Recovery Kinetics and Postoperative Outcomes of Propofol-Based Total Intravenous Anesthesia Versus Sevoflurane in Ambulatory Surgery: A Systematic Review and Meta-Analysis of Randomized Studies.

Abstract

Background: Optimal anesthetic selection is critical for recovery and patient outcomes in ambulatory surgery. This systematic review and meta-analysis compares propofol-based total intravenous anesthesia (TIVA) with sevoflurane in adults undergoing outpatient procedures, focusing on randomized evidence published since 2014 to reflect contemporary clinical practice.

Methods: We performed a PRISMA-compliant, random-effects meta-analysis of 15 randomized controlled trials (n = 1345 randomized participants), published between 2014 and 2025, comparing propofol TIVA with sevoflurane in adults undergoing ambulatory surgery. Primary outcomes were readiness for discharge, postanesthesia care unit (PACU) length of stay (LOS), and emergence time. Secondary outcomes included postoperative nausea and vomiting (PONV) and pain scores, requirement for rescue antiemetics and analgesics, unplanned hospital admissions, and adverse events. All-cause mortality was prespecified for extraction but was not reported in the included trials (PROSPERO: CRD420251151311).

Results: Fifteen RCTs were included. For the primary outcomes, discharge readiness was shorter with TIVA in a single core trial (not a pooled meta-analytic estimate) (mean difference [MD] -5.8 min; 95% confidence interval [CI] -10.63 to -0.97; p = 0.019), although no significant differences were observed for PACU LOS (MD -1.3 min; 95% CI -7.3 to 4.8; p = 0.56). Emergence times were not pooled due to extreme heterogeneity between studies. Regarding secondary outcomes, TIVA was associated with a lower risk of PONV (risk ratio 0.67; 95% CI 0.47-0.96; absolute risk difference -0.11; approximate number needed to treat 9), with attenuation toward the null under trim-and-fill, and with lower postoperative pain scores (standardized mean difference [SMD] -0.30; among VAS 0-10 trials, MD -0.29 points). Mortality was not reported in any of the included trials.

Conclusions: Contemporary randomized evidence suggests that propofol TIVA may reduce PONV and yield a small reduction in postoperative pain scores. Evidence regarding discharge readiness, PACU LOS, and emergence is limited or inconsistent and does not support a general claim of faster early recovery with either technique. Anesthetic choice should balance these symptomatic effects against patient factors and institutional resources.