Does a Combined Intravenous-volatile Anesthesia Offer Advantages Compared to an Intravenous or Volatile Anesthesia Alone

A Systematic Review and Meta-analysis


BMC Anesthesiol. 2021;21(52) 

In This Article

Abstract and Introduction


Background: In anesthesia, additive drug interactions are used for reducing dose and dose-dependent side-effects. The combination of propofol with volatile anesthetics is rather unusual but might have advantages compared to the single use regarding PONV, time to extubation, movement during surgery and postoperative pain perception.

Methods: We searched PubMed, Scopus, Web of Science, and CENTRAL for relevant studies comparing combined intravenous volatile anesthesia with total intravenous or balanced anesthesia. The studies identified were summarized in a meta-analysis with the standardized mean difference or risk ratio as the effect size.

Results: Ten studies provided data. The risk for PONV in the recovery room was significantly reduced for a combined anesthesia compared to a balanced anesthesia (RR 0.657, CI 0.502–0.860, p-value 0.002). There was no significant difference detected either in the time to extubation or in pain perception. Movement during surgery was significantly reduced for a combined compared to a total intravenous anesthesia (RR 0.241, CI 0.135–0.428, p-value 0.000).

Conclusions: The combination of propofol and volatiles may have some advantages in the early occurrence of PONV compared to a balanced anesthesia. To sufficiently evaluate potential advantages of a combination of volatiles and propofol further high-quality trials are needed.

Trial registration: PROSPERO CRD42019126627.


Combinations of different drugs, acting synergistically or in addition to one another, are commonly used in anesthesia: opioids in combination with hypnotics. Recent strategies of anesthesia mainly use these synergistic drug-interactions to reduce the dose and dose dependent side-effect of single substances. Another example are benzodiazepines used as premedication with additive effects on hypnosis induction and maintenance. The combination of volatile anesthetics like iso-, sevo- or desflurane with propofol is less common and maybe underestimated in its benefit although these two drugs work additively and have different elimination pathways. These properties might be beneficial compared to the use of one agent alone. In the following meta-analysis we compared the combination of intravenous and volatile anesthetics (CIVA) with a total intravenous anesthesia (TIVA) and a balanced anesthesia (BAL) regarding the occurrence of PONV, time to extubation, movement during surgery and pain perception.