Total Intravenous vs Volatile Inhalational Anesthesia for Major Noncardiac Surgery
Shaman JhanjiKatie BoothLouise HillerJohn BraunJanet DunnLucy EgglestonLlewellyn Fenton-MaySam FrempongKatie GilchristClaire JacquesMonica JeffordRebecca KandiyaliDalbir KaurJames MasonS. Ramani MoonesingheRupert PearseRavishankar Rao BaikadyToby ReynoldsBen ShelleyRhona C. F. SinclairThomas TeareCecilia Vindrola‐PadrosJoyce YeungVITAL Trial TeamPetrus FourieHelen WilliamsElizabeth HoodMarcela VizcaychipiSundar Raj AshokKariem ElboghdadlyMandeep PhullTim HughesCaroline ThomasBrendon SloanJamie StrachanMichael GilbertManjunatha PatelRik KapilaTariq QureshiRhidian JonesJaimin PatelRichard RamsaranBen ClevengerChris JonesTim CookCatriona FranklingSean CopeBenjamin AveryKanika DuaChloe FairbairnsAnil HornisCeri-Ann B LynchAndrew WoodgateValasubramaniam MahadevanJeremy FabesAndrew ClarkChetan PatakiClifford SheltonAgnieszka Kubisz-PudelkoEleni SyrrakouMichael GrocottMichael G IrwinChris Partlettcatherine houghtonDave ChutterStephen BrettNatalie RowlandMatthew RowlandKhalid ZahirJ.B. LawsonRichard TimoneyBasel ObeidatJoshua WatsonSteffan MorganR.M. GrimesStephen BerryVasiliki Manou‐StathopoulouPeggy FooksEleanor TanquerayEnoch OnyaSophie JonesShirin DasturLaura KempEdward HareInez ArmstrongRobert JestyEsther ThomasAlex HunterSimantika GhoshLaura Heggiemohammed Asif AleemDavid OuSean RobertsMAHEEKA RAJAMUNIAmrita KaulBethan MorganA. ChurtonFerrari MatteoPhoebe D'Orton-GibsonSean Warburton
Key result
Total intravenous anesthesia fails to improve days alive and at home versus inhalational anesthesia.
- incidence rate ratio 1.00
- 95% CI 0.99-1.02
- P=.68
- n=2,508
Why the study?
Older adults undergoing major noncardiac surgery face substantial postoperative morbidity, and the comparative effectiveness of TIVA versus volatile-based inhalational anesthesia on recovery and safety remains uncertain.
Does total intravenous anesthesia improve days alive and at home at 30 days compared with inhalational anesthesia in older adults undergoing major noncardiac surgery?
Study Design
Type
RCT (n=2,508)
Blinding
Open-label
Randomization
1:1
Multicenter
Yes
Structured PICO
Does total intravenous anesthesia improve days alive and at home at 30 days compared with inhalational anesthesia in older adults undergoing major noncardiac surgery?
P
Population
2,508 adults aged 50 years or older scheduled for elective major noncardiac surgery, followed for up to 6 months.
I
Intervention
Total intravenous anesthesia (TIVA) (propofol infusion) for maintenance of general anesthesia.
C
Comparator
Volatile-based inhalational agents for maintenance of general anesthesia.
O
Outcome
Days alive and at home at 30 days.composite
Main Result
Relative Risk: 1 (95% CI 0.99–1.02)
Absolute Event Rate: 22.5% vs 22.4%
p-value: p=.68
Total intravenous anesthesia did not improve days alive and at home at 30 days compared with volatile inhalational anesthesia in older adults undergoing major noncardiac surgery.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
DBDr. BernardAnesthesiologist
“First of all, congratulations both to Joyce, Shaman, and the people group, you know, and the U.K. for actually executing this trial and recruiting. So it's a fabulous feat. I think as you said, it's absolutely a positive study... in the sense that it's reassuring that the techniques that are available to us as a community... it's absolutely reassuring that whatever anesthetic choice we have available to us, patients will do well.”
“When you looked at quality recovery and patient satisfaction, there's a clear difference in some of the questions that were asked. For example, it was very strong and definitely statistically significant for postoperative nausea and vomiting, hoarseness, and thirst... So looking at the data, I'm quite convinced that patients do have a better experience if they were given TIVA anesthesia.”
“This is one of the burning questions from the anesthetic community, and it's been an age-old debate, isn't it? Those people are really pro-TIVA... whereas other anesthetists want to give volatile because they believe it's safer, less risk of accidental awareness... we realized that actually the evidence base is not very strong.”
Implication
TIVA confers no recovery advantage over inhalational anesthesia; supports either approach in older adults undergoing major noncardiac surgery.
Abstract
Importance Older adults undergoing major noncardiac surgery experience substantial postoperative morbidity and health care use. The comparative effectiveness of total intravenous anesthesia (TIVA) vs volatile-based inhalational anesthesia on recovery and safety remains uncertain. Objectives To determine whether TIVA improves days alive and at home at 30 days compared with inhalational anesthesia and to evaluate differences in patient-centered outcomes and recovery. Design, Setting, and Participants Pragmatic, multicenter, open-label randomized clinical trial conducted in 49 UK National Health Service hospitals from January 2022 to April 2024 (final follow-up, October 2024) among patients aged 50 years or older scheduled for elective major noncardiac surgery. Interventions Participants were randomized 1:1 to receive maintenance of general anesthesia with either TIVA (propofol infusion) (n = 1254) or volatile-based inhalational agents (n = 1254). All other perioperative care was at clinician discretion. Main Outcomes and Measures The primary outcome was days alive and at home at 30 days. Secondary outcomes included days alive and at home at 90 days; mortality at 30 days, 90 days, and 6 months; Quality of Recovery–15 score at day 3; patient satisfaction (Bauer Patient Satisfaction Questionnaire) at day 1; delirium (4 As Test [4AT]) at day 3; unintentional awareness under anesthesia; and major postoperative complications within 30 days. Results Among the 2508 randomized participants, the mean age was 67 (SD, 8.9) years, and 55% were male. Characteristics were balanced across randomized groups. Days alive and at home at 30 days were similar between groups (mean, 22.5 [SD, 6.8] days vs 22.4 [SD, 6.6] days for TIVA vs inhalational anesthesia, respectively; incidence rate ratio, 1.00; 95% CI, 0.99-1.02; adjusted P = .68). There were no differences in days alive and at home at 90 days; mortality at 30 days, 90 days, or 6 months; or Quality of Recovery–15 score at day 3. Lower rates of thirst, hoarseness, and nausea and vomiting were reported in the TIVA group. Levels of delirium were similar between groups, with the majority (87.6%) having no delirium at day 3. Major complications occurred in 12.4% of patients overall, with no significant between-group differences. Two cases of certain or probable unintentional awareness under anesthesia were reported, both in the TIVA group. Conclusions and Relevance Among older adults undergoing major noncardiac surgery, TIVA did not improve days alive and at home at 30 days compared with inhalational anesthesia. Trial Registration ISRCTN.org Identifier: ISRCTN62903453
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Cite This Study
Jhanji et al. (2026) conducted an RCT in Elective major noncardiac surgery (n=2,508). Total intravenous anesthesia (TIVA) vs. Volatile-based inhalational anesthesia was evaluated on Days alive and at home at 30 days (incidence rate ratio 1.00, 95% CI 0.99-1.02, p=.68). Total intravenous anesthesia did not improve days alive and at home at 30 days compared with inhalational anesthesia for major noncardiac surgery (IRR 1.00; 95% CI 0.99-1.02; P=.68).