Inhalational anesthesia with sevoflurane and total intravenous anesthesia (TIVA) with propofol are two techniques for general anesthesia that can be used effectively in the outpatient setting. Both provide effective anesthesia and facilitate postoperative recovery, but they differ in their pharmacological properties, administration, and recovery characteristics. Deciding whether sevoflurane or propofol TIVA is the appropriate technique for pediatric outpatient surgery requires consideration of induction conditions, emergence delirium, postoperative pain, nausea and vomiting, and discharge readiness [1,2].
Sevoflurane is a volatile anesthetic characterized by low blood-gas solubility, allowing rapid induction and emergence. Its principal advantage in pediatric patients is the ability to induce anesthesia through a face mask without requiring intravenous access beforehand. Propofol TIVA, sometimes combined with other intravenous agents, provides an alternative. However, intravenous induction may be challenging in children, while propofol administration requires careful titration because pediatric pharmacokinetics differ considerably from those in adults [1].
Research suggests that one benefit of propofol TIVA over sevoflurane for pediatric surgery is decreased risk of emergence delirium. Characterized by agitation, disorientation, restlessness, and inconsolable crying, it is particularly common in preschool-aged children following volatile anesthesia. In a randomized trial involving 94 children undergoing strabismus surgery, Chandler et al. reported emergence delirium in 38.3% of patients receiving sevoflurane compared with 14.9% receiving propofol-remifentanil TIVA. Postoperative pain scores were also significantly lower in the TIVA group, suggesting improved recovery quality [3].
Similar findings were reported by Kocaturk and Keles in 116 children undergoing outpatient dental rehabilitation. Emergence delirium occurred in 65.5% of the sevoflurane group compared with 3.4% of the TIVA group. Propofol anesthesia was also associated with lower postoperative pain scores and greater parental satisfaction. Importantly, extubation and recovery times were comparable between groups, indicating that improved emergence quality did not necessarily delay physiological recovery [4].
Postoperative nausea and vomiting is another important consideration, particularly because it can prolong observation and contribute to unplanned admission. Propofol TIVA has antiemetic advantages over inhalational anesthesia, although pharmacological prophylaxis may mitigate this difference. A systematic review of four randomized trials involving 558 children undergoing strabismus surgery found comparable postoperative vomiting rates between TIVA and inhalational anesthesia combined with a single prophylactic antiemetic (risk ratio 0.99). However, most inhalational regimens used halothane rather than sevoflurane, limiting direct applicability to contemporary practice [2].
In terms of recovery speed, Chandler et al. found that TIVA prolonged the time to postanesthesia care unit (PACU) discharge compared with sevoflurane (68 versus 50 minutes), despite reducing emergence delirium. Conversely, Kocaturk and Keles observed identical median recovery times of 13 minutes in both groups. Duration may depend on anesthetic protocols, surgical procedures, and discharge criteria rather than anesthetic selection alone [3,4].
Sevoflurane permits noninvasive induction and straightforward adjustment of anesthetic depth, whereas TIVA requires reliable intravenous access, infusion equipment, and age-appropriate dosing. Excessive propofol administration may produce cardiovascular or respiratory depression, making continuous monitoring and careful titration essential [1].
Propofol TIVA offers advantages in reducing emergence delirium and improving postoperative comfort, while sevoflurane remains particularly valuable for inhalational induction in pediatric surgery patients. Neither technique consistently provides faster discharge, and postoperative vomiting can be addressed through appropriate antiemetic prophylaxis. Anesthetic selection should be individualized according to patient characteristics, procedural requirements, and recovery priorities.
References
- Mani V, Morton NS. Overview of total intravenous anesthesia in children. Pediatr Anesth. 2010;20(3):211–222. doi:10.1111/j.1460-9592.2009.03112.x.
- Schaefer MS, Kranke P, Weibel S, Kreysing R, Ochel J, Kienbaum P. Total intravenous anesthesia vs single pharmacological prophylaxis to prevent postoperative vomiting in children: a systematic review and meta-analysis. Pediatr Anesth. 2018. doi:10.1111/pan.13268.
- Chandler JR, Myers D, Mehta D, et al. Emergence delirium in children: a randomized trial to compare total intravenous anesthesia with propofol and remifentanil to inhalational sevoflurane anesthesia. Pediatr Anesth. 2013;23(4):309–315. doi:10.1111/pan.12090.
- Kocaturk O, Keles S. Recovery characteristics of total intravenous anesthesia with propofol versus sevoflurane anesthesia: a prospective randomized clinical trial. J Pain Res. 2018;11:1289–1295. doi:10.2147/JPR.S164106.