Total Intravenous vs Volatile Inhalational Anesthesia for Major Noncardiac Surgery: A Randomized Clinical Trial.

Summary

In this pragmatic multicenter randomized trial of 2508 adults aged 50 years or older undergoing major noncardiac surgery, TIVA did not increase days alive and at home at 30 days compared with volatile anesthesia. Mortality, delirium, quality of recovery, and major postoperative complications were also similar, although TIVA was associated with less thirst, hoarseness, and nausea and vomiting.

Key Findings

• Days alive and at home at 30 days were similar with TIVA and volatile anesthesia: mean 22.5 versus 22.4 days, incidence rate ratio 1.00, adjusted P=.68.
• There were no significant differences in 90-day recovery, mortality through 6 months, Quality of Recovery-15 scores, delirium, or major postoperative complications.
• TIVA was associated with lower rates of thirst, hoarseness, and nausea and vomiting, while both reported cases of certain or probable accidental awareness occurred in the TIVA group.

Clinical Implications

Clinicians should not expect TIVA to improve short-term recovery or major safety outcomes solely because of the anesthetic technique. Choice of TIVA versus volatile anesthesia can be guided by patient characteristics, procedural requirements, clinician expertise, resource availability, and preferences regarding symptoms such as nausea or hoarseness.

Limitations

• The trial was open-label, and other perioperative care was left to clinician discretion.
• The findings apply primarily to adults aged 50 years or older undergoing elective major noncardiac surgery in the UK National Health Service and may not generalize to emergency surgery or other health systems.

Future Directions

Future research should examine whether specific surgical subgroups, frail patients, or patients at high risk for postoperative nausea, delirium, or cognitive dysfunction derive differential benefit from either technique, and should evaluate longer-term functional outcomes and environmental effects.