Inhalational versus total intravenous anesthesia in noncardiac surgery: a comparative review of clinical outcomes

Inhalational anesthetics have long been the cornerstone of general anesthesia in noncardiac surgery owing to their reliable pharmacokinetics, ease of administration, and cardiopulmonary benefits such as bronchodilation and myocardial preconditioning. Total intravenous anesthesia (TIVA), achieved using short-acting agents such as propofol and remifentanil, and supported by target-controlled infusion systems and depth-of-anesthesia monitors, has emerged as a widely adopted alternative. TIVA is associated with improved recovery profiles, reduced incidence of postoperative nausea and vomiting, and potential neuroprotective and immunomodulatory effects. In this review, we compared the pharmacological mechanisms and clinical implications of inhalational anesthesia and TIVA, focusing on myocardial injury after noncardiac surgery and other perioperative outcomes. We summarized evidence from randomized controlled trials, large-scale observational studies, and health system-level analyses across multiple outcome domains: all-cause mortality, cardiovascular complications, pulmonary and renal outcomes, oncological prognosis, and system-level factors, such as cost-effectiveness and environmental impact. While inhalational agents demonstrated advantages in terms of cardioprotection and airway management, TIVA was found to offer potential benefits in select populations, particularly in cancer surgery and neuroanesthesia. No single technique demonstrated consistent superiority across all clinical contexts. Therefore, the selection of anesthetic technique should be personalized based on surgical risk, patient comorbidities, institutional infrastructure, and clinician expertise. Emerging trends in sustainability and precision medicine further underscore the need for individualized evidence-based strategies. By combining mechanistic insights with evidence from clinical practice, this review aimed to provide a balanced framework to guide optimal anesthetic decision-making in noncardiac surgery.