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

Area of Science:

• Anesthesiology
• Perioperative Medicine
• Geriatric Surgery

Background:

• Older adults undergoing major noncardiac surgery face significant postoperative complications and healthcare utilization.
• The comparative effectiveness of total intravenous anesthesia (TIVA) versus volatile-based inhalational anesthesia for recovery and safety in this population remains unclear.

Purpose of the Study:

• To determine if TIVA improves "days alive and at home" at 30 days compared to inhalational anesthesia.
• To evaluate differences in patient-centered outcomes and recovery between TIVA and inhalational anesthesia.

Main Methods:

• A pragmatic, multicenter, open-label randomized trial involving 2508 patients aged 50 years or older scheduled for elective major noncardiac surgery.
• Participants were randomized to receive general anesthesia maintenance with either TIVA (propofol infusion) or volatile-based inhalational agents.
• The primary outcome was "days alive and at home" at 30 days, with secondary outcomes including mortality, recovery scores, patient satisfaction, delirium, and major complications.

Main Results:

• "Days alive and at home" at 30 days were similar between TIVA and inhalational anesthesia groups (mean 22.5 vs 22.4 days).
• No significant differences were observed in 90-day "days alive and at home," mortality rates at various time points, or Quality of Recovery-15 scores.
• The TIVA group reported lower rates of thirst, hoarseness, and nausea/vomiting, while delirium and major complication rates were comparable between groups.

Conclusions:

• Total intravenous anesthesia (TIVA) did not demonstrate superiority over inhalational anesthesia in improving "days alive and at home" at 30 days for older adults undergoing major noncardiac surgery.
• While TIVA was associated with fewer minor side effects like thirst and nausea, it did not offer a significant advantage in overall recovery or major complication rates.