Can a patient with significant medical history or advanced age use Target-Controlled Infusion (TCI) for Total Intravenous Anesthesia (TIVA) without a Bispectral Index (BIS) monitor?

TCI for TIVA Without BIS Monitoring: Not Recommended

When using TIVA with neuromuscular blockade, a processed EEG monitor (such as BIS) should be used alongside quantitative neuromuscular blockade monitoring. 1

Guideline-Based Recommendation

The 2021 Association of Anaesthetists guidelines explicitly state that processed EEG monitoring is required when administering TIVA with neuromuscular blockade. 1 This represents the current standard of care and directly addresses patient safety concerns related to:

• Prevention of intraoperative awareness - The most critical safety concern when patients cannot move or communicate due to paralysis 1
• Avoidance of excessive anesthetic depth - Particularly important in elderly patients where deep anesthesia increases risk of postoperative delirium and cognitive dysfunction 1
• Optimization of drug dosing - Reducing unnecessary exposure to anesthetic agents 2

Evidence Supporting BIS Monitoring with TIVA-TCI

Awareness Prevention

• BIS-guided TIVA reduced confirmed awareness from 0.65% to 0.14% (OR = 0.21, p = 0.002) in a multicenter trial of 5,228 patients, with the main cause of awareness being light anesthesia (BIS > 60 for prolonged periods). 3
• The Society for Intravenous Anesthesia specifically recommends processed EEG monitoring (BIS or Entropy) targeting BIS 40-60 to prevent awareness during TIVA administration in difficult clinical situations, including patients with difficult infusion site monitoring or use of neuromuscular blocking agents. 4

Drug Dose Optimization

• BIS monitoring significantly reduced total doses of both propofol and fentanyl during TCI-based TIVA for lumbar surgery without compromising hemodynamic stability. 2
• Maintaining BIS 40-60 provides the therapeutic window that balances awareness prevention with avoidance of excessive depth. 5, 6, 4

Special Population Considerations

• Elderly patients (>60 years): Avoiding BIS values below 35 and burst suppression patterns reduces postoperative delirium risk. 1, 6 Depth monitoring helps prevent anesthetic overdose that is particularly harmful in this population. 1
• Obese patients: Listed as a specific situation requiring processed EEG monitoring due to pharmacokinetic variability. 4
• Patients with low body weight (≤18 kg): Identified as "triple low" patients requiring BIS monitoring. 4

Clinical Situations Where BIS is Especially Critical

The following scenarios mandate processed EEG monitoring during TIVA-TCI: 4

• Any use of neuromuscular blocking agents - Patient cannot signal awareness through movement 1, 4
• Triple low patients - Low blood pressure, low propofol effect-site concentration, low body weight ≤18 kg 4
• Difficult infusion site monitoring - Cannot reliably verify drug delivery 4
• Prolonged procedures - Increased cumulative risk of awareness or excessive depth 5
• Hemodynamically unstable patients - Need to balance adequate depth with cardiovascular stability 1, 6

Practical Implementation

Target BIS Values

• Maintain BIS 40-60 throughout the procedure for optimal balance between awareness prevention and avoiding excessive depth 5, 6, 4
• Avoid BIS < 35 in elderly patients to reduce delirium risk 1, 6
• Avoid burst suppression patterns especially in patients over 60 years 1, 6

TCI Dosing with BIS Guidance

• Propofol effect-site target: 0.5-1 mcg/mL combined with remifentanil 0.05-0.3 mcg/kg/min 5, 6
• Avoid bolus dosing to prevent hemodynamic instability 5, 6
• Titrate based on BIS values rather than fixed dosing schedules 2, 3

Common Pitfalls to Avoid

• Relying solely on clinical signs (heart rate, blood pressure, movement) when neuromuscular blockade is used - these signs are unreliable for detecting awareness in paralyzed patients 1
• Assuming TCI models eliminate the need for depth monitoring - pharmacodynamic variability between patients means the same target concentration produces different depths of anesthesia 2
• Using outdated practices - the 2021 guidelines represent current standard of care and explicitly require processed EEG monitoring for TIVA with paralysis 1
• Ignoring age-related sensitivity - elderly patients require lighter anesthesia targets to prevent delirium 1, 6

Alternative Monitoring Without BIS

If processed EEG monitoring is absolutely unavailable, the following modifications are necessary but represent suboptimal care:

• Avoid neuromuscular blocking agents entirely - use spontaneous ventilation techniques when feasible 1
• Use lower propofol targets (effect-site 0.5 mcg/mL) and titrate cautiously 6
• Maintain continuous clinical vigilance for signs of light anesthesia (tearing, sweating, movement if not paralyzed) 3
• Consider using volatile anesthetics instead where end-tidal monitoring provides objective drug concentration measurement 1

However, these alternatives do not meet current guideline standards when neuromuscular blockade is employed. 1