Introduction
Drugs used in TIVA

Total Intravenous Anaesthesia

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.

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