Introduction
Drugs used in TIVA
General Considerations for TIVA
General Principles of Operation
Pre-Procedure Preparation
  • Use a checklist to minimize errors during TIVA pre-anaesthetic setup
  • Conduct an apparatus checkout before administration of anaesthesia
  • Ensure that the batteries of the pumps are charged
  • Ensure the occlusion alarm has been set
Equipment Setup
  • Select a syringe of an equivalent diameter from the pump library
  • Use non-return/one-way valves on any intravenous line
  • If a one way valve is not available, use a dedicated intravenous cannula G20 and above for TCI
  • It is advisable to use Luer Lock systems
  • Clearly label intravenous connectors and valves
  • Minimize dead space
During Procedure Monitoring
  • Avoid non-invasive blood pressure (NIBP) monitoring on the same arm as the intravenous infusion
  • Choose a large peripheral vein
  • Sites of intravenous infusions should be visible and intermittently monitored
  • Check for leakage at all points intermittently
  • Check for kinks in the infusion tubing intermittently
Practical Management of Total Intravenous Anaesthesia
Induction of Anaesthesia
Administer midazolam as pre-medication, start remifentanil TCI at 2 ng/ml, then propofol TCI at 4 μg/ml. If LOC not achieved within 1 minute, increase propofol by 0.5 μg/ml every 30 seconds. Administer muscle relaxant for ETT placement.
Maintenance of Anaesthesia
Maintain remifentanil TCI at ≥3 ng/ml if BP >100/60, otherwise at 2 ng/ml. Adjust propofol TCI between 2.5–6 μg/ml and remifentanil between 1–8 ng/ml based on clinical responses. Increase remifentanil when surgical stimulation is expected.
Emergence from Anaesthesia
Administer appropriate analgesic towards end of surgery. Maintain propofol TCI during skin closure, stopping once final sutures are applied. Aim for remifentanil concentration of 1 ng/ml at end of dressing. Reverse paralysis if neuromuscular blockers were used.
Post-Operative Pain Management
Consider regional techniques/local infiltration. Administer morphine 0.05-0.1 mg/kg early or at least one hour before end of surgery. Consider parecoxib, ketorolac or paracetamol before surgery ends. For severe recovery room pain, use fentanyl or morphine boluses.
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.
TIVA Algorithm
Step 1
Determine patient characteristics (age, weight, comorbidities)
Step 2
Select appropriate target-controlled infusion (TCI) model
Step 3
Set initial target plasma and effect-site concentrations
Step 4
Titrate infusion rates to achieve desired clinical effect
Step 5
Monitor depth of anesthesia, blood pressure, and hemodynamic stability and adjust as needed
TIVA Safety Checklist
Equipment Verification
Check TCI pump function and battery. Verify drug labels and concentrations match programmed values.
Patient Parameters
Confirm weight, age, height, and ASA status are correctly entered.
Drug Preparation
Use standard concentrations: propofol 10mg/ml and remifentanil 50μg/ml. Double-check all calculations.
Monitoring Setup
Establish BIS monitoring before induction. Ensure baseline vitals are documented.
Crisis Management Plan
Have vasopressors readily available. Know how to transition to alternative anesthesia if needed.
TIVA Safety Checklist
Equipment Preparation
Target Controlled Infusion pumps with power cables, drug-filled syringes with perfusor tubings, and dedicated IV line or non-return valves with two three-way taps connected to patient's IV cannula.
Drug Preparation
Propofol 1% (10 mg/ml) & remifentanil (50 µg/ml). For remifentanil, add 4 mls NaCl to a 5 mg vial, take 2 mls & dilute to 50 mls with NaCl (50 µg/ml).
TCI Programming
For propofol, use Schnider or Marsh Model (enter Age, Weight, Height and Sex). For remifentanil, use Minto model, plasma or effect-site concentration.
During Procedure
Ensure no leakages and that patient's IV cannula is always visible. Check infusion lines every 15 minutes. No other drugs should be administered via the TCI infusion line unless absolutely necessary.
TCI Drug Selection Guide
Select the appropriate TCI model based on patient characteristics, surgical requirements, and institution protocols. Personalize target concentrations based on individual response and monitoring.
TCI Model Comparison
TIVA Drug Administration Guide