Can Total Intravenous Anesthesia (TIVA) be combined with a neuraxial block for this patient?

Can TIVA Be Combined with Neuraxial Block?

Yes, Total Intravenous Anesthesia (TIVA) can be safely combined with a neuraxial block, but simultaneous administration should be avoided due to the risk of precipitous blood pressure drops. 1

Key Safety Principle

• Do not administer spinal anesthesia and general anesthesia (including TIVA) simultaneously, as this combination is associated with severe intra-operative hypotension 1
• The neuraxial block should be established first, with the patient monitored for hemodynamic stability, before proceeding with TIVA if needed 1

When This Combination Is Appropriate

Sequential Administration

• Neuraxial anesthesia can be used as the primary anesthetic technique, with TIVA added later if conversion to general anesthesia becomes necessary 2
• Alternatively, a neuraxial block can be placed for postoperative analgesia before or after TIVA-based general anesthesia 2

Clinical Scenarios Favoring This Approach

• For major abdominal or thoracic surgery: Thoracic epidural analgesia with local anesthetics can be combined with TIVA general anesthesia to provide superior postoperative pain control 3
• For orthopedic procedures: Peripheral nerve blocks (which carry less hemodynamic risk than neuraxial blocks) can be safely combined with TIVA 4
• When postoperative analgesia is a priority: Neuraxial opioids or continuous epidural infusions can extend analgesia after TIVA-based surgery 1

Technical Considerations for Safe Combination

Neuraxial Block Placement

• Use ultrasound guidance when performing any regional technique to reduce complications and local anesthetic systemic toxicity 2, 4
• Administer neuraxial blocks in incremental doses (3-5 mL) with frequent aspiration to detect intravascular or intrathecal injection 5
• A test dose containing 10-15 mg bupivacaine and 10-15 mcg epinephrine should be given before full neuraxial dosing 5

Hemodynamic Management

• Establish intravenous access with fluids running before neuraxial block placement 5
• Monitor blood pressure continuously, as both neuraxial sympathectomy and TIVA agents can cause hypotension 5
• Have vasopressors immediately available, particularly when combining techniques that both affect sympathetic tone 2

TIVA Administration After Neuraxial Block

• If converting from neuraxial to general anesthesia, use reduced doses of propofol for induction in patients who already have sympathetic blockade 3
• Maintain standard TIVA monitoring including processed EEG (BIS or Entropy) to prevent awareness 6
• Use short-acting agents to allow rapid awakening for neurological assessment 3

Contraindications to Neuraxial Blocks

• Coagulopathy: INR >1.4, platelets <75,000, or recent LMWH administration 1
• Active infection or sepsis at the proposed injection site 2
• Patient refusal or inability to cooperate 2
• Hemodynamic instability that would be worsened by sympathetic blockade 2

Alternative: Peripheral Nerve Blocks with TIVA

• Peripheral nerve blocks are safer than neuraxial blocks when combined with general anesthesia because they do not cause sympathectomy or widespread hemodynamic effects 2, 4
• Femoral, sciatic, and other peripheral blocks can provide excellent surgical anesthesia or postoperative analgesia without the cardiovascular risks of neuraxial techniques 4
• These blocks can be performed before, during, or after TIVA without the same concerns about precipitous hypotension 2

Common Pitfalls to Avoid

• Never give the neuraxial block and induce general anesthesia at the same time - this is the most critical error 1
• Do not use high-dose neuraxial blocks in hemodynamically unstable patients - consider peripheral blocks instead 2
• Avoid ester-type local anesthetics if the patient has received anticholinesterase medications - use amides like bupivacaine instead 2
• Do not skip the test dose - unrecognized intrathecal or intravascular injection can cause catastrophic complications 5