Is Total Intravenous Anesthesia (TIVA) better than volatile anesthesia for a caesarean section?

Regional Anesthesia is Preferred Over TIVA or Volatile Anesthesia for Cesarean Section

Regional anesthesia is the preferred method of anesthesia for cesarean delivery as part of an enhanced recovery protocol, rather than either TIVA or volatile anesthesia. 1

Primary Anesthetic Recommendations for Cesarean Section

• Regional anesthesia (spinal, epidural, or combined spinal-epidural) should be the first-line technique for cesarean delivery whenever possible 1
• Neuraxial techniques are preferred to general anesthesia for most cesarean deliveries due to reduced maternal and neonatal risks 1
• An indwelling epidural catheter may provide equivalent onset of anesthesia compared with initiation of spinal anesthesia for urgent cesarean delivery 1

When General Anesthesia is Necessary

In certain situations, general anesthesia may be required for cesarean delivery:

• Profound fetal bradycardia requiring immediate delivery 1
• Ruptured uterus 1
• Severe hemorrhage 1
• Severe placental abruption 1
• Contraindications to neuraxial anesthesia (e.g., coagulopathy, patient refusal) 1

TIVA vs. Volatile Anesthesia for Cesarean Section

When general anesthesia is required, the choice between TIVA and volatile anesthesia should consider:

• Postoperative nausea and vomiting (PONV): TIVA using propofol reduces PONV compared to volatile anesthetics 1, 2
• Uterine tone: After delivery, switching from volatile anesthetics to intravenous anesthetics has traditionally been recommended to avoid uterine atony 3
• Hemodynamic stability: Propofol TIVA may cause more hypotension, requiring careful titration in hemodynamically compromised patients 4
• Recovery profile: TIVA may offer a superior recovery profile with faster emergence 2

Practical Considerations for General Anesthesia in Cesarean Section

• Rapid sequence induction is recommended due to increased aspiration risk in pregnant patients 1, 3
• If using rocuronium instead of succinylcholine, higher doses (0.9-1.2 mg/kg) are recommended for rapid sequence induction 1
• Depth of anesthesia monitoring using BIS or processed EEG is recommended, especially in patients over 60 years of age, to avoid awareness and anesthesia-induced hypotension 1
• Multimodal analgesia should be employed postoperatively to reduce opioid requirements and improve recovery 3

Caveats and Special Considerations

• Despite theoretical advantages of TIVA in certain situations, there is no strong evidence to recommend one anesthetic agent over another for maintenance of anesthesia in terms of postoperative outcomes 1
• The limited evidence suggests TIVA may confer benefits for cesarean delivery, including potentially reducing the risk of hemorrhage, but more research is needed 5
• Uterine displacement (usually left displacement) should be maintained until delivery regardless of the anesthetic technique used 1
• In women with SARS-CoV-2 infection, neuraxial anesthesia remains the preferred technique to limit respiratory complications 1

Conclusion

While the debate between TIVA and volatile anesthesia continues, the most important recommendation is that regional anesthesia should be the first choice for cesarean delivery whenever possible. When general anesthesia is required, either TIVA or volatile anesthesia can be used effectively, with the choice individualized based on specific patient factors and anesthesiologist expertise.