Anesthetic Clinical Pharmacology

E ORIGINAL CLINICAL RESEARCH REPORT

Effect of Sevoflurane Versus Isoflurane on Emergence
Time and Postanesthesia Care Unit Length of Stay:
An Alternating Intervention Trial
Kamal Maheshwari, MD, MPH,*† Sanchit Ahuja, MD,*† Edward J. Mascha, PhD,†‡
Kenneth C. Cummings III, MD, MS,* Praveen Chahar, MD, FCARCSI,* Hesham Elsharkawy, MD, MBA, MSc,*†
Andrea Kurz, MD,*† Alparslan Turan, MD,*† and Daniel I. Sessler, MD†

BACKGROUND: We previously reported that the duration of hospitalization was not different
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between isoflurane and sevoflurane. But more plausible consequences of using soluble volatile
anesthetics are delayed emergence from anesthesia and prolonged stays in the postanesthesia
care unit (PACU). We therefore compared isoflurane and sevoflurane on emergence time and
PACU duration.
METHODS: We reanalyzed data from 1498 adults who participated in a previous alternating
intervention trial comparing isoflurane and sevoflurane. Patients, mostly having colorectal sur-
gery, were assigned to either volatile anesthetic in 2-week blocks that alternated for half a year.
Emergence time was defined as the time from minimum alveolar concentration fraction reach-
ing 0.3 at the end of the procedure until patients left the operating room. PACU duration was
defined from admission to the end of phase 1 recovery. Treatment effect was assessed using
Cox proportional hazards regression, adjusted for imbalanced baseline variables.
RESULTS: A total of 674 patients were given isoflurane, and 824 sevoflurane. Emergence time
was slightly longer for isoflurane with a median (quartiles) of 16 minutes (12–22 minutes) vs
14 minutes (11–19 minutes) for sevoflurane, with an adjusted hazard ratio of 0.81 (97.5%
CI, 0.71–0.92; P < .001). Duration in the PACU did not differ, with a median (quartiles) of
2.6 hours (2.0–3.6 hours) for isoflurane and 2.6 hours (2.0–3.7 hours) hours for sevoflurane.
The adjusted hazard ratio for PACU discharge time was 1.04 (97.5% CI, 0.91–1.18; P = .56).
CONCLUSIONS: Isoflurane prolonged emergence by only 2 minutes, which is not a clinically
important amount, and did not prolong length of stay in the PACU. The more soluble and much
less-expensive anesthetic isoflurane thus seems to be a reasonable alternative to sevoflurane. 
(Anesth Analg 2020;130:360–6)

KEY POINTS
• Question: Does emergence time and postanesthesia care unit (PACU) length of stay is longer
with isoflurane compared with sevoflurane?
• Findings: Isoflurane prolonged emergence by only 2 minutes when compared with sevoflurane.
Isoflurane and sevoflurane use had similar PACU length of stay.
• Meaning: Given similar emergence time and PACU length of stay, isoflurane seems to be a
reasonable alternative to sevoflurane.

L
imiting emergence time and postanesthesia care type of volatile anesthetic being potentially important.
unit (PACU) length of stay is desirable but chal- For example, generally soluble and thus longer-acting
lenging. Anesthetic technique and duration of volatile anesthetics promote residual sedation and pro-
surgery have been identified as common factors affect- longed PACU length of stay.1 In contrast, less soluble and
ing emergence time and PACU length of stay,1 with thus shorter-acting anesthetics promote quicker emer-
gence and shorter PACU stays.2 Quicker emergence is
From the Departments of *General Anesthesiology and †Outcomes
Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio;
characterized by various end points: time from discon-
and ‡Department of Quantitative Health Sciences, Cleveland Clinic, tinuation of anesthesia to opening of eyes, response to
Cleveland, Ohio.
verbal commands, or to achieving orientation and is
Accepted for publication January 18, 2019.
thus inconsistent among studies.3 In addition, at simi-
Funding: Internal.
The authors declare no conflicts of interest.
lar fresh gas flow, shorter-acting sevoflurane, per mini-
Supplemental digital content is available for this article. Direct URL citations
mum alveolar concentration (MAC) hour, is 12 times
appear in the printed text and are provided in the HTML and PDF versions of more expensive than isoflurane.4 While isoflurane and
this article on the journal’s website (www.anesthesia-analgesia.org).
sevoflurane are the most commonly used volatile anes-
Reprints will not be available from the authors.
thetics in the United States,5,6 it is still not clear whether
Address correspondence to Kamal Maheshwari, MD, MPH, Departments
of General Anesthesiology and Outcomes Research, Anesthesiology Insti- the upfront cost differential of the anesthetic can be jus-
tute, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Ave, E31, tified by resultant cost savings from quicker recovery.
­Cleveland, OH 44195. Address e-mail to maheshk@ccf.org.
Copyright © 2019 International Anesthesia Research Society
Concentrations of volatile anesthetics are quan-
DOI: 10.1213/ANE.0000000000004093 tified by MAC, which in turn reflects the brain

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 E ORIGINAL CLINICAL RESEARCH REPORT
concentration.7 Typically, emergence from volatile
anesthetics happens at 0.3 MAC (MAC awake).8 For
example, compared to isoflurane, sevoflurane has low
blood solubility and thus rapidly achieves equilib-
rium in the brain leading to quicker onset and offset.
Thus, induction and recovery should be faster with
sevoflurane as compared to isoflurane.3,9
Prolonged emergence and prolonged PACU
length of stay have been linked to increased cost.10,11
However, cost savings are difficult to realize unless
more surgeries are performed in the saved operat-
ing room time or PACU nurse staffing hours are
decreased. Nevertheless, extra time spent in the oper-
ating room and delay from PACU discharge are per-
ceived as burdensome to patients and their families,
as well as nursing and other staff and affects surgical
work flow.12 It also adversely affects patient and fam-
ily satisfaction. Isoflurane, although less expensive,
may increase overall cost if it substantially increases
emergence time and PACU length of stay. We, there-
fore, tested the primary hypothesis that the PACU
length of stay and emergence time are longer with
isoflurane than sevoflurane.
METHODS
We present a secondary analysis of a previously pub-
lished alternating intervention trial.13 Our reanalysis
was approved by the Cleveland Clinic Institutional
Review Board (11–440), and written informed con-
sent was waived by the Institutional Review Board.
The trial was registered before patient enrollment at
ClincialTrials.gov (NCT01379664; principal investi-
gator: D.I.S.; date of registration: June 23, 2011). The
original trial compared the effects of isoflurane and
sevoflurane on the duration of hospitalization and
concluded that hospital length of stay was similar
with each anesthetic. In this analysis, we compare
emergence time and duration in the PACU.
The protocol for the original trial was previously
reported.13 Briefly, we included patients who had
noncardiac surgery and volatile anesthesia with sevo-
flurane or isoflurane. The study was restricted to
an isolated set of operating rooms usually used for
colorectal, thyroid, and parathyroid surgery that are
managed by a small group of anesthesiologists. We
excluded patients who were given >1 volatile anes-
thetic, had emergent surgery, or were already hospi-
talized for medical conditions. We assessed the effect
of volatile anesthetic by alternating each anesthetic at
2-week intervals for half a year. No other aspects of
anesthetic management were controlled.
We extracted information on the primary outcomes,
emergence time, and PACU length of stay from the
electronic anesthesia records. Demographic and mor-
phometric characteristics were similarly extracted.
We excluded patients who were directly admitted to
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an intensive care unit, had no MAC fraction exceed-
ing 0.3, or completely bypassed the PACU.
The primary outcomes were emergence time and
PACU length of stay. Emergence time was defined as
the period from that last MAC fraction of ≥0.3 toward
the end of the procedure and when the patient left
the operating room. With an alternating intervention
trial design and a limited group of providers, we can
probably assume similar patterns of agent delivery
between the groups. PACU length of stay was defined
as the time from PACU admission to the end of phase
1 recovery.
We descriptively compared the isoflurane and
sevoflurane groups on demographic and morphomet-
ric characteristics using standard descriptive statistics
and absolute standardized differences. Summary
statistics are presented as percent of observations of
patients, means ± SDs, or medians (25th percentile
[Q1], 75th percentile [Q3]) as appropriate. The abso-
lute standardized difference was calculated as abso-
lute difference in means or proportions divided by
the pooled SD. We planned adjusted analyses for vari-
ables that were imbalanced between groups (defined
as absolute standardized difference >0.10) to reduce
potential confounding.
We primarily compared isoflurane and sevoflurane
on emergence time and PACU length of stay. Analysis
was based on time-to-event models, specifically a Cox
proportional hazards model for time to anesthetic
emergence or PACU discharge. We adjusted for imbal-
anced baseline variables in each model. We assessed
the proportional hazards assumption for each of the
primary outcomes by testing the group (isoflurane
versus sevoflurane) by time (log scale) interaction. No
violations were detected.
Both abdominal and nonabdominal surgeries were
included in the original trial; we thus assessed the
interaction between treatment and each of abdominal
surgery (yes/no) and duration of surgery on the pri-
mary outcomes. If significant, we would report results
for each surgery group separately, but still interpret
the overall results as primary. We conducted sensitiv-
ity analyses for the time-to-event outcomes using the
Wilcoxon rank sum test.
Results are reported as hazard ratios, with an
hazard ratio exceeding 1 representing the fractional
risk of having the event sooner with isoflurane than
sevoflurane. A Bonferroni correction for having 2 pri-
mary outcomes was implemented, such that the sig-
nificance criterion was P < .025 for each outcome, and
overall significance level of .05. SAS 9.4 software (SAS
Institute, Cary, NC) was used for all analyses.
RESULTS
A total of 1584 operations were included from July
18, 2011 to December 29, 2011. We excluded 71 cases
 Isoflurane Versus Sevoflurane Effect on Emergence

(4.5%) who went from the operating room to an inten-

sive care unit, 4 patients (0.3%) in whom MAC never
exceeded 0.3, and 1 patient (0.06%) who bypassed the
PACU. There remained 1498 operations, in which iso-
flurane was used in 674 and sevoflurane in 824. The
study flow chart is summarized in Figure 1. The dis-
crepancy was largely due to sevoflurane alone being
used during the month of July when the study began.
Patient characteristics by inhalational agent are
summarized in Table 1, except for surgical procedures,
which is found in Supplemental Digital Content,
Table, http://links.lww.com/AA/C752. The isoflu-
rane and sevoflurane groups were imbalanced on
American Society of Anesthesiologists physical sta-
tus, weight loss, procedure, anesthesia provider, sur-
Figure 1. Study flow chart.
geon, and time-weighted average end-tidal volatile

Table 1.  Demographic and Morphometric Characteristics

Isoflurane Sevoflurane Absolute Standardized
Factor (N = 674) (N = 824) P Difference
Body mass index (kg/m2) 27 ± 7 28 ± 7 .74a 0.02
Patient age, y 53 ± 16 53 ± 16 .80a 0.01
Duration of surgery, h 2.5 (1.6, 3.8) 2.5 (1.6, 3.6) .62b 0.03
Caucasian, N (%) 605 (90) 725 (88) .28c 0.06
Male, N (%) 286 (42) 345 (42) .83c 0.01
ASA physical status .002b 0.16
 I 13 (1.9) 17 (2.1)
 II 293 (43.5) 421 (51.1)
 III 338 (50.1) 362 (43.9)
 IV 30 (4.5) 24 (2.9)
Emergency, N (%) 10 (1.5) 9 (1.1) .50c 0.03
Congestive heart failure 19 (2.8) 23 (2.8) .97c 0.00
Valvular disease 9 (1.3) 9 (1.1) .67c 0.02
Pulmonary circulation disease 3 (0.45) 7 (0.85) .34c 0.05
Peripheral vascular disease 9 (1.3) 14 (1.7) .57c 0.03
Hypertension 197 (29.2) 252 (30.6) .57c 0.03
Chronic pulmonary disease 54 (8.0) 69 (8.4) .80c 0.01
Diabetes without chronic complications 64 (9.5) 75 (9.1) .79c 0.01
Hypothyroidism 72 (10.7) 72 (8.7) .20c 0.07
Renal failure 19 (2.8) 30 (3.6) .37c 0.05
Liver disease 16 (2.4) 14 (1.7) .35c 0.05
Lymphoma 3 (0.45) 7 (0.85) .34c 0.05
Metastatic cancer 69 (10.2) 60 (7.3) .042c 0.10
Solid tumor without metastasis 103 (15.3) 123 (14.9) .85c 0.01
Rheumatoid arthritis/collagen vascular disease 11 (1.6) 14 (1.7) .92c 0.01
Coagulopathy 21 (3.1) 14 (1.7) .071c 0.09
Obesity 58 (8.6) 72 (8.7) .93c 0.00
Fluid, electrolyte disorders 126 (18.7) 133 (16.1) .19c 0.07
Deficiency anemias 41 (6.1) 65 (7.9) .18c 0.07
Drug abuse 4 (0.59) 6 (0.73) .75c 0.02
Psychoses 15 (2.2) 13 (1.6) .36c 0.05
Depression 64 (9.5) 82 (10.0) .77c 0.02
Abdominal surgery 466 (69.1) 564 (68.4) .77c 0.01
Time-weighted average end-tidal volatile anesthetic (%) 1.9 (1.1, 3.0) 2.3 (1.3, 3.4) <.001b 0.21
Total intraoperative opioid use (mg)d 25 (18, 36) 26 (20, 38) .11b 0.08
Time-weighted BIS 44 (40, 50) 44 (39, 50) .88b 0.01
Pain scorese 3.6 ± 1.9 3.6 ± 1.8 .69a 0.02
Statistics presented as mean ± SD, median (P25, P75), median (minimum, maximum), or N (column %).
P values in bold text indicate statistical significance at P < .05.
Abbreviations: ASA, American Society of Anesthesiologists; BIS, bispectral index.
a
ANOVA.
b
Kruskal–Wallis test.
c
Pearson χ2 test.
d
As morphine IV equivalent.
e
The pain score is a 0–10 verbal response scale.

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 E ORIGINAL CLINICAL RESEARCH REPORT

Table 2.  Outcome Analysis

Isoflurane Sevoflurane Hazard Ratioa (97.5% CI)
Factor (N = 674) (N = 824) (Isoflurane Versus Sevoflurane) P Valueb
Primary analysis
  Emergence time (min) 16 (12–22) 14 (11–19) 0.81 (0.71–0.92)d .0001
  PACU length of stay (h) 2.6 (2.0–3.6) 2.6 (2.0–3.7) 1.0 (0.91–1.18)d .56
Secondary analysesc
  PACU length of stay (h)
  Abdominal surgery (N = 466) (N = 564)
2.9 (2.2–3.8) 2.8 (2.1–3.9) 0.95 (0.82–1.11) .48
  Nonabdominal surgery (N = 208) (N = 260)
2.1 (1.6–2.8) 2.2 (1.6–3.0) 1.32 (1.05–1.66) .006
Abbreviations: ASA, American Society of Anesthesiologists; PACU, postanesthesia care unit.
a
Hazard ratio was estimated from Cox proportional hazards model. Higher hazard indicates earlier discharge from PACU or earlier emergence. Therefore, a hazard
ratio >1 is “protective” for these outcomes.
b
Significance criterion. A Bonferroni correction was used to maintain an overall significance level of .05 for the primary analyses; the significance criterion was
thus 0.05/2 and 97.5% CIs are reported. The same was done for the 2 secondary analyses.
c
In secondary analyses, we assessed the interaction between treatment effect on each primary outcome and type of procedure (abdominal versus not) while
adjusting for the same imbalanced variables. The interaction was significant for PACU length of stay (P = .01) but not for emergence time (P = .86).
d
For primary analysis, the model was adjusted for imbalanced variables (absolute standardized difference, >0.10), including ASA physical status, weight loss,
procedure, anesthesia provider, surgeon, and time-weighted average end-tidal volatile.

an adjusted hazard ratio of 1.04 (97.5% CI, 0.91–1.18;

Figure 2. Forest plot comparing isoflurane and sevoflurane ratio
of means and 97.5% CI for emergence time (minutes) and PACU
length of stay (minutes). The adjusted hazard ratio for emergence
time was 0.81 (97.5% CI, 0.71–0.92) for isoflurane versus sevoflu-
rane (P < .001), indicating that average emergence time was about
20% (CI, 8%–29%) later for isoflurane than sevoflurane. There was
no significant difference in time to PACU discharge between isoflu-
rane and sevoflurane, with an adjusted hazard ratio of 1.04 (97.5%
CI, 0.91–1.18) (P = .56). A hazard ratio >1 indicates that isoflurane
is “better” (associated with reduced time), whereas a hazard ratio
<1 indicates sevoflurane is “better.” PACU indicates postanesthesia
care unit.
anesthetic (absolute standardized difference, >0.10).
We, therefore, adjusted for these potential confound-
ing factors in our primary comparisons between the
anesthetic exposures.
The median (quartiles) of emergence time was 16
minutes (12–22 minutes) for isoflurane and 14 min-
utes (11–19 minutes) for sevoflurane. The adjusted
hazard ratio for emergence time was 0.81 (97.5%
CI, 0.71–0.92) for isoflurane versus sevoflurane (P <
.001), implying that the average emergence time was
about 20% later (or more precisely, 20% less likely
to be transported out of the operating room at any
given time) for isoflurane than sevoflurane (Table  2;
Figure 2).
The median (quartiles) of PACU length of stay was
2.6 hours (2.0–3.6 hours) in the isoflurane group and
2.6 hours (2.0–3.7 hours) in the sevoflurane group.
There was no significant difference in time to PACU
discharge between isoflurane and sevoflurane, with
P  =  .56), adjusted for imbalanced variables (Table  2;
Figure 2).
Due to the imbalance in number of patients
between groups, we performed a sensitivity analysis
removing the first month of the study (only sevoflu-
rane patients), and the results were nearly identical,
with hazard ratios of 0.82 (0.71–0.94; P  =  .0008) for
emergence timing and 1.00 (0.87–1.15; P  =  .99) for
PACU length of stay.
To evaluate whether the association between anes-
thetic agent and outcomes—emergence time and
PACU length of stay—was consistent across types
of surgery, we categorized the procedure types into
abdominal and nonabdominal surgery. Within the
patients who received isoflurane, 466 (69%) had
abdominal surgery; among those given sevoflurane,
564 (68%) had abdominal surgery. The interaction
between type of surgery (abdominal versus not) and
treatment was significant (P = .011) for PACU length
of stay. Specifically, patients given isoflurane who did
not have abdominal surgery were discharged signifi-
cantly earlier than those given sevoflurane, hazard
ratio (CI) of 1.3 (1.1–1.7), whereas discharge times for
abdominal surgery did not differ between anesthet-
ics (hazard ratio, 0.95 [0.82–1.1]; Table  2). This inter-
action was still significant (P  =  .003) after adjusting
for duration of surgery. However, there was no such
interaction between anesthetic type and abdominal
surgery for time to emergence (interaction P  =  .86).
The interaction between treatment and duration of
surgery on PACU length of stay was not significant
(P = .84), while for emergence time, the interaction P
value was .052.
As a sensitivity analysis to the Cox proportional
hazards regression model, we compared the isoflu-
rane and sevoflurane groups on length of PACU stay

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 Isoflurane Versus Sevoflurane Effect on Emergence
and the length of emergence time using Wilcoxon
rank sum tests, without adjusting for any confound-
ing variables. The results were consistent with the
primary analysis. Emergence took slightly, but sta-
tistically significantly, longer with isoflurane than
with sevoflurane (P < .0001), whereas PACU length
of stay did not differ between the 2 groups (P = .86).
DISCUSSION
Isoflurane increased the median emergence time by
just 2 minutes, from 14 to 16 minutes, correspond-
ing to an average delay of about 20% (hazard ratio of
0.81) for leaving the operating room when compared
with sevoflurane. In a prospective observational trial
(N  =  50) for ambulatory surgical patients, Sloan et
al14 reported that the time to eye opening for sevo-
flurane (8.1 ± 1.0 minutes) did not differ significantly
from those for isoflurane (10.6 ± 1.3 minutes), but the
mean difference was 2.5 minutes which is similar to
our finding. Smith et al15 compared isoflurane–nitrous
oxide and sevoflurane–nitrous oxide and found a
mean difference in emergence time of 2.7 minutes.
Thus, the relatively faster emergence time in the sevo-
flurane group is consistent with previous studies.3,16–20
Previous studies estimated emergence time by var-
ious methods such as time to eye opening, response
to verbal commands, or orientation. We do not have
specific data on these events; however, we quantified
emergence as the time needed after reaching 0.3 MAC
of either agent, thus providing a consistent objective
definition. More importantly, our alternating inter-
vention trial is by far the largest evaluating anesthetic
emergence (N  =  1498). The underlying trial was not
randomized; instead, it used a novel alternating inter-
vention design that provides many of the protections
of randomization while being far more efficient. As
might thus be expected, patients given each anes-
thetic were generally well balanced, and any substan-
tive outcome differences should be assumed to result
from anesthetic selection rather than chance.
Surgical duration may affect the emergence time.
The difference in emergence times with isoflurane
and sevoflurane would presumably be less for shorter
surgeries and greater for longer surgeries.3,21 Ebert et
al3 performed a systematic review comparing recov-
ery characteristics of sevoflurane and isoflurane and
found faster emergence in patients given sevoflurane
for surgeries lasting >1 hour, whereas there was no
significant difference in emergence for surgeries last-
ing less than an hour. Little or no effect of volatile
anesthetic solubility in short cases is just as would be
expected from pharmacokinetic analyses.22
Median PACU length of stay did not differ between
isoflurane and sevoflurane. Our results are consistent
with previous small studies,3,9,15,23,24 which reported no
significant difference in readiness for PACU discharge
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times in noncardiac surgical patients. Furthermore,
Jones et al22 and Parker et al25 report similar intensive
care unit length of stay, complications, and mortality
with isoflurane and sevoflurane for cardiac surgery. A
meta-analysis26 comparing recovery profiles of sevoflu-
rane and isoflurane in a total of 1562 patients also failed
to demonstrate a difference in time to discharge eligi-
bility from the PACU. Presumably, other surgical and
anesthetic factors including duration of surgery, hemo-
dynamic instability, nausea and vomiting, drowsiness,
and poorly controlled pain may contribute to PACU
length of stay, not the inhalational anesthetic choice.
We cannot comment on specific association of these
adverse events and the anesthetic choice. However, our
data show that isoflurane can be used in clinical prac-
tice without increasing PACU length of stay.
Delayed emergence and PACU length of stay can
theoretically increase operating room costs.27,28 But
there will not be actual savings unless the observed
few minute difference in emergence time translates
to reduced turnover time, lower staffing, or increased
surgical volume. In contrast, sevoflurane costs 12 times
as much per MAC hour as isoflurane.4 Specifically, at 2
L/min fresh gas flow, 13 mL of sevoflurane is used per
hour compared to 6 mL of isoflurane. The sevoflurane
bottle is 3–4 times more expensive than isoflurane.
Therefore, switching from sevoflurane to isoflurane
provides an immediate cost savings which is almost
surely not offset by a 2-minute longer emergence time.
Because there was a significant interaction with
type of surgery, we performed subgroup analyses
within abdominal and nonabdominal surgeries.
Interestingly, there was a significantly longer PACU
length of stay with sevoflurane in the nonabdominal
surgery group. Patients in the nonabdominal sur-
gery group mostly underwent minor procedures like
examinations under anesthesia, and these patients
were discharged from the PACU 40–50 minutes ear-
lier than patients who had abdominal surgery. The
mean PACU length of stay was 11 minutes shorter
for isoflurane; 123 (95–166) for isoflurane versus 134
(98–177) for sevoflurane (P < .006). These conflict-
ing results support the contribution of factors other
than inhalational choice. For example, Gabriel et al29
reported that PACU length of stay is affected more by
patient factors like morbid obesity, hypertension, and
case duration than inhalational agent choice. And in
any case, it is unlikely that such small differences in
PACU discharge times are clinically important.
Our study has a few limitations. The inhalational
agent was not randomly assigned to each 2-week inter-
vention period, and neither the anesthesiologist nor the
surgeon was blinded in the study. However, it seems
unlikely that emergence time or PACU length of stay
would be impacted. Differences in the use of nitrous
oxide and variable timing of opioid administration
ANESTHESIA & ANALGESIA
 E ORIGINAL CLINICAL RESEARCH REPORT
near the conclusion of surgery between groups may
also affect emergence time. However, the prospective
alternating intervention design protects against the bias
of individual anesthesia providers and limits its influ-
ence on our conclusion. One may also posit that the
starting point chosen for the emergence duration (0.3
MAC) could be imprecise given the dynamic nature of
emergence and the multiple factors affecting alveolar
concentration such as fresh gas flow, minute ventila-
tion, cardiac output, and others. However, we believe
that this provides the most objective starting point in
an admittedly complex emergence process which is
assessed subjectively otherwise. Finally, the measured
outcomes in our study do not procure all aspects of dis-
criminative ability between the 2 inhalational agents.
In summary, emergence time was about 2 minutes
longer with isoflurane than sevoflurane for anesthet-
ics lasting a median of 2.5 hours, an amount that is not
clinically important. There will be even less difference
for shorter operations. PACU durations did not differ
between the volatile anesthetics. Isoflurane, which is
less expensive than sevoflurane, thus seems suitable
for most anesthetics. E
DISCLOSURES
Name: Kamal Maheshwari, MD, MPH.
Contribution: This author helped design the study, review
and analyze the data, write the manuscript, and review and
approve the final manuscript.
Name: Sanchit Ahuja, MD.
Contribution: This author helped design the study, review
and analyze the data, write the manuscript, and review and
approve the final manuscript.
Name: Edward J. Mascha, PhD.
Contribution: This author helped design the study, review
and analyze the data, write the manuscript, and review and
approve the final manuscript.
Name: Kenneth C. Cummings III, MD, MS.
Contribution: This author helped review the data, write the
manuscript, and review and approve the final manuscript.
Name: Praveen Chahar, MD, FCARCSI.
Contribution: This author helped analyze the data, write the
manuscript, and review and approve the final manuscript.
Name: Hesham Elsharkawy, MD, MBA, MSc.
Contribution: This author helped review and approve the final
manuscript.
Name: Andrea Kurz, MD.
Contribution: This author helped review and approve the final
manuscript.
Name: Alparslan Turan, MD.
Contribution: This author helped review and approve the final
manuscript.
Name: Daniel I. Sessler, MD.
Contribution: This author helped design the study, review
and analyze the data, write the manuscript, and review and
approve the final manuscript.
This manuscript was handled by: Ken B. Johnson, MD.
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