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Chapter 46. Management of Total Intravenous Anesthesia (TIVA)

Donald M. Mathews, MD

  • General anesthesia with intravenous agents requires administration of both hypnotic and antinociceptive medications
  • Total intravenous anesthesia (TIVA) usually accomplished with propofol and opioid agents, although other agents and combinations are possible

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Agents Used for TIVA
Hypnotic agentsAntinociceptive agents
PropofolOpioids
BarbituratesKetamine
BenzodiazepinesNitrous oxide
EtomidateAlpha-2 agonists
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TIVA Using Propofol Compared with Balanced Anesthesia with Inhalational Agents
Comments
Advantages
Less nauseaMultiple studies, true even with multimodal PONV prophylaxis
Better postoperative moodEuphoria may be related to effect on internal cannabinoids
Less painSome suggestive data: low doses (0.1 MAC) of volatile agents are hyperalgesic (pain-worsening) in animal models
No malignant hyperthermia triggerNo need for dantrolene storage (assuming no succinylcholine usage)
No anesthesia machineHighly portable anesthetic: just need monitors, delivery vehicles (pumps), and oxygen delivery equipment
Antioxidant propertiesFree radical scavenging
  • No ambient gas in OR
  • No greenhouse gases
Better for OR personnel, environment
Disadvantages
More setup requiredMust prepare agents
Possible propofol infusion syndromeRare: usually seen in prolonged ICU infusions in critically ill patients
Lipid overloadOnly with prolonged infusion
No “ischemia-like” preconditioningVolatile agents limit tissue damage from ischemia: whether this effect is more protective than propofol’s antioxidant properties depends on experimental model

  • Propofol TIVA requires understanding of and attention to pharmacokinetic (Pk) and pharmacodynamic (Pd) principles
  • Propofol infusions over time result in accumulation with increasing plasma levels: to maintain a stable level, rates must be decreased over time (see below)
  • Context-sensitive half-time (time required for plasma level to fall 50%) of propofol is relatively predictable (approximately 20–40 minutes, depending on duration of infusion)
  • Target-controlled infusion (TCI) pumps (not available in the United States) maintain stable predicted plasma or effect-site concentrations of propofol and opioids
  • Propofol as a sole agent requires enormous doses to achieve state of general anesthesia
  • Propofol infusion rates can be significantly decreased with the addition of moderate amounts of opioids because of a synergistic relationship

Figure 46-1. Schematic Representation of Synergistic Relationship between Propofol and Opioids
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Dashed box represents “sweet spot” of interaction, combinations that allow adequate states of GA with relatively fast emergence.

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Suggested Propofol Administration Schedules
“Low” schedule“High” schedule
Bolus2 mg/kg2.5 mg/kg
First 15 min100 μg/kg/min150 μg/kg/min
15–45 min80 μg/kg/min125 μg/kg/min
After 45 min70 μg/kg/min100 μg/kg/min

  • Propofol administration: with adequate opioid administration, most patients will have adequate propofol levels when infusions are delivered between the “low” and “high” dosing schedules (Figure 46-2)
  • TCI targets of 2.5–4.0 μg/mL usually result in adequate dosing
  • Processed EEG monitoring is useful in assisting with propofol titration: act as Pd monitor of adequacy of propofol level

Figure 46-2. Predicted Plasma Concentrations of Propofol at ...

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