We read with great interest the study conducted by Yoo et al. [1] evaluating the incidence of nausea and vomiting after general anesthesia with remimazolam versus sevoflurane. We greatly appreciate the efforts of the authors and wish to present our reflections on this study.

The authors indicated that the patients in the remimazolam group received 0.2 mg flumazenil for reversal of remimazolam after surgery. As a benzodiazepine antagonist, flumazenil reverses the effects of benzodiazepines during anesthesia or in the treatment of poisoning. Challenges associated with the use of flumazenil include the need for precise dosage modification and the potential effects of panic, anxiety, seizures, or other indications of quick withdrawal from benzodiazepines [2]. Furthermore, flumazenil may increase irritability, dizziness, and postoperative nausea and vomiting (PONV) [3]. Given these factors, the effect of flumazenil on each item of the Quality of Recovery-15 (QoR-15) score should be assessed separately. Specifically, considering how flumazenil may have affected item 10 (having a feeling of general well-being) alone and not in combination with other items such as 13 (nausea and vomiting) and 14 (feeling worried and anxious) is essential. Therefore, low scores for item 10 of the QoR-15 for the remimazolam group may be attributable to the undesirable effects of flumazenil administration.

As PONV is a common adverse effect of general anesthesia, various mitigation strategies have been developed. According to the most recent consensus guidelines for reducing PONV released by Gan et al. [4], a patient’s risk factors should be assessed when formulating a treatment approach for PONV and an appropriate quantity of antiemetic medications should be administered based on the number of risk factors. The Apfel score is a valuable tool for predicting the risk of PONV, considering factors such as sex, history of motion sickness or PONV, postoperative opioid consumption for pain management, and smoking status. The investigators in this study used the Apfel score; however, the same treatment procedure was followed regardless of whether the Apfel score was 0 or 4. The investigators should have considered the risk factors when selecting the patients and compared those with the same Apfel scores. This may have made it easier to standardize the patient population and to apply the PONV treatment method recommended by the guidelines to mitigate the risk of PONV.

In summary, we would like to thank Yoo et al. [1] for conducting this valuable study and would like to suggest that the aforementioned criteria be considered to enhance the quality of the manuscript.