General anaesthetic choice did not change recovery after major noncardiac surgery

Whether an anaesthetist keeps a patient asleep with an intravenous drip of propofol or with an inhaled gas made no difference to how older adults recovered from major surgery, according to the VITAL trial published in JAMA [s1]. The two techniques left patients with the same number of days alive and at home a month later, and the same rates of death, delirium and major complications [s1].

The question is a practical one that anaesthetists face at the start of almost every operation. General anaesthesia is most often maintained in one of two ways: total intravenous anaesthesia (TIVA), usually a continuous propofol infusion, or volatile-based inhalational anaesthesia delivered as a gas [s1]. Whether one produces better recovery or fewer complications in older, higher-risk patients has long been debated, with observational studies pointing in different directions [s1]. VITAL set out to answer it with a randomised head-to-head comparison.

What the trial did

VITAL was a pragmatic, multicentre, open-label randomised trial conducted in 49 UK National Health Service hospitals from January 2022 to April 2024, with final follow-up in October 2024 [s1]. It enrolled patients aged 50 years or older scheduled for elective major noncardiac surgery [s1]. Participants were randomised 1:1 to maintenance of general anaesthesia with either TIVA using a propofol infusion (1,254 patients) or volatile-based inhalational agents (1,254 patients); all other perioperative care was left to the clinicians' discretion [s1]. The trial was registered as ISRCTN62903453 and sponsored by the University of Warwick [s2].

The primary outcome was days alive and at home at 30 days — a patient-centred measure that rolls death, a prolonged hospital stay and early readmission into a single number, so that a worse recovery on any of those fronts lowers the score [s1]. Secondary outcomes included days alive and at home at 90 days; mortality at 30 days, 90 days and 6 months; a quality-of-recovery score at day 3; delirium; patient satisfaction; and major postoperative complications [s1].

What it found

Among the 2,508 participants, the mean age was 67 years and 55% were male, and the two groups were well matched [s1]. Days alive and at home at 30 days were almost identical: a mean of 22.5 days with TIVA against 22.4 days with inhalational anaesthesia, an incidence rate ratio of 1.00 (95% confidence interval, 0.99 to 1.02; adjusted P=.68) [s1]. There were no differences in days alive and at home at 90 days, in mortality at 30 days, 90 days or 6 months, or in the day-3 quality-of-recovery score [s1]. Delirium was similar in both groups, with the large majority — 87.6% of patients — showing no delirium at day 3 [s1]. Major complications occurred in 12.4% of patients overall, with no significant difference between groups [s1].

The techniques did differ at the margins. Patients in the TIVA group reported lower rates of thirst, hoarseness, and nausea and vomiting [s1]. But there were two cases of certain or probable unintentional awareness under anaesthesia — a patient becoming aware during the operation — and both occurred in the TIVA group [s1].

How to read it

On the outcomes that matter most to patients — surviving, getting home, avoiding complications and delirium — the choice of maintenance technique is a wash [s1]. That is a useful result precisely because it is negative: it means neither approach can claim superiority on hard outcomes, and the decision can rest instead on side-effect profiles, patient factors and cost. TIVA's edge on nausea and sore throat is real but modest, and it is set against the awareness signal, a known trade-off of an intravenous technique in which the depth of anaesthesia cannot be measured as directly as an exhaled gas concentration [s1].

The trial was pragmatic and academically sponsored rather than run by a drug or device manufacturer, which strengthens confidence that the comparison was not built to favour a product [s2]. Its main limitation is unavoidable: anaesthetists cannot be blinded to which technique they are using, so subjective outcomes such as satisfaction could be influenced by expectation, even though the hardest outcomes cannot [s1]. The findings apply to older adults undergoing elective major noncardiac surgery, not to emergency operations or to younger, lower-risk patients [s1]. And with only two awareness events, the trial cannot precisely quantify that risk [s1].

Why it matters

Anaesthesia is one of the most common medical interventions in the world, so a genuine difference between these two techniques would matter at enormous scale. VITAL indicates there is no such difference for the outcomes patients care about most [s1]. For readers, the message is reassurance: both routes are reasonable, and the specifics can be tailored to the person on the table.

For a related trade-off in perioperative care, see our coverage of preventing delirium in older hospital patients.

This article describes trial results and is not medical advice. Decisions about anaesthesia are for patients and their treating clinicians.

Sources

• Total Intravenous vs Volatile Inhalational Anesthesia for Major Noncardiac Surgery — JAMA, August 2026 (primary trial report)
• VITAL trial registration, ISRCTN62903453 — ISRCTN registry (trial registration; sponsor University of Warwick)