What are the indications for using Total Intravenous Anesthesia (TIVA) with peripheral nerve blocks?

Indications for Using TIVA with Peripheral Nerve Blocks

Total intravenous anesthesia (TIVA) combined with peripheral nerve blocks is indicated when you want to avoid volatile anesthetics while providing superior postoperative analgesia, particularly for orthopedic procedures of the extremities, ambulatory surgery requiring prolonged pain control, and in patients at high risk for postoperative nausea and vomiting (PONV). 1

Primary Clinical Indications

Orthopedic Surgery of the Extremities

• Total hip arthroplasty and total knee arthroplasty are the strongest indications, where combining TIVA with peripheral nerve blocks (femoral, fascia iliaca, or lumbar plexus blocks) provides superior pain control compared to general anesthesia alone 1
• Upper extremity procedures benefit from TIVA combined with brachial plexus blocks (axillary, infraclavicular, or supraclavicular approaches), providing both intraoperative anesthesia and extended postoperative analgesia 1, 2, 3
• Lower extremity procedures including ankle and foot surgery are well-suited for TIVA with sciatic and femoral nerve blocks 1, 4

Ambulatory and Outpatient Surgery

• Peripheral nerve blocks combined with TIVA are preferred for ambulatory surgery because they provide superior pain control, reduced PONV, and faster discharge readiness compared to general anesthesia with volatile agents 2, 3
• The combination allows patients to be discharged with ongoing analgesia from the nerve block while avoiding opioid-related side effects 2, 5

Patients at High Risk for PONV

• TIVA significantly reduces PONV compared to volatile anesthetics, making it the preferred technique when combined with peripheral nerve blocks for procedures where PONV would be particularly problematic 1, 6, 7
• This is especially relevant in gynecologic procedures (vulvar and vaginal surgery) where multimodal analgesia including peripheral nerve blocks can be combined with TIVA 1

Specific Patient Populations

Elderly and Frail Patients

• In elderly trauma patients with hip fractures, peripheral nerve blocks should be placed at presentation combined with TIVA for operative management to reduce preoperative and postoperative opioid use 1
• For elderly patients undergoing hip or knee arthroplasty, the combination reduces opioid consumption, delirium risk, and improves mobilization 1
• BIS monitoring should target 40-60 during TIVA to avoid excessive depth (BIS <35) which increases postoperative delirium risk in patients over 60 years 1, 6, 7

Patients with Respiratory Compromise

• During the COVID-19 pandemic, peripheral nerve blocks combined with TIVA were preferred over neuraxial techniques to avoid respiratory complications and reduce aerosol-generating procedures 1
• Blocks that preserve respiratory function (axillary or infraclavicular over supraclavicular; avoiding interscalene blocks) should be selected when combined with TIVA 1

Prolonged Surgical Procedures

• For procedures lasting 4-6 hours (such as endoscopic spine surgery or scoliosis correction), TIVA with propofol TCI (effect-site target 0.5-1 mcg/mL) combined with remifentanil (0.05-0.3 mcg/kg/min), ketamine, and dexmedetomidine provides stable anesthesia 6, 8
• Peripheral nerve blocks can be added for additional postoperative analgesia in appropriate anatomic distributions 5

Technical Advantages of the Combination

Opioid-Sparing Benefits

• Peripheral nerve blocks reduce systemic opioid requirements both intraoperatively and postoperatively, which is particularly important when using TIVA with remifentanil to prevent opioid-induced hyperalgesia 6, 8
• The combination allows for lower doses of intravenous opioids during TIVA maintenance 1, 3

Hemodynamic Stability

• Most peripheral nerve blocks do not cause sympathectomy or hypotension (unlike neuraxial techniques), making them safer when combined with TIVA in hemodynamically unstable patients 1
• This is particularly relevant in elderly patients who are more sensitive to propofol's cardiovascular effects 7

Extended Analgesia Duration

• Continuous peripheral nerve blocks via catheters can be maintained for days, providing analgesia well beyond the duration of TIVA while the patient recovers 3, 5
• Single-shot blocks with long-acting local anesthetics (bupivacaine, ropivacaine) provide 12-24 hours of analgesia after TIVA has been discontinued 3, 5

Contraindications and Cautions

When to Avoid This Combination

• Patients receiving therapeutic anticoagulation require careful evaluation before neuraxial or deep plexus blocks, though most peripheral nerve blocks carry lower bleeding risk 1
• Infection at the proposed block site is an absolute contraindication 1
• Patient refusal or inability to cooperate with block placement may necessitate TIVA alone 1

Common Pitfalls to Avoid

• Do not use nitrous oxide with TIVA, as it increases PONV and negates one of TIVA's primary advantages 1, 6, 7
• Avoid excessive sedation during block placement that could compromise respiratory function, particularly in patients with sleep-disordered breathing 1, 7
• Ensure adequate block testing before surgical incision to prevent emergent conversion to deeper general anesthesia or addition of volatile agents 1
• Calculate safe maximum local anesthetic doses and use ultrasound guidance to reduce risk of local anesthetic systemic toxicity 1

Monitoring Requirements

Essential Monitoring During TIVA with Peripheral Nerve Blocks

• BIS or entropy monitoring targeting 40-60 is recommended to prevent awareness and avoid excessive anesthetic depth 1, 6, 7
• Quantitative neuromuscular monitoring is mandatory when muscle relaxants are used, documenting train-of-four ratio ≥0.90 before extubation 6, 7, 8
• Consider invasive arterial blood pressure monitoring earlier in elderly or hemodynamically unstable patients receiving TIVA 1, 6