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PII: S1053-0770(15)00047-6
DOI: http://dx.doi.org/10.1053/j.jvca.2015.01.024
Reference: YJCAN3187
Cite this article as: Talmage D. Egan MD, Total Intravenous Anesthesia Versus
Inhalation Anesthesia: A Drug Delivery Perspective, Journal of Cardiothoracic and
Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2015.01.024
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Total Intravenous Anesthesia Versus Inhalation Anesthesia: A Drug Delivery Perspective
Talmage D. Egan, MD
Talmage D. Egan, MD
50 N Medical Dr,
E-mail: Talmage.Egan@hsc.utah.edu
Acknowledgments
When formulating an anesthetic plan, the anesthesiologist deliberates over numerous therapeutic
decisions. Perhaps chief among these is whether to proceed with an inhalation or intravenous
anesthetic technique. Although there are many differences between the two approaches, they
1
differ most fundamentally in terms of how the anesthesiologist gains access to the circulation for
delivery of the anesthetic. This brief review aims to compare and contrast inhalation anesthesia
with total intravenous anesthesia (TIVA) from a drug delivery perspective, making the case that
advances in TIVA drugs, clinical pharmacology concepts, technologies, and techniques over the
last 25 years have transformed TIVA into an attractive alternative to more traditional inhalation
anesthesia methods.
Administering volatile anesthetics through the lung via a calibrated vaporizer affords several
fundamental advantages compared with intravenous delivery as summarized in the upper panel
of Fig 1.1 These advantages are primarily a function of gaining access to the circulation
indirectly through the lung. Because uptake of inhaled anesthetic progressively diminishes as
equilibrium between alveolar and pulmonary capillary partial pressures is approached, the
vaporizer setting is a proportional reflection of the anesthetic concentration in the blood and
therefore at the site of drug action at steady state. This enables accurate administration of the
inhaled drug to a target concentration; the anesthesiologist can set an upper limit above which
the partial pressure cannot rise. Moreover, the expired concentration of inhaled agent can be
measured and confirmed by respiratory gas monitoring, ensuring that the targeted concentration
has been achieved (pharmacokinetic [PK] exactness). Finally, the pharmacodynamic (PD)
2
As summarized in the lower panel of Fig 1, at the beginning of the TIVA era, intravenous
anesthesia techniques were associated with significant disadvantages compared with inhalation
anesthesia.1 When access to the circulation for drug delivery is obtained directly as with all
intravenous techniques, there is nothing to prevent indefinite uptake of drug (ie, there is no
equilibration process as with inhalation drug delivery). Therefore, without the aid of a PK model,
the infusion rate of an intravenous anesthetic does not reveal much about the temporal profile of
concentration. Moreover, there was not a method to measure continually the concentration of
intravenous anesthetics in real time, preventing equivalent PK exactness. Finally, at the dawn of
the TIVA era, concentration-effect relationships analogous to MAC for intravenous anesthetics
had not yet been firmly established, hindering the achievement of equivalent PD exactness
Intravenous anesthesia research over the last 25 years has focused on mitigating these
shortcomings identified in the early days of TIVA practice. Because the fundamental advantage
of inhalation anesthesia (ie, the equilibration process that occurs when gaining access to the
circulation via the lung) is obviously not applicable to intravenous techniques, the disadvantages
of TIVA stemming from this difference in access to the circulation must be addressed in other
ways. As summarized in Table 1, TIVA advances have focused on achieving enhanced drug
delivery and improved PK and PD exactness.2 These advances have come in the form of new
3
NEW DRUGS: PROPOFOL AND REMIFENTANIL
From a practical perspective, to gain traction over inhalation anesthesia techniques, TIVA
practice required anesthetic agents with certain qualities. Perhaps most importantly, the drugs
needed to be sufficiently short acting that recovery could be achieved reasonably quickly despite
long infusions. Some PD advantages of TIVA compared with inhalation agents, such as less
The advent of propofol ushered in the TIVA era. Propofol has PK and PD properties that are well
suited to the implementation of a TIVA paradigm. The reasonably rapid decline in concentration
despite long infusions3 and the clear headed, often nausea-free recovery contributed to making
propofol the pharmacologic foundation of TIVA practice.4-7 Prior to propofol’s availability, the
existing sedative-hypnotic agents were either too long active (eg, sodium thiopental) or were
associated with unacceptable adverse effects with prolonged administration (eg, etomidate).
Remifentanil, an esterase-metabolized opioid, was designed with the priorities of a modern, often
outpatient anesthesia practice in mind. Utilizing a “soft-drug” paradigm wherein the drug is
designed to be metabolically labile and thus have a very high clearance,8 remifentanil’s effects
dissipate quickly after an infusion is terminated.9 The high clearance is also the kinetic attribute
partly responsible for the rapid achievement of a steady state after beginning a remifentanil
infusion; that is, both the “front-end” and “back-end” kinetics of remifentanil are well suited to
the establishment, maintenance, and recovery from TIVA.10 Given these pharmacologic
properties, remifentanil is frequently combined with propofol for the provision of TIVA.
variety of new agents that may enhance TIVA practice in the future.11 Capitalizing on the
advantages of the “soft-drug” approach applied to anesthesia, these research efforts are in large
4
part focused on esterase-metabolized benzodiazepines (eg, remimazolam) and other sedative
hypnotics (eg, etomidate and propanidid analogues).12-14 Novel propofol formulations, typically
Enabling drug administration in the concentration domain was an obvious early goal of
intravenous anesthesia research efforts. By coding a PK model into a computer program and
linking it to an electronic pump, delivery according to a drug’s specific kinetic profile was
achieved.16 This concept was first applied to propofol17; commercial embodiments of the idea are
now available for many commonly used intravenous anesthetics (although sadly not in the
United States).18 Called target-controlled infusion (TCI) systems, the user of a TCI system
designates a target concentration to achieve rather than specifying an infusion rate as with a
traditional calculator pump. Using a PK-model-based BET (bolus, elimination, and transfer”)
algorithm, the TCI system then calculates the necessary infusion rates to achieve the targeted
models, and the concept of covariate effects for special populations (eg, age, body weight). TCI
systems approximate the concept of a vaporizer for IV anesthetics, although the analogy is not
fully applicable because a vaporizer utilizes the principles of physics, whereas TCI systems rely
A natural augmentation of PK-based TCI technology was to extend the concept into the PD
domain. Clinical pharmacology advisory systems are now available to support clinical decision-
making by informing the anesthesiologist of predictions about both the temporal profile of drug
5
concentrations and the likelihood of certain anesthetic effects.21,22 Based on high-resolution
PK/PD models, including a model of the synergistic PD interaction between propofol and
opioids,23,24 this technology automatically acquires from pumps the drug doses administered by
the clinician and then presents the drug dosing history (bolus doses, infusion rates), the predicted
drug concentrations in the effect-site (past, present and future), and the predicted drug effects,
including sedation, analgesia, and neuromuscular blockade. Although in their infancy, these
kinds of advisory systems bring sophisticated clinical pharmacology information from the
literature to the point of care and may eventually prove to be useful to clinicians.25,26
Anesthesiologists have always viewed the ability to measure in real time the concentration of
volatile anesthetics in the expired gas of anesthetized patients as a significant advantage of the
concentration domain (see Fig 1). Recent work by several laboratories has shown that it might be
feasible to commercialize a device that measures the concentration of propofol in expired gas.
The feasibility of the concept was first demonstrated using a variation of mass spectrometry
known as proton transfer reaction mass spectrometry that can detect propofol in minute amounts
(parts per billion by volume) in the expired breath of anesthetized patients.27 More recently,
several groups have further refined the technology using similar techniques.28-30 Preliminary
results suggest that the overall concept and technique are indeed promising and could have far
reaching implications in TIVA research and practice.31 Of course, there are many obstacles (eg,
miniaturization, validation, cost barriers) to be overcome before the technology could move into
6
ADVANCES IN PHARMACOKINETIC AND PHARMACODYNAMIC CONCEPTS
provide the scientific foundation upon which TIVA practice could be based. Some PK/PD
concepts (eg, terminal half-life) developed for other therapeutic areas proved almost useless
when applied in anesthesia practice.32 Thus, the early days of TIVA research were marked by
One such concept tailored for anesthesia practice is the context-sensitive half-time (CSHT). The
CSHT is a simulation that predicts the time necessary to achieve a 50% decrease in drug
concentration in the plasma after termination of a variable length, continuous infusion to a steady
state drug level.34 The "context” is the duration of a continuous infusion, a context that is
obviously relevant to TIVA. Drawing upon ideas developed earlier,35 these CSHT simulations
are an attempt to provide information about drug offset time that is not reflected in the terminal
isolation.36 The CSHT has also been referred to as the 50% decrement time (when using effect-
site concentrations instead of plasma).37 Of course, the simulations can be conducted for other
degrees of concentration decline depending on the clinical context (eg, 20% or 80% decrement
times, etc.). The CSHT and decrement time are important conceptual tools in comparing the
kinetic behavior of intravenous sedatives and opioids and have become a fundamental
Because in anesthesia practice the key drugs are rarely administered in isolation, the
Anesthesiologists take advantage of the PD synergy that results when two drugs with different
mechanisms of action but similar therapeutic effects (eg, an opioid and a sedative) are combined.
7
These synergistic combinations can be advantageous because the therapeutic goals of the
anesthetic often can be achieved with less toxicity and faster recovery than when the individual
By creating a three-dimensional plot of the sedative and opioid concentrations versus drug effect,
response-surface methods describe the PD interaction of the two drugs for any degree of drug
effect. Combined with PK information, the response-surface interaction approach can be used to
identify target concentrations of the two drugs that optimize the recovery process.33 The clinical
application of these drug interaction models through the use of computer simulation constitutes a
CONCLUSION
The introduction of propofol marked the beginning of the TIVA revolution, but compared with
the inhalation approach to anesthesia there were significant disadvantages associated with TIVA
in its early days. These disadvantages stemmed largely from gaining access to the circulation
directly; exploiting the equilibration process that occurs when delivering a drug through the lung
Theoretical and practical scientific advances related to intravenous anesthetics have now
addressed most of the early shortcomings associated with TIVA. Chief among these advances are
more suitable drugs, TCI technology, and sophisticated PK/PD concepts. TIVA is now a popular
8
technique internationally and compares very favorably with traditional inhalation anesthesia
approaches.
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FIGURE LEGEND
(lower panel) at the beginning of the TIVA era. Inhalational anesthetic delivery benefits from the
fundamental advantage of gaining access to the circulation indirectly. The equilibration process
that takes place across the lung vasculature enables drug delivery to well defined anesthetic
targets (ie, MAC) in the concentration domain using a calibrated vaporizer. See text for detailed
13
Table 1. Advances in TIVA addressing disadvantages compared to inhalation anesthesia
None
Drug Delivery
Pharmacokinetic/Pharmacodynamic Exactness
Kinetically responsive drugs (eg, propofol, remifentanil, and other “soft drugs” in
development)
concept)
14
Fig 1
15