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Dr Fauzia Minai
Department of Anaesthesia AKUH

Course : 6
Year : 2008
Language : English
Country : Pakistan
City : Karachi
Weight : 167 kb
Related text : no
Objectives of this session
• To facilitate those who wish to practice TIVA
• Review some of the basic principles of
• Discuss the choice of drugs & technique
• Discuss its feasability of TIVA practice in a
developing country like Pakistan
Focus of this presentation
 Introduction and Definition
 Rationale for using TIVA
 What is important to know before giving
 Drugs used in TIVA
 Delivery systems for TIVA
 Monitoring in TIVA
 Application in developing countries

The concept of total intravenous anaesthesia

has evolved from primarily intravenous
induction of anaesthesia to induction as well
as maintenance of anaesthesia with
intravenously administered drugs
Definition of TIVA

TIVA is defined as a method of inducing and

maintaining general anaesthesia exclusively by
intravenously administered drugs, without
simultaneous administration of any inhalation
Search for suitable drugs and techniques to meet
changing demands of
 Advanced diagnostic and therapeutic treatment
modalities requiring alleviation of patient
 Need to provide safe anaesthesia with rapid
patient turnover as in ambulatory care setting, to
facilitate maximum no of patients
 Anaesthesia in non operative locations where
inhalational anaesthetics are logistically difficult

Availability of
• Rapid short acting, easily titratable
intravenous hypnotic, analgesic and muscle
relaxant drugs

• Pharmaco-kinetic and -dynamic based IV

delivery systems which are portable

• Monitors to measure the depth of the

hypnotic component of the anaesthetic state
Advantages over commonly used
inhalational agents

 Easy titratability of drugs

 Quick induction and reversal

 Superior recovery profile

 Portable delivery system

 Less operating room pollution


 Cost
 Availability of the most suitable drugs and
delivery systems
 No reliable technique for monitoring plasma
concentration of drugs equivalent to ET
inhalational agent monitoring
 Increased risk of awareness specially with
concurrent use of muscle relaxants

No single intravenous anaesthetic agent

provides all components of anaesthesia in its
therapeutic dose viz:
• Amnesia
• Hypnosis
• Analgesia
• +/- muscle relaxation
Hence necessity of
• Suitable drug combinations
• Awareness of drug interactions
for optimal choice of drugs and dosing strategies
tailored to the patient and procedure requirements
and fast track recovery

• Basically most of the analgesic and muscle

relaxant components of TIVA are the same as
those which supplement inhalational
anaesthetics in current use

• The difference is mainly in the choice of

drugs for the hypnotic component
Drugs for TIVA
Individually or in combination, depending upon
the Patient and Procedure:
Propofol, Ketamine, Benzodiazepines, Etomidate,
Fentanyl, Remifentanyl, sufentanil, alfentanil,
methadone, morphine
Muscle relaxants
Atracurium, Vecuronium
What is important to know before
giving TIVA?

As for any anaesthetic

 Patient evaluation

 Procedure specifications
 Basic pharmacological actions and interaction
of the drugs used

 Effective concentration range of the drugs

used or therapeutic window has to be defined
because of individual pharmacodynamic
Context sensitive half time
One important drug characteristic for TIVA (since
it is being used for a variable length of time in
infusion form) is the Context sensitive half time

• Context is the duration of drug administration

and this property refers to the time taken for
50% decrease of drug concentration at effector
site after discontinuing the infusion

• This has approximation to awakening time. Is

independent of elimination half time

Dose titration to desired clinical effect of

sedation and hypnosis is essential to prevent
adverse effects on other organ systems, drug
accumulation and delayed recovery
This is facilitated by routine clinical monitoring
as well as EEG based newer monitors
Example of a drug regimen
• Midazolam bolus as adjunct to propofol
loading dose followed by continuous infusion
of propofol
Combined with
• Fentanyl boluses or infusion
• Atracurium boluses or infusion

Most commonly used hypnotic for TIVA

• No active metabolites
• Short CSHT
• Rapid onset
• Antiemetic
10-20 mg dose in postoperative period
• Not an MH trigger
• CBF: Autoregulation and CO2 responsiveness not
Cerebroprotective effects

• Proportional Reduction in CMRO2 and CBF,

decrease in ICP

• Free radical scavenging-prevention of free radical

induced lipid peroxidation

• Membrane stabilisation

• Anticonvulsant

• Paediatric infusion syndrome

• Myoclonic phenomenon-imbalance between excitatory

and inhibtory phenomena

• Pain on injection

• Allergic reactions

• Bacterial growth
How is TIVA delivered?

TIVA can be given by:

 Simple intravenous boluses

 Variable rate continuous infusion

Continuous infusion devices

Manually controlled infusion through simple

syringe pumps using disposition kinetics such
as the 10-8-6 rule

Microprocessor controlled automated delivery

systems – Target Controlled Infusion Pumps-
BET infusion scheme

B = Loading dose
E = terminal elimination
T = transfer to peripheral compartment

Anaesthetist chooses “target” blood or brain

(effective site) drug concentration
Microprocessor of the pump infuses the drug
at the rate needed to rapidly achieve and
maintain the desired concentration based on
population pharmacokinetic- dynamic data
No feedback signal of output
• Is the future
• Feedback signal of effect site concentration
built into the delivery system
• Prospective utilization of BIS and AER
Advantages of continuous variable rate

 Greater hemodynamic stability

 More stable depth of anaesthesia

 More predictable and rapid recovery

 Potential lower total dose of drug used

Monitoring in TIVA

• Routine ASA recommended monitoring +/-

invasive monitoring as per requirement of
patient and procedure

• EEG based monitoring of hypnosis

(anaesthetic depth)
Bispectral Index
Auditory Evoked Response
Applications of TIVA

• As general anaesthetic-neurosurgery, day

case surgery, bariatric surgery

• Supplement to regional, local anaesthetic

• Sedation analgesia for diagnostic/therapeutic

Application in developing countries
The availability of the most suitable drugs and
delivery system may be a reason which
hinders the promotion/ utilization of TIVA in
developing countries like Pakistan.
We need to conduct trials on easily available
drugs given in boluses or infusion, singly or in
combination to achieve safe and effective

 Eyres R. Update on TIVA. Pediatric

Anesthesia 2004;14:374-379.

 White PF, Romero G. Nonopioid Intravenois

anaesthesia. Clinical Anaethesia 5th Ed

Barash, Cullen & Stoelting