocol for a randomised controlled trial. Trials. 2023;24(1):819.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Myles PS, Wengritzky R. Simplified postoperative nausea and vomiting impact scale for audit and post-discharge review. Br J Anaesth. 2012;108(3):423–9.

    Article  CAS  PubMed  Google Scholar 

  22. Kleif J, Waage J, Christensen KB, et al. Systematic review of the QoR-15 score, a patient- reported outcome measure measuring quality of recovery after surgery and anaesthesia. Br J Anaesth. 2018;120(1):28–36.

    Article  CAS  PubMed  Google Scholar 

  23. Laboratories ATSCoPSfCPF. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111–7.

    Article  Google Scholar 

  24. Dell-Kuster S, Gomes NV, Gawria L, et al. Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study. BMJ. 2020;370:m2917.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Yang J, Huang L, Liu S, et al. Effect of electroacupuncture on postoperative gastrointestinal recovery in patients undergoing thoracoscopic surgery: a feasibility study. Med Sci Monit. 2020;26:e920648.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Termpornlert S, Vijitpavan A, Ngodngamthaweesuk M, et al. Analgesic efficacy of intravenous dexamethasone as an adjunct to ultrasound-guided paravertebral block with bupivacaine in video-assisted thoracoscopic surgery. J Pain Res. 2022;15:2351–61.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Massoth C, Schwellenbach J, Saadat-Gilani K, et al. Impact of opioid-free anaesthesia on postoperative nausea, vomiting and pain after gynaecological laparoscopy - A randomised controlled trial. J Clin Anesth. 2021;75: 110437.

    Article  CAS  PubMed  Google Scholar 

  29. Feng CD, Xu Y, Chen S, et al. Opioid-free anaesthesia reduces postoperative nausea and vomiting after thoracoscopic lung resection: a randomised controlled trial. Br J Anaesth. 2024;132(2):267–76.

    Article  CAS  PubMed  Google Scholar 

  30. Leger M, Perrault T, Pessiot-Royer S, et al. Opioid-free Anesthesia Protocol on the early quality of recovery after major surgery (SOFA trial): a Randomized Clinical Trial. Anesthesiology. 2024;140(4):679–89.

    Article  CAS  PubMed  Google Scholar 

  31. Comelon M, Raeder J, Stubhaug A, et al. Gradual withdrawal of remifentanil infusion may prevent opioid-induced hyperalgesia. Br J Anaesth. 2016;116(4):524–30.

    Article  CAS  PubMed  Google Scholar 

  32. Devine G, Cheng M, Martinez G, et al. Opioid-free anesthesia for lung cancer resection: a case-control study. J Cardiothorac Vasc Anesth. 2020;34(11):3036–40.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank all colleagues in the Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine, and Beijing Chao-Yang Hospital, Capital Medical University for their substantial contributions to the study.

Funding

Capital’s Funds for Health Improvement and Research (2022-2Z-2039) from Beijing Municipal Administration of Hospitals.

Author information

Author notes

  1. Xiang Yan and Chen Liang contributed equally to the study.

Authors and Affiliations

  1. Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China

    Xiang Yan, Jia Jiang, An-Shi Wu & Chang-Wei Wei

  2. Department of Medical Statistics, Medieco Group Co., Ltd, Beijing, China

    Chen Liang

  3. Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao- Yang Hospital, Capital Medical University, Beijing, China

    Ying Ji

Authors
  1. Xiang Yan
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Chen Liang
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Jia Jiang
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Ying Ji
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. An-Shi Wu
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Chang-Wei Wei
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

Development of hypothesis: XY, A-SW, C-WWStudy planning: XY, CL, A-SWExecution of study protocol: XY, JJ, JY, C-WWData acquisition: XY, CLAnalysis and interpretation of results: XY, CL, JJ, A-SW, C-WWDrafting of manuscript: XY, CL, JJ, C-WWContributed to, approved, and take accountability for the final manuscript: all authors.

Corresponding authors

Correspondence to An-Shi Wu or Chang-Wei Wei.

Ethics declarations

Ethics approval and consent to participate

This study was reviewed by the institutional ethics committee. IRB number: 2022-ke-19, Date of approval: Feb 7, 2022. All included subjects in this study signed written informed consent before study inclusion.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yan, X., Liang, C., Jiang, J. et al. Effects of balanced opioid-free anesthesia on post-operative nausea and vomiting in patients undergoing video-assisted thoracic surgery: a randomized trial. BMC Anesthesiol 25, 62 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12871-025-02938-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12871-025-02938-x

Keywords

BMC Anesthesiology

ISSN: 1471-2253

Contact us