Abstract

Background: Older adults undergoing short-duration surgery are vulnerable to opioid-related complications. It is uncertain whether an opioid-free total intravenous anesthesia (OFA) can reduce these events. We aimed to determine if OFA reduces the incidence of major postoperative adverse events compared with standard opioid-based total intravenous anesthesia (OBA).
Materials and Methods: This single-center, randomized clinical trial was conducted in China. From May to August 2025, 400 patients aged 60 years or older undergoing elective, short-duration surgery were randomized 1:1 to receive either OFA (propofol, esketamine, dexmedetomidine, lidocaine; n=200) or OBA (propofol, sufentanil, remifentanil; n=200). The primary outcome was a composite of postoperative hypoxemia, delirium, or nausea and vomiting (PONV) within 48 hours.
Results: Among 400 randomized patients (mean [SD] age, 69.5 [7.0] years; 125 [31.3%] women), all completed the trial and were included in the intention-to-treat analysis. The primary composite outcome occurred in 50 patients (25.0%) in the OFA group and 87 patients (43.5%) in the OBA group (adjusted odds ratio, 0.40; 95% CI, 0.25 to 0.62; P < .001). Of the components, the OFA group had a lower incidence of hypoxemia (15.0% vs 32.0%) and PONV (8.0% vs 16.0%). Intraoperative hemodynamic stability was greater in the OFA group.
Conclusion: In this trial of older adults undergoing short-duration surgery, OFA significantly reduced the incidence of a composite of postoperative adverse events compared with OBA. These findings support the use of OFA as a strategy to enhance perioperative safety in this patient population.

Keywords

Opioid-free anesthesia, postoperative complications, elderly, randomized controlled trial, total intravenous anesthesia