Effect of low-dose propofol infusion with sevoflurane versus propofol-only total intravenous anesthesia on postoperative nausea and vomiting in high-risk patients: a single-blind randomized controlled clinical trial

Citation:

Keck WL, Deng E, Liu WM, Kanekar R, Lomivorotov V, Sharma S. Effect of low-dose propofol infusion with sevoflurane versus propofol-only total intravenous anesthesia on postoperative nausea and vomiting in high-risk patients: a single-blind randomized controlled clinical trial. BMC Anesthesiol. 2026;26:136. doi:10.1186/s12871-026-03649-7

Single-center randomized trial in high-risk adults undergoing elective laparoscopic surgery compared a hybrid anesthetic (low-dose propofol infusion plus sevoflurane) with propofol-only total intravenous anesthesia, with all patients receiving dexamethasone and ondansetron prophylaxis. Rates of postoperative nausea and vomiting over 24 hours and rescue antiemetic use were similar, and adjusted odds ratios had very wide confidence intervals spanning benefit and harm. Overall certainty for differences between techniques in postoperative nausea and vomiting or antiemetic use is very low, so these findings are best viewed as exploratory rather than practice-changing.

Study at a glance

- Design and setting: Prospective, single-blind, individually randomized controlled trial in a single United States academic medical center, enrolling high-risk adults undergoing elective laparoscopic general, gynecologic, or urologic surgery under general anesthesia.

- Participants: Sixty-five adults aged 18 years or older with a history of postoperative nausea and vomiting and/or motion sickness, predominantly American Society of Anesthesiologists physical status II–III and mostly female, were randomized to hybrid anesthesia (n=32) or propofol-only total intravenous anesthesia (n=33).

- Intervention and comparator: Hybrid group: induction with propofol plus opioids and neuromuscular blockade, then low-dose propofol infusion combined with sevoflurane for maintenance under bispectral index guidance. Comparator group: propofol-based total intravenous anesthesia for maintenance under bispectral index guidance without volatile agents. Both groups received standardized prophylaxis with dexamethasone 4 milligrams after induction and ondansetron 4 milligrams at closure, similar fluid and vasoactive management, and opioid-based analgesia.

- Primary outcome: 24-hour postoperative nausea and vomiting: Cumulative postoperative nausea and vomiting (any nausea, retching, or vomiting within 24 hours after surgery) occurred in 19 of 32 patients (59%) in the hybrid group versus 14 of 33 (42%) in the propofol-only group. Adjusted odds ratio 1.59; 95% confidence interval 0.51 to 4.93; p=0.80. GRADE certainty for this outcome is rated Very Low due to some concerns about selective reporting and very serious imprecision.

- Secondary outcomes: early postoperative nausea and vomiting and rescue antiemetics: Post-anesthesia care unit postoperative nausea and vomiting occurred in 9 of 32 (28%) hybrid versus 7 of 33 (21%) propofol-only patients; adjusted odds ratio 1.83; 95% confidence interval 0.52 to 6.48; p=0.34 (Very Low certainty). Rescue antiemetic use in the post-anesthesia care unit occurred in 9 of 32 (28%) versus 7 of 33 (21%); adjusted odds ratio 1.59; 95% confidence interval 0.51 to 4.92; p=0.48 (Very Low certainty).

- Secondary outcomes: 24-hour rescue antiemetic use and overall antiemetic consumption: Within 24 hours, rescue antiemetics were used in 12 of 32 (38%) hybrid versus 8 of 33 (24%) propofol-only patients; adjusted odds ratio 1.84; 95% confidence interval 0.56 to 6.04; p=0.31 (Very Low certainty). Overall, any postoperative rescue antiemetic (post-anesthesia care unit or 24 hours) was given to 16 of 32 hybrid versus 13 of 33 propofol-only patients (no adjusted estimate reported; Very Low certainty).

- Pain and opioid use: Visual analog scale pain scores in the post-anesthesia care unit and total perioperative morphine milligram equivalents did not differ meaningfully between groups (for example, median total morphine equivalents 20 vs 27.5, p=0.19), and no clear analgesic or opioid-sparing advantage of the hybrid technique was demonstrated; these outcomes were not formally graded for certainty in this appraisal.

- Risk of bias and certainty: Randomization, protocol adherence, and outcome measurement were generally robust, with low risk of bias for most domains. However, incomplete visibility of the prespecified analysis plan and selective emphasis on adjusted models led to an overall risk-of-bias judgement of "some concerns." All key postoperative nausea and vomiting and antiemetic outcomes (24-hour and post-anesthesia care unit) were rated Very Low certainty by GRADE because of this risk-of-bias concern and very serious imprecision from the small sample and wide confidence intervals.

- Bottom line for practice: In high-risk adults undergoing elective laparoscopic surgery with standardized dexamethasone and ondansetron prophylaxis, hybrid low-dose propofol plus sevoflurane did not clearly reduce 24-hour postoperative nausea and vomiting, early postoperative nausea and vomiting, or rescue antiemetic use compared with propofol-only total intravenous anesthesia. Given the Very Low certainty of evidence, these findings should not on their own drive a change in anesthetic technique for the purpose of postoperative nausea and vomiting prevention; choice of hybrid versus propofol-only anesthesia should instead be guided by other clinical considerations until larger, higher-certainty trials are available.