TIVA vs Inhalational Anaesthesia in Major Noncardiac Surgery: JAMA | August 2026

Introduction:

Total intravenous anaesthesia (TIVA) with propofol is increasingly used as an alternative to volatile inhalational anaesthesia, with proposed advantages in postoperative recovery and safety. However, robust evidence demonstrating better patient-centred outcomes has been lacking. The VITAL trial compared these two widely used anesthetic strategies in older adults undergoing major elective noncardiac surgery.

Why was this study needed?

TIVA use has expanded considerably despite limited large randomized evidence.

Anesthetic technique may influence postoperative recovery, complications, and delirium.

Previous studies suggested less nausea and faster early recovery with TIVA.

A pragmatic comparison was needed to determine whether these differences translate into meaningful clinical benefit.

Results:

Among 2,508 patients across 49 UK hospitals, days alive and at home at 30 days were virtually identical with TIVA and inhalational anesthesia.

There were no meaningful differences in mortality, major postoperative complications, delirium, or overall quality of recovery.

TIVA produced fewer minor symptoms, including postoperative nausea and vomiting, thirst, and hoarseness.

Two cases of probable or definite intraoperative awareness occurred, both with TIVA, although events were too few for firm conclusions.

Clinical Impact:

For major noncardiac surgery, TIVA does not appear to improve major postoperative outcomes compared with volatile anesthesia. Choice of anesthetic technique can therefore be individualized according to patient characteristics, postoperative nausea risk, procedural requirements, clinician expertise, and environmental considerations rather than an expectation of superior overall recovery.

Bottom Line:

TIVA and volatile inhalational anesthesia provide comparable major clinical outcomes after elective noncardiac surgery. TIVA reduces some minor postoperative symptoms but does not improve overall recovery, mortality, delirium, or major complications.