Nausea and vomiting are common complications of spinal anesthesia that stem from sympathetic blockade-induced hypotension and increased gastrointestinal peristalsis. Preventing IONV is essential not only for improving patient satisfaction with intraoperative anesthesia, but also for reducing the risk of aspiration. Benzodiazepines can reduce nausea and vomiting by decreasing the dopamine input at the chemoreceptor trigger zone in the central nervous system [2]. In patients undergoing cesarean section under spinal anesthesia, IONV incidence rates have been reported to be as high as 80% [3]. Lee et al. [4] found that remimazolam, a benzodiazepine with rapid onset and offset characteristics, significantly decreased both the incidence and severity of IONV compared with midazolam. Remarkably, remimazolam demonstrated hemodynamic stability, with no significant differences in vital signs compared with midazolam, even while achieving deeper sedation. Furthermore, recent meta-analyses suggest that in total intravenous anesthesia, remimazolam does not increase PONV risk compared to propofol and reduces PONV incidence compared to volatile anesthetics [5], suggesting broader applicability of remimazolam in anesthesia.

Opioids serve as an essential component of balanced anesthesia, contributing to the stabilization of vital signs and attenuation of surgical stimuli during general anesthesia. However, opioids are also well-known risk factors for PONV, particularly among women and non-smokers. According to the enhanced recovery after surgery (ERAS) guidelines, opioid-sparing strategies are strongly recommended to lower the incidence of PONV [6]. The fourth consensus guidelines for PONV management also advocate minimizing both intraoperative and postoperative opioid use; however, most studies focus on the effects of postoperative opioid use [7]. Nam et al. [8] demonstrated that opioid-sparing anesthesia reduces nausea in the post-anesthesia care unit after laparoscopic gynecological surgery. Their study distinguished patients who received continuous intraoperative opioid exposure from those who received opioids only at the time of induction. Additionally, postoperative pain control relies primarily on non-steroidal anti-inflammatory drugs and non-opioid rescue analgesics via intravenous patient-controlled analgesia, which allows for an objective assessment of the impact of intraoperative opioid use on PONV. The conclusions of this study were strengthened by a subgroup analysis that excluded patients who received postoperative opioids. Common opioid alternatives include dexmedetomidine, ketamine, magnesium sulfate, lidocaine, and beta-blockers for pain control and hemodynamic stability. Using magnesium sulfate without altering the concentration of volatile anesthetics demonstrated a creative solution to the ethical concerns surrounding patient care in studies without opioids.

Minimizing the occurrence of nausea and vomiting in surgical patients requires continuous attention from anesthesia providers. These two studies propose novel approaches and therapeutic options for mitigating nausea and vomiting in a surgical setting, reaffirming the importance of individualized sedation and anesthesia management. Integrating these sedatives with alternative therapies enable anesthesiologists to enhance patient safety and satisfaction, ultimately supporting a more efficient and patient-centered approach to anesthesia care.