Total Intravenous Anesthesia (TIVA)

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Total intravenous anesthesia (TIVA) traditionally refers to general anesthesia maintained by intravenous medications without using inhaled volatile (“gas”) anesthetics. To safely accomplish this, one must understand the pharmacokinetics involved with maintaining an appropriate plasma/brain concentration for a given medication (propofol, dexmedetomidine, opioids, ketamine, etc.) and the synergy/side effects of these agents.

Interestingly, there is mixed data suggesting TIVA may confer better analgesic effects compared to classical “balanced” anesthetics using inhaled agents. Additionally, TIVA tends to lead to smoother emergence from anesthesia, less nausea/vomiting post-operatively, and it avoids the risk of malignant hyperthermia.

So what are the drawbacks? One could argue that compared to measuring end-tidal concentrations of volatile agents to gauge anesthetic depth, there’s no good way to know how “deep” someone is under TIVA. The BIS monitor is often used to help with this endeavor, but it’s only an adjunct that should be interpreted in the entire clinical picture (ie, significant hemodynamic changes in response to surgical stimulus could suggest inadequate depth). Furthermore, TIVA is thought to be more expensive than volatile-based anesthetics, but it’s hard to really calculate the potential cost savings from such a technique (ie, fewer admissions for post-op nausea/vomiting?).

As a cardiothoracic anesthesiologist, I most commonly use TIVA in cases where intraoperative neuromonitoring is utilized (ie, thoracoabdominal aortic aneurysm repairs) since this technique interferes less with measuring evoked potentials. I go through plenty of propofol vials for these long cases!

Drop me a comment below with questions! 🙂

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8 responses to “Total Intravenous Anesthesia (TIVA)”

  1. Jan Avatar
    Jan

    Hey, I’m a resident in anaesthesia, writing from Germany. I recently stumbled upon a meta-analysis suggesting that TIVA is inducing PONV as well, but later than volatiles (often when the patient is already discharged from recovery/anaesthesia dept.) They suggest volatiles combined with an antiemetic like ondansetron would result in equal if not better results in terms of nausea and vomiting.

    Schäfer, M., Kranke, P., Weibel, S., Kreysing, R., Kienbaum, P. (2016)
    Total intravenous anaesthesia versus single-drug pharmacological antiemetic
    prophylaxis in adults – A systematic review and meta-analysis.
    Eur J Anaesthesiol 2016; 33:1–11

    Reply
    1. Rishi Avatar
      Rishi

      Thanks so much for sharing, Jan! Hope you’re enjoying your residency training! I’ll definitely be reading this article!

      Reply
  2. Cameron Avatar
    Cameron

    What’s your opinion on doing say, spinal surgery, utilizing around .5 MAC of gas plus a remifentanil infusion? I know the literature states that it’s possible to do this without interfering too much with the neuromonitoring. However, would you ever opt for this over straight TIVA alongside a remi infusion? In my experience I still feel that the use of .5 MAC volatile interferes with my neuromonitoring.

    Reply
    1. Rishi Avatar
      Rishi

      Interesting question! When I was a resident, our intraoperative neuromonitorists were okay with a fixed MAC of volatile anesthetic (I typically did 0.5 MAC of sevoflurane) with, as you mentioned, IV anesthetics alongside it (I did some combination of propofol, sufentanil, remifentanil, ketamine, and dexmedetomidine depending on the situation). These cases were long but fairly homogeneous.

      Now as a cardiothoracic anesthesia fellow, we have to negotiate with our neuromonitorists to allow 0.2-0.3 MAC of isoflurane (which makes a HUGE difference) for cases like thoracoabdominal aortic aneurysm repairs which have significant variability. If we do a straight TIVA for these, we’d be using an inordinate amount of propofol. Additionally, the pharmacokinetics of these medications are altered when we’re on cardiopulmonary bypass. The bypass machine has the ability to bleed in volatile anesthetic which is what our perfusionists are comfortable doing. I’ll compromise with them and most often run 0.3 MAC of isoflurane with propofol and sufentanil drips.

      Reply
      1. Jim Avatar
        Jim

        Wow, I’d never heard of infusing volatiles directly into the bloodstream. How do you translate from MAC to ppm/ppb?

        Reply
        1. Rishi Avatar
          Rishi

          We still go by percentages. For example, my perfusion colleagues utilize 0.5 – 2% isoflurane added to the oxygenator gas inflow line. I’m not sure about the details beyond this though.

          Reply
          1. Jim Avatar
            Jim

            So the perfusionist is controlling the vaporizer (or whatever delivery method is utilized)? Then they are essentially acting as the anesthesiologist. I don’t think I would be so comfortable with that. The again, I have not done a heart since I was a resident almost 20 years ago so I don’t have too much business commenting about it. 🙂

          2. Rishi Avatar
            Rishi

            I absolutely AM comfortable with that. When managing pressures on bypass, I want perfusionists to be able to utilize everything from pressors, pump flow, halogenated volatiles, etc. to adjust cardiac output and systemic vascular resistance. They’re trained for this. I’ll confirm with them that their vaporizer is on when we go onto full-flow bypass. Additionally, much of the anesthetic is maintained with intravenous medications (dexmedetomidine, narcotics, etc.)

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