Recovery from general anesthesia represents a dynamic transition from an anesthetized state to restoration of consciousness, protective airway reflexes, adequate spontaneous ventilation, hemodynamic stability, and cognitive function. The quality and speed of this transition are clinically important because delayed emergence can prolong operating-room occupancy, increase post-anesthesia care unit (PACU) utilization, and potentially contribute to postoperative morbidity. The increasing use of minimally invasive and ambulatory surgical procedures has further increased interest in anesthetic techniques that permit rapid and predictable recovery.[1,2] The characteristics of recovery are determined by multiple factors, including the pharmacokinetic and pharmacodynamic properties of the anesthetic agent, duration of anesthesia, patient age, body composition, concomitant opioids and sedatives, neuromuscular blockade, surgical characteristics, and underlying physiological status. Among these factors, the primary anesthetic used for maintenance represents a modifiable determinant of emergence.[1,3] Propofol is an intravenous hypnotic characterized by rapid redistribution and relatively rapid recovery following short-duration administration. Propofol-based total intravenous anesthesia (TIVA) is extensively used because it permits titratable anesthesia and is associated with a reduced incidence of postoperative nausea and vomiting compared with volatile anesthetic techniques.[1,4] However, context-sensitive drug accumulation during prolonged infusions and interindividual pharmacokinetic variability may influence recovery. Sevoflurane is a commonly used volatile anesthetic with relatively low blood-gas solubility. Its favorable airway characteristics and relatively rapid elimination facilitate smooth induction and emergence. Compared with older volatile agents such as isoflurane, sevoflurane has consistently demonstrated faster emergence, response to commands, extubation, and orientation.[5,6] These properties have made it particularly useful when rapid postoperative neurological assessment or ambulatory recovery is desirable. Desflurane has an even lower blood-gas partition coefficient and consequently permits rapid changes in anesthetic depth and relatively rapid elimination after discontinuation. Randomized studies comparing desflurane with sevoflurane have demonstrated shorter times to eye opening and extubation with desflurane, although the magnitude of benefit varies among surgical populations.[7,8] Later recovery endpoints, including readiness for discharge, may show considerably smaller differences than early emergence parameters.[1] Recovery quality cannot, however, be evaluated solely by the speed of awakening. Postoperative nausea and vomiting, respiratory events, pain, dizziness, agitation, and cognitive recovery influence patient comfort and readiness for discharge. Propofol-based anesthesia is associated with lower PONV rates than volatile anesthesia,[1] whereas desflurane may produce more airway irritation than sevoflurane in susceptible patients.[9] Consequently, determining the optimal anesthetic technique requires simultaneous assessment of early emergence and postoperative recovery characteristics. Comparative studies involving several commonly used anesthetic techniques under a standardized perioperative protocol may therefore provide clinically useful information regarding their relative advantages. The present study was designed to compare recovery characteristics following propofol-, sevoflurane-, and desflurane-based general anesthesia in adults undergoing elective surgical procedures. Aim To compare the recovery profiles of patients receiving propofol, sevoflurane, or desflurane for maintenance of general anesthesia. Objectives The primary objective was to compare the time to spontaneous eye opening, response to verbal commands, and tracheal extubation among the three anesthetic techniques. The secondary objectives were to compare the time required to achieve a modified Aldrete score ≥9 and the incidence of postoperative adverse events including nausea, vomiting, emergence agitation, respiratory events, and requirement for rescue antiemetics.

Study Design and Setting This prospective, parallel-group comparative study was conducted in the Department of Anaesthesiology of a tertiary-care teaching hospital. Adult patients scheduled for elective surgery under general anesthesia were screened for eligibility. The study protocol was approved by the Institutional Ethics Committee before commencement of patient recruitment. Written informed consent was obtained from every participant. Study Population A total of 120 patients aged 18–60 years undergoing elective surgical procedures under general anesthesia were included. Patients were divided into three groups of 40 patients each according to the anesthetic agent used for maintenance. • Group P: Propofol-based total intravenous anesthesia • Group S: Sevoflurane-based anesthesia • Group D: Desflurane-based anesthesia Inclusion Criteria Patients aged 18–60 years, either sex, ASA physical status I or II, scheduled for elective surgery requiring general anesthesia and endotracheal intubation, and providing written informed consent were eligible. Exclusion Criteria Patients with anticipated difficult airway, clinically significant cardiovascular, respiratory, hepatic, renal, or neurological disease; pregnancy; known hypersensitivity to study drugs; chronic opioid or sedative use; history of malignant hyperthermia; severe obesity; or requirement for postoperative mechanical ventilation were excluded. Pre-anesthetic Evaluation All participants underwent detailed pre-anesthetic assessment including medical history, physical examination, airway evaluation, routine hematological and biochemical investigations, and additional investigations when clinically indicated. Standard fasting instructions were followed. Baseline heart rate, non-invasive blood pressure, peripheral oxygen saturation, respiratory rate, and electrocardiographic parameters were documented. Anesthetic Technique Standard monitoring consisting of electrocardiography, non-invasive blood pressure, pulse oximetry, capnography, and temperature monitoring was instituted. After preoxygenation, anesthesia was induced using intravenous propofol and an opioid according to the standardized institutional protocol. Neuromuscular blockade was achieved using an appropriate non-depolarizing neuromuscular blocking agent. After adequate neuromuscular blockade, the trachea was intubated using an appropriately sized cuffed endotracheal tube. Mechanical ventilation was adjusted to maintain end-tidal carbon dioxide within the clinically accepted range. In Group P, anesthesia was maintained using a continuous intravenous propofol infusion titrated according to clinical requirements. In Group S, anesthesia was maintained using sevoflurane in an oxygen-air mixture, with the end-tidal concentration adjusted to maintain adequate anesthetic depth. In Group D, anesthesia was maintained using desflurane in an oxygen-air mixture, similarly titrated to maintain adequate anesthetic depth. Analgesic administration, intravenous fluid therapy, ventilation, temperature management, and neuromuscular blockade were standardized as far as clinically possible. Approximately 10 minutes before anticipated completion of surgery, anesthetic administration was adjusted according to the standardized emergence protocol. At completion of surgery, the maintenance anesthetic was discontinued. Residual neuromuscular blockade was antagonized according to institutional practice after confirmation of adequate spontaneous recovery. Tracheal extubation was performed when patients demonstrated adequate spontaneous ventilation, airway protective reflexes, appropriate response to commands, and satisfactory neuromuscular recovery. Assessment of Recovery Recovery time was calculated from discontinuation of the maintenance anesthetic. The following parameters were recorded: • Time to eye opening: Interval between discontinuation of anesthetic and spontaneous eye opening or eye opening on verbal request. • Time to response to verbal commands: Time required for the patient to appropriately perform a simple verbal instruction. • Time to extubation: Interval from discontinuation of maintenance anesthetic to removal of the endotracheal tube. • Modified Aldrete score: Assessed during PACU recovery. Time required to achieve a score ≥9 was recorded. • Patients were also monitored for nausea, vomiting, emergence agitation, cough/laryngospasm or other clinically important respiratory events, and requirement for rescue antiemetics. Outcome Measures The primary outcome was the difference in early recovery parameters among propofol-, sevoflurane-, and desflurane-based anesthesia. Secondary outcomes included PACU recovery and postoperative adverse events. Statistical Analysis Data were entered into a spreadsheet and analyzed using standard statistical software. Continuous variables were expressed as mean ± standard deviation and categorical variables as frequency and percentage. The normality of continuous variables was assessed before parametric testing. Normally distributed variables among the three groups were compared using one-way analysis of variance (ANOVA). When the overall ANOVA was significant, appropriate post-hoc pairwise comparisons were performed. Categorical variables were compared using the chi-square test or Fisher's exact test where appropriate. A two-sided P value <0.05 was considered statistically significant.

A total of 120 patients were included in the analysis, with 40 patients each in the propofol, sevoflurane, and desflurane groups. Table 1. Baseline demographic and perioperative characteristics Variable Propofol (n=40) Sevoflurane (n=40) Desflurane (n=40) P value Age (years) 39.6 ± 10.8 40.2 ± 11.1 38.9 ± 10.5 0.862 Male/Female 22/18 21/19 23/17 0.904 BMI (kg/m²) 24.7 ± 3.1 24.4 ± 3.3 24.9 ± 3.0 0.775 ASA I, n (%) 27 (67.5) 26 (65.0) 28 (70.0) 0.889 ASA II, n (%) 13 (32.5) 14 (35.0) 12 (30.0) Duration of surgery (min) 83.6 ± 19.4 85.1 ± 20.1 82.9 ± 18.7 0.870 Duration of anesthesia (min) 101.2 ± 21.5 103.4 ± 22.0 100.8 ± 20.6 0.838 Narrative The three study groups were comparable with respect to demographic characteristics and operative duration. Mean age was 39.6 ± 10.8 years in the propofol group, 40.2 ± 11.1 years in the sevoflurane group, and 38.9 ± 10.5 years in the desflurane group (P=0.862). There were no statistically significant differences in sex distribution, BMI, or ASA physical status. Similarly, the mean duration of surgery and anesthesia was comparable among the groups (P>0.05), indicating an adequately balanced baseline profile. Table 2. Comparison of early recovery parameters Recovery parameter (min) Propofol Sevoflurane Desflurane P value Eye opening 9.1 ± 3.0 8.5 ± 2.7 6.2 ± 2.1 <0.001 Response to verbal commands 10.4 ± 3.2 9.8 ± 3.0 7.4 ± 2.4 <0.001 Extubation 11.2 ± 3.5 10.6 ± 3.1 8.1 ± 2.6 <0.001 Orientation 13.8 ± 4.0 12.9 ± 3.7 10.2 ± 3.1 <0.001 Narrative Significant differences were observed in all early recovery parameters. Patients receiving desflurane showed the most rapid emergence. Mean time to eye opening was 6.2 ± 2.1 minutes with desflurane compared with 8.5 ± 2.7 minutes with sevoflurane and 9.1 ± 3.0 minutes with propofol (P<0.001). The mean time to response to verbal commands was also significantly shorter in the desflurane group (7.4 ± 2.4 minutes) compared with the sevoflurane (9.8 ± 3.0 minutes) and propofol groups (10.4 ± 3.2 minutes; P<0.001). Extubation occurred earliest following desflurane anesthesia, at 8.1 ± 2.6 minutes, compared with 10.6 ± 3.1 minutes following sevoflurane and 11.2 ± 3.5 minutes following propofol (P<0.001). Orientation was restored at 10.2 ± 3.1 minutes in the desflurane group, significantly earlier than in the other groups. Table 3. Post-anesthesia recovery characteristics Parameter Propofol Sevoflurane Desflurane P value Aldrete score at 10 min 7.8 ± 0.9 8.0 ± 0.8 8.5 ± 0.7 <0.001 Time to Aldrete score ≥9 (min) 20.6 ± 5.8 19.1 ± 5.2 15.8 ± 4.6 <0.001 PACU stay (min) 46.8 ± 10.7 45.2 ± 11.0 42.1 ± 9.8 0.132 Rescue analgesia, n (%) 11 (27.5) 12 (30.0) 13 (32.5) 0.887 Narrative The modified Aldrete score at 10 minutes was significantly higher among patients receiving desflurane (8.5 ± 0.7) than among those receiving sevoflurane (8.0 ± 0.8) or propofol (7.8 ± 0.9; P<0.001). Patients in the desflurane group achieved a modified Aldrete score ≥9 after a mean of 15.8 ± 4.6 minutes, compared with 19.1 ± 5.2 minutes in the sevoflurane group and 20.6 ± 5.8 minutes in the propofol group (P<0.001). Despite these differences in early recovery, the mean duration of PACU stay did not differ significantly among groups (P=0.132). This suggests that faster emergence did not translate into an equivalent reduction in overall PACU duration. Table 4. Postoperative adverse events Adverse event Propofol n (%) Sevoflurane n (%) Desflurane n (%) P value Nausea 4 (10.0) 9 (22.5) 10 (25.0) 0.191 Vomiting 2 (5.0) 5 (12.5) 6 (15.0) 0.331 Rescue antiemetic 3 (7.5) 8 (20.0) 9 (22.5) 0.153 Emergence agitation 2 (5.0) 3 (7.5) 6 (15.0) 0.271 Respiratory event 1 (2.5) 2 (5.0) 4 (10.0) 0.359 Narrative Postoperative nausea occurred in 10.0% of patients receiving propofol compared with 22.5% receiving sevoflurane and 25.0% receiving desflurane. Similarly, vomiting occurred in 5.0%, 12.5%, and 15.0% of patients, respectively. Although these differences did not reach statistical significance in this sample, the numerical trend favored propofol. Emergence agitation occurred in 5.0% of the propofol group, 7.5% of the sevoflurane group, and 15.0% of the desflurane group. Respiratory events were uncommon in all groups. No severe postoperative respiratory complication requiring reintubation was observed.

The present study compared early and intermediate recovery characteristics following propofol-, sevoflurane-, and desflurane-based general anesthesia. The principal finding was that desflurane produced more rapid early emergence, demonstrated by shorter times to eye opening, response to verbal commands, extubation, and orientation. Desflurane was also associated with earlier achievement of a modified Aldrete score ≥9. In contrast, propofol demonstrated a numerical advantage regarding postoperative nausea, vomiting, and antiemetic requirement. The rapid emergence observed with desflurane can primarily be explained by its low blood-gas partition coefficient. Rapid equilibration between alveolar gas, blood, and tissues facilitates prompt reduction of anesthetic partial pressure following discontinuation. This property is particularly relevant when rapid awakening is desirable following ambulatory or relatively prolonged surgical procedures. The findings are consistent with the randomized study by Nathanson et al.,[7] who compared desflurane and sevoflurane for outpatient anesthesia. They reported more rapid emergence and earlier extubation with desflurane, although intermediate recovery and discharge characteristics were similar. This distinction between early awakening and later functional recovery is clinically important because faster eye opening does not necessarily translate directly into earlier hospital discharge. Similarly, comparative studies of ambulatory anesthesia have demonstrated faster awakening with desflurane than sevoflurane. Ghuman et al.[8] reported significantly shorter times to eye opening, response to verbal commands, orientation, and overall recovery with desflurane. These observations support the pharmacokinetic explanation for the faster early recovery observed with desflurane. A prospective randomized double-blind comparison in patients undergoing laparoscopic cholecystectomy also demonstrated significantly faster early recovery with desflurane than with sevoflurane.[10] Patients receiving desflurane achieved important recovery endpoints, including extubation and satisfactory modified Aldrete scores, earlier than patients receiving sevoflurane. Collectively, these findings indicate that the advantage of desflurane is most consistent during the immediate emergence phase. The systematic review by Gupta et al.[1] provides broader evidence regarding comparative recovery following ambulatory anesthesia. The investigators analyzed 58 studies comparing propofol, isoflurane, sevoflurane, and desflurane and found that early recovery generally favored the newer volatile anesthetics, particularly desflurane. However, differences in later recovery and home readiness were relatively small. Importantly, postoperative nausea and vomiting were less frequent following propofol anesthesia. This finding is relevant to the present observations. Although the differences in PONV did not reach statistical significance, nausea occurred less frequently in patients receiving propofol than in those receiving either volatile agent. Propofol's antiemetic properties are well recognized and constitute an important potential advantage of TIVA, particularly in patients at high risk for PONV. Sevoflurane nevertheless possesses several desirable recovery characteristics. Earlier comparative analyses demonstrated that recovery following sevoflurane was faster than after isoflurane, particularly regarding emergence, response to commands, extubation, and orientation.[5,6] Sevoflurane also has relatively favorable airway properties and lacks the pungency associated with desflurane. Airway responses represent a potential disadvantage of desflurane. Although severe events were uncommon in the present study, respiratory events were numerically more frequent in the desflurane group. A systematic review and meta-analysis comparing desflurane with sevoflurane in ambulatory surgery reported a higher incidence of respiratory complications with desflurane while confirming significantly faster eye opening.[9] Thus, the speed of emergence should be balanced against airway tolerability, particularly in susceptible patients. More recent meta-analytic evidence has further strengthened the association between desflurane and rapid extubation. Large-scale analyses of randomized comparisons have demonstrated a substantially lower probability of prolonged extubation with desflurane compared with sevoflurane or isoflurane.[11-15] However, the clinical importance of a several-minute reduction in extubation time depends on operating-room workflow, patient characteristics, surgical complexity, and institutional fast-track protocols. An important observation in the present study was that significant differences in early recovery did not produce a statistically significant difference in PACU stay. Several factors other than anesthetic emergence determine PACU discharge, including pain, nausea, hemodynamic stability, surgical requirements, institutional discharge protocols, and availability of ward beds. Consequently, pharmacologically faster emergence cannot be assumed to produce proportional reductions in total postoperative recovery time [16-20]. Comparisons between intravenous and inhalational anesthesia are similarly complex. Propofol may not consistently produce faster eye opening than low-solubility volatile agents, but its recovery profile includes advantages beyond emergence speed, especially reduced PONV. Therefore, selection of an anesthetic technique should be individualized rather than based exclusively on a single recovery endpoint. The present findings have practical implications. Desflurane may be advantageous when rapid neurological assessment or rapid emergence is a priority. Sevoflurane offers relatively rapid recovery with favorable airway characteristics. Propofol-based TIVA remains particularly useful when minimizing PONV is important. Thus, the concept of an optimal recovery profile encompasses speed, quality, adverse effects, and overall readiness for discharge rather than simply the interval between discontinuation of anesthesia and eye opening. Limitations Several limitations should be considered. First, the study involved a relatively modest sample size and may therefore have been insufficiently powered to identify differences in infrequent adverse events. Second, recovery can be influenced by surgical type, opioid administration, anesthetic duration, neuromuscular blocking agents, and individual pharmacokinetic variability. Although perioperative management was standardized, complete elimination of these confounding variables is difficult. Third, the modified Aldrete score predominantly evaluates physiological recovery and does not comprehensively assess cognitive or patient-reported quality of recovery. Dedicated instruments such as validated postoperative quality-of-recovery scores could provide additional information. Finally, the study focused on immediate postoperative recovery. Longer-term outcomes such as postoperative cognitive recovery, patient satisfaction, time to functional independence, and quality of recovery during the first postoperative days were not assessed.

Desflurane-based general anesthesia was associated with significantly faster early recovery than sevoflurane- and propofol-based techniques, as demonstrated by shorter times to eye opening, response to verbal commands, extubation, orientation, and achievement of a modified Aldrete score ≥9. However, the advantage in early emergence did not result in a statistically significant reduction in overall PACU stay. Propofol demonstrated a favorable trend regarding postoperative nausea, vomiting, and antiemetic requirement, whereas respiratory events and emergence agitation were numerically more frequent with desflurane. These findings emphasize that the choice of general anesthetic should not be determined solely by speed of awakening. Selection should consider the required rapidity of emergence, airway characteristics, risk of PONV, surgical factors, patient characteristics, and overall quality of postoperative recovery

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