What is a recommended regimen for Total Intravenous Anesthesia (TIVA)?

Total Intravenous Anesthesia (TIVA) Regimen

For TIVA, use propofol via target-controlled infusion (TCI) at an effect-site concentration of 0.5-1 mcg/ml combined with remifentanil TCI at 1-3 ng/ml, avoiding bolus dosing to prevent over-sedation and respiratory depression. 1

Induction Protocol

Propofol Administration

• Administer propofol as an initial bolus for rapid induction (typical dose 2 mg/kg) 2, 3
• Alternatively, use propofol TCI targeting effect-site concentration of 0.5-1 mcg/ml 1
• Never exceed 1.5 mcg/ml propofol effect-site concentration, as doses above this carry significant risk of over-sedation and hypoventilation, especially with concomitant opioid use 1

Opioid Selection for Induction

• Remifentanil is the preferred opioid: administer 0.5-1 mcg/kg over 30-60 seconds if intubation occurs within 8 minutes 4
• Alternative opioids if remifentanil unavailable:
  • Fentanyl: 0.5-1 mcg/kg bolus 1
  • Alfentanil: 5-10 mcg/kg bolus 1
  • Sufentanil: 0.2 mcg/kg bolus 5

Muscle Relaxation

• Rocuronium 0.9-1.2 mg/kg for rapid sequence induction 6
• Alternatively, succinylcholine 1-2 mg/kg 6
• Vecuronium 0.1 mg/kg is acceptable for non-emergent cases 3

Maintenance Protocol

Propofol Maintenance

• Target-controlled infusion at effect-site concentration of 0.5-1 mcg/ml 1
• Manual infusion alternative: 50-100 mcg/kg/min (3-6 mg/kg/h) 7, 3
• Avoid bolus dosing during maintenance to prevent hemodynamic instability 1

Opioid Maintenance

• Remifentanil (preferred): continuous infusion at 0.05-0.3 mcg/kg/min 4

  • Standard maintenance rate: 0.2 mcg/kg/min 2
  • Adjust in 25-50% increments every 2-5 minutes based on surgical stimulus 4
  • Avoid bolus dosing during maintenance to prevent respiratory depression 1

• Alternative opioid regimens:

  • Sufentanil: 0.3 mcg/kg/h continuous infusion 5
  • Alfentanil: 30 mcg/kg/h continuous infusion 1
  • Fentanyl: 1-2 mcg/kg boluses as needed (less ideal for TIVA) 1

Essential Monitoring Requirements

Depth of Anesthesia

• Use processed EEG monitoring (BIS or Entropy) targeting BIS 40-60 1
• This prevents both awareness and excessive anesthetic depth 1
• In patients over 60 years, avoid BIS values below 35 to reduce postoperative delirium risk 6
• Avoid burst suppression patterns on EEG 6

Neuromuscular Monitoring

• Quantitative neuromuscular monitoring is mandatory when using muscle relaxants 1
• Document train-of-four ratio ≥0.90 before extubation 1, 2

Hemodynamic Monitoring

• Establish invasive arterial blood pressure monitoring before induction when feasible 1
• Position transducer at tragus level 1
• Have vasopressors immediately available (ephedrine or metaraminol) as propofol decreases cardiac output and blood pressure in a dose-dependent manner 1, 7

Advantages of TIVA Over Volatile Anesthetics

• Significantly reduced postoperative nausea and vomiting (PONV) 6
• Rapid, predictable emergence with fast return of airway reflexes 1, 8
• Hemodynamic stability when properly dosed 8, 9
• No environmental pollution 3
• Possible beneficial effects on cancer outcomes (laboratory and retrospective data) 6

Critical Pitfalls to Avoid

• Never use propofol alone for induction without an opioid, as loss of consciousness cannot be assured and there is high incidence of apnea, muscle rigidity, and tachycardia 4
• Avoid nitrous oxide as it increases PONV and delays bowel function 6, 2
• Do not use propofol in patients with egg or soy allergies 7
• Propofol is NOT contraindicated in sulfonamide allergy 7
• Pain on injection occurs in up to 30% of patients; consider lidocaine co-administration 7

Special Population Considerations

Elderly Patients (>60 years)

• Target lighter anesthesia depth (BIS 50 vs 35) to reduce postoperative delirium 6
• Avoid extremely low BIS values and burst suppression 6
• Monitor closely for hypotension as elderly are more sensitive to propofol's cardiovascular effects 6

Obese Patients

• Dose propofol based on lean body weight 1
• Assume all obese patients have some degree of sleep-disordered breathing 1
• Propofol increases vasopressor requirements in hemodynamically challenged patients 6

Emergence and Recovery

• Ensure return of airway reflexes and adequate tidal volumes before extubation 1
• Extubate awake in sitting position 1
• Typical emergence times with propofol-remifentanil TIVA: 4-5 minutes to extubation 8, 9
• For obese patients with confirmed OSA, insert nasopharyngeal airway before emergence and reinstate home CPAP immediately 1
• No residual analgesic activity remains 5-10 minutes after remifentanil discontinuation; administer alternative analgesics before stopping remifentanil 4