Safety and recovery profile of patients after inhalational anaesthesia versus target-controlled or manual total intravenous anaesthesia: a systematic review and meta-analysis of randomised controlled trials.

Background: In the UK, total intravenous anaesthesia (TIVA) is used in 25% of general anaesthetics and is gaining traction because of its lower environmental impact and effectiveness in reducing postoperative nausea and vomiting (PONV). Although meta-analyses have compared TIVA and inhalational anaesthesia (IA), the optimal delivery method-manual infusion or target-controlled infusion (TCI)-remains underexplored. This review addresses this gap, leveraging the rapidly growing body of evidence to guide optimal anaesthetic practice.

Methods: We searched PubMed, Embase, Cochrane CENTRAL and Web of Science from inception to October 10, 2024. Studies comparing TIVA and IA across several patient-related and efficiency outcomes were included. Meta-analyses were performed for all outcomes. Subgroup analyses were performed to assess the contribution of different factors including a comparison of TCI with manual infusion in TIVA.

Results: In total, 385 RCTs were included. No significant difference in ClassIntra grade 3-4 adverse events was observed between TIVA and IA (risk ratio [RR]: 1.00, 95% confidence interval [CI]: 0.88-1.12; P=0.97). Subgroup analysis also showed no significant difference for TCI (RR: 0.89, 95% CI: 0.66-1.21; P=0.46) or manual infusion (RR: 1.03, 95% CI: 0.90-1.17; P=0.70) groups. IA was favoured in recovery times and costs, whereas the incidence of PONV and agitation on emergence favoured TIVA. No statistical difference was observed in our other outcomes.

Conclusions: TIVA and IA are comparably safe, with TIVA reducing PONV and agitation, whereas IA offers faster recovery and lower costs. The use of TCI in TIVA might decrease postoperative cognitive dysfunction and increase recovery time, highlighting the need for a systematic review directly comparing TCI and manual infusion.

Systematic Review Protocol: This review was registered prospectively with PROSPERO (CRD42024413368) on October 10, 2024. A single amendment to the title and order of outcomes was performed on November 21, 2024.