Total Intravenous Anesthesia (TIVA) For Idiopathic Scoliosis Surgery
Total intravenous anesthetics (TIVAs) are awesome. For cases involving neurophysiologic monitoring like motor evoked potentials (MEPs), TIVAs become necessary as volatile anesthetics (ie, anesthesia “gases”) will alter the monitoring. I wanted to share an anesthetic recipe of sorts which has worked great for several idiopathic scoliosis repairs I’ve done on this rotation.
- Lines: two peripheral IVs and an arterial line
- Monitors: standard ASA monitors, BIS monitor
- IV Induction: 2-3 mg/kg propofol, 1 mcg/kg sufentanil, 0.2 mg/kg methadone, 30 mg/kg tranexamic acid
- IV Maintenance: tranexamic acid (3 mg/kg/hr), propofol (100-200 mcg/kg/min), sufentanil (0.25 – 1.0 mcg/kg/hr), nicardipine (1 – 4 mcg/kg/min)
- IV Emergence: ondansetron (0.1 mg/kg), ketorolac (0.5 mg/kg), acetaminophen (15 mg/kg)
Scoliosis surgery basically involves placing two metal rods on either side of the involved spinal column and using them as a scaffold to straight the spine. Once the second rod is placed, I switch off the sufentanil and nicardipine infusions and await the final neuromonitoring assessment prior to turning off the propofol and tranexamic acid infusions. For the remainder of the case, I run 3-4% desflurane (~0.5 MAC of volatile) which is more than enough given the lingering sufentanil. Before we flip from prone to supine, the patient is already breathing, desflurane is almost all exhaled, and I’m maintaining the anesthetic with intermittent boluses of propofol.
These patients wake up incredibly well, and I owe it to the multimodal analgesia provided by methadone, ketorolac, and acetaminophen. 🙂