Total Intravenous Anesthesia (TIVA) means using IV drugs—rather than inhaled gases—to induce and maintain anesthesia.
TIVA: Advantages & Common Agents
Advantages of TIVA
Reduced incidence of postoperative nausea and vomiting
Reduced atmospheric pollution
More predictable and rapid recovery
Greater haemodynamic stability
Ease of titration with TCI
Commonly Used Agents
Propofol - hypnotic agent for induction and maintenance
Remifentanil - ultra short acting opioid
Sufentanil - potent opioid analgesic
Alfentanil - structural analogue of fentanyl
Dexmedetomidine - sedative and analgesic
Appropriate Indications for Total Intravenous Anaesthesia
Neurosurgical Procedures
TIVA provides stable cerebral perfusion and reduced intracranial pressure
Neurophysiological Monitoring
Spine surgery and other procedures requiring monitoring
Ambulatory Surgery
Rapid recovery and reduced PONV
Malignant Hyperthermia
Safe for susceptible patients
Respiratory Procedures
Bronchoscopy, ENT-Laser surgery, and thoracic procedures
Procedural Sedation
Monitored anaesthesia care
Principles of Total Intravenous Anaesthesia
Ensure Adequate Hypnosis
Apply pharmacokinetic and pharmacodynamic knowledge
Depth of anaesthesia monitoring helps ensure adequate hypnosis
Ensure Adequate Analgesia
Titrate remifentanil or alfentanil infusion to intensity of surgical stimulus
Higher doses can prevent movement
Ensure adequate post-operative analgesia
Ensure Haemodynamic Stability
Consider hypotensive agents if blood pressure is persistently elevated
Consider fluids, vasoactive agents or inotropic agents if blood pressure is persistently low
Consider atropine if brachycardia develops
Ensure Muscle Relaxation
Propofol has weaker muscle relaxant properties than inhalation agents. Thus, more frequent doses of neuromuscular blockers may be required when using propofol for maintenance of anaesthesia without remifentanil/alfentanil
Important Considerations and Contraindications
Even with comprehensive TIVA protocols, several critical considerations must be addressed to ensure patient safety and optimal outcomes.
Absolute Contraindications
Allergy to propofol or remifentanil components, including soy or egg products.
Awareness Monitoring
Use BIS or Entropy monitoring to prevent intraoperative awareness.
Technical Failure Planning
Have backup delivery systems ready if TCI pump malfunctions occur.
Hemodynamic Management
Treat hypotension with fluid boluses or vasopressors as needed.
Always perform a thorough pre-anesthetic assessment to identify patients at high risk for TIVA complications.