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! 🙂