Comparison of Postoperative Pain in Pediatric Patients after Maintenance Anesthesia with Propofol or Sevoflurane 

Despite advancements in anesthetic and analgesic techniques, postoperative pain remains a significant concern in pediatric patients. As a result, the ways in which anesthetic factors influence recovery have been more closely examined. Able to be used across many clinical scenarios, propofol and sevoflurane are among the most commonly used agents for maintaining general anesthesia in children. However, their effects on postoperative pain appear to differ. A recent systematic review and meta-analysis of 13 randomized controlled trials involving more than 1,100 patients found that pediatric patients who received sevoflurane for anesthesia maintenance were more likely to experience postoperative pain and require additional analgesia than those who received propofol.¹ These findings suggest that anesthetic choice may play a meaningful role in early postoperative outcomes. 

Evidence from individual randomized trials generally supports this pattern, with most studies reporting lower postoperative pain scores and reduced analgesic requirements in pediatric patients receiving propofol maintenance compared with sevoflurane. In children undergoing hernia repair, Hasani et al. found that propofol-based anesthesia was associated with less early postoperative pain and decreased need for additional analgesia.² Similar findings have been reported in strabismus surgery, where propofol-based total intravenous anesthesia resulted in lower pain scores during recovery.³ Additional prospective studies using validated pediatric pain scales, including observational measures based on behavioral indicators, have also demonstrated lower pain scores with propofol.⁴ Although the magnitude of the difference is not consistent across all studies, the overall trend favors propofol, particularly in the immediate postoperative period. 

The observed differences in postoperative pain may be partly explained by the pharmacologic properties of the anesthetic agents. Propofol has been shown to exert anti-inflammatory effects, which may reduce the physiologic response to surgical tissue injury and contribute to lower pain levels after surgery.¹ In addition, it appears to influence central nervous system pathways involved in pain processing, which may further reduce pain perception during recovery. In contrast, in some studies, inhalational agents such as sevoflurane have been associated with increased sensitivity to pain in the early postoperative period.¹ While these mechanisms are not fully understood, they provide a plausible explanation for the consistent clinical trend favoring propofol. 

Interpretations of these findings should be attentive to several limitations in the available studies. The included trials vary in surgical procedures, patient populations, intraoperative analgesic use, and methods of pain assessment, all of which can affect postoperative pain outcomes. Differences in pain measurement—particularly in younger children, for whom researchers must rely on observational scales—make direct comparisons between studies less precise.¹

In addition, the use of adjuncts such as opioids or regional anesthesia may independently alter pain levels and make it difficult to isolate the effect of the anesthetic agent. As a result, while the overall trend is consistent, the extent of the difference between propofol and sevoflurane is less clearly defined. Further practical considerations include the advantages and disadvantages of the two agents in terms of patient comfort, accessibility, and potential contraindications. Additionally, mask anesthesia is often favored for children due to lower patient anxiety and discomfort compared to IV methods. 

Current evidence indicates that propofol-based maintenance anesthesia is associated with lower postoperative pain in pediatric patients compared with sevoflurane, particularly in the early recovery period. This difference appears consistent across multiple studies, although its magnitude varies depending on surgical and perioperative factors. Within a broader, multimodal approach to pain management, anesthetic choice may therefore contribute to improved postoperative comfort. Further research using standardized pain assessment methods and procedure-specific designs would help clarify the clinical significance of this effect. 

References 

1. Abdallah BM, Elshoeibi AM, ElTantawi N, et al. Comparison of postoperative pain in children after maintenance anaesthesia with propofol or sevoflurane: a systematic review and meta-analysis. Br J Anaesth. 2024;133(1):93-102. doi:10.1016/j.bja.2024.03.022 

2. Hasani A, Gecaj-Gashi A, Llullaku S, Jashari H. Postoperative analgesia in children after propofol versus sevoflurane anesthesia. Pain Med. 2013;14(3):442-446. doi:10.1111/pme.12031 

3. Chandler JR, Myers D, Mehta D, et al. Emergence delirium in children: a randomized trial to compare total intravenous anesthesia with propofol and remifentanil to inhalational sevoflurane anesthesia. Paediatr Anaesth. 2013;23(4):309-315. doi:10.1111/pan.12090 

4. Kocaturk O, Keles S. Recovery characteristics of total intravenous anesthesia with propofol versus sevoflurane anesthesia: a prospective randomized clinical trial. J Pain Res. 2018;11:1289-1295. Published 2018 Jul 6. doi:10.2147/JPR.S164106