PHARMACOLOGY

Total intravenous Learning objectives

anaesthesia After reading this article, you should be able to:
C describe the indications for using TIVA
Eoghan McGrenaghan C discuss the advantages and disadvantages of TIVA
Ming Wilson C set up a target controlled infusion to deliver induction and
maintenance levels of intravenous anaesthesia

Abstract
Total intravenous anaesthesia (TIVA) is a technique to induce and
maintain general anaesthesia exclusively with intravenous anaesthetic anaesthesia while also providing a quick patient wake up time.
agents, thereby avoiding the use of inhalational agents. It is essential Propofol is the preferred intravenous anaesthetic agent due to its
that all practicing anaesthetists are competent in the delivery of TIVA relatively rapid offset and clear-headed recovery. It is usually
and able to perform it safely. TIVA is necessitated in a wide variety administered simultaneously with an opioid infusion most
of clinical situations when the delivery of inhalational agents is abso- commonly remifentanil due to its synergistic relationship with
lutely or relatively contraindicated; for example, in patients with malig- Propofol and its rapid onset and offset time. Its synergistic rela-
nant hyperthermia or severe postoperative nausea and vomiting. In tionship with Propofol facilitates a decrease in the required
other situations, it may not be possible or practical to deliver inhala- Propofol target concentration to achieve appropriate levels of
tional anaesthesia such as during patient transfer or anaesthesia for anaesthesia while minimizing haemodynamic instability. It also
airway surgery. This article describes the use of target controlled infu- enables swift manipulation of effect site levels to ensure
sion models and principles, which enable anaesthetists to deliver TIVA adequate levels of anaesthesia when the degree of surgical
safely. The Association of Anaesthetists of Great Britain and Ireland stimulus is increased suddenly.
and the Society of Intravenous Anaesthesia have produced Guidelines
for safe practice of TIVA in 2018. Indications for TIVA
Keywords Anaesthesia; intravenous; intravenous agents; target
Table 1 illustrates the various indications for TIVA.
controlled infusions (TCI); total intravenous anaesthesia (TIVA)

Royal College of Anaesthetists CPD Matrix: 1A02; 1A03 Pharmacokinetic principles

Effective TIVA relies on clinically adequate levels of Propofol and
remifentanil concentrations at the brain, the target effect site
(Cet) while maintaining an equilibrium with the levels in the
It was documented in the fifth National Audit Project (NAP5) that plasma, the plasma effect site (Cpt).4
total intravenous anaesthesia (TIVA) has been associated with Following the intravenous administration of a drug it is
accidental awareness in 28 cases, the majority of which were simultaneously subjected to distribution, metabolism and elimi-
deemed to be preventable and due to poor understanding of the nation resulting in exponential decline in three distinct phases.
underlying pharmacokinetic principles. It concluded that all These complex processes can be described as a three-
anaesthetists need to be skilled in the administration of TIVA and compartment model to allow the prediction of drug behaviour
have a sound understanding of its principles to deliver it safely following its administration. These compartments are neither
and it was felt that this is currently not the case.1 A recent survey anatomical nor related to a corresponding organ but rather a
of anaesthetists working in the UK and Ireland found that the theoretical construct.5
current training in TIVA was felt to be inadequate and at present When an intravenous drug is administered it directly enters
many anaesthetists do not feel confident utilizing the technique.2 into the plasma which is the central compartment (V1) where it is
Following the publication of NAP5 the Association of Anaes- then simultaneously redistributed to the other compartments
thetists of Great Britain and Ireland (AAGBI) and the Society of while simultaneously undergoing elimination by metabolism and
Intravenous Anaesthesia (SIVA) have produced Guidelines for excretion. By knowing the rate at which the drug moves between
safe practice of TIVA in 2018.3 these compartments and the theoretical volumes of these com-
partments, mathematical models can be used to predict the
Background concentration of the drug in V1 after a specified dose is admin-
The ideal anaesthetic agents for TIVA should have fast onset/ istered intravenously. In order to achieve this population studies
offset times to enable prompt manipulation of depth of have been performed to adjust for individual variables such as
age, gender and weight allowing for predictive values by utilizing
these mathematical models.
Eoghan McGrenaghan MB BCh FRCA Specialist Anaesthesia
Trainee, Salford Royal Hospital, Manchester, UK. Conflicts of Three compartment model
interests: none declared. These compartments are described as a central compartment
Ming Wilson MB ChB FRCA Consultant Anaesthetist, Salford Royal (V1) which represents plasma volume or initial volume of dis-
Hospital, Manchester, UK. Conflicts of interests: none declared. tribution and two other equilibrating compartments.

ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 1 Ó 2018 Published by Elsevier Ltd.

Please cite this article as: McGrenaghan E, Wilson M, Total intravenous anaesthesia, Anaesthesia and intensive care medicine, https://doi.org/
10.1016/j.mpaic.2018.12.010
 PHARMACOLOGY

V1 subsequent small doses will be continually required to pro-

Indications for TIVA vide an acceptable level of concentration and therefore maintain
Patient indications Procedural/surgical Other indications an adequate level of anaesthesia. This will inevitably produce
indications peaks and troughs potentially resulting in sub-therapeutic or
toxic levels of the drug.
Malignant Airway surgery Remote site anaesthesia The delivery of a drug at a constant rate can produce a steady
hyperthermia Neurosurgery where volatile agents state within V1 but this may take a considerable period of time
Severe PONV Surgery requiring may not be available which may be impractical. For example, Propofol would require
Neuromuscular neurophysiological Reduce atmospheric up to 24 hours before establishing a central steady state.5 The
disorders and monitoring pollution CSHT of a drug increases as the duration of infusion increases
intolerance of Patient transfer Day case surgery until eventually reaching a plateau. This is because the periph-
muscle relaxants eral compartment will not equilibrate with the central compart-
ment following a brief infusion and the drug will be redistributed
Table 1 and eliminated. Following a prolonged infusion, a decline in the
central compartment will be limited by the redistribution of the
drug from the periphery.
Compartment 2 (V2) and compartment 3 (V3) are mathematical
constructs to represent the speed at which the drug will redis- The effect site
tribute to well-perfused (V2) and less well-perfused tissues (V3). The effect site is the location where a drug has its intended ef-
V2 represents well-perfused tissue i.e. (muscle) and V3 represents fect and in the case of anaesthetic agents this will be the brain
poorly perfused tissue (i.e. fatty tissue) (Figure 1).5 rather than the plasma. By including this in the three-
Rate constants are used to describe the proportion of drug compartment model a pharmacokinetic-pharmacodynamic
moving between the above compartments, for example K12 rep- model is created. By specifying a rate constant for movement
resents movement from V1 to V2 and K21 represents the move- of a drug into and out of a compartment (ke0) it is possible to
ment of drug from V2 to V1. K10 is a metabolic rate constant predict the expected time for a clinical effect to be achieved. The
representing the proportion of drug being metabolized or elimi- theoretical volume of this compartment is negligible, meaning
nated in V1 at any given time. Ke0 represents the proportion of that it does not have any impact on the behaviour of the
drug diffusing from the central compartment to the effect site i.e. pharmacokinetic model.5
the brain.
TIVA via manual regimes
Steady-state and context sensitive half-time (CSHT)
An initial fast bolus dose (600e1200 ml/hr) will result in a peak Manual infusion regimes are now rarely used as they have been
V1, concentration which will rapidly decline due to redistribution found to be laborious and prone to error. However, as their design
and elimination. In order to maintain a constant concentration in provides useful insight into the requirements of a variable rate

The three-compartment model

Drug administered

K 01

K 13 K 12

V3 Central
compartment (V 1 ) V2

K 31 K 21

K 10

Drug eliminated

Figure 1

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Please cite this article as: McGrenaghan E, Wilson M, Total intravenous anaesthesia, Anaesthesia and intensive care medicine, https://doi.org/
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 PHARMACOLOGY

infusion to maintain a constant central compartment concentra- TCI pumps display the brain or target effect site (Cet), and the
tion we will discuss it for completeness. The bolus, elimination plasma effect site (Cpt). A typical system calculates the bolus
transfer (BET) scheme dictates the three components of TIVA. dose and speed of subsequent infusion required to maintain the
target plasma drug concentration (Cpt). Calculations are repeated
Bolus (B) every 10 seconds and the infusion rate is continued until the Cpt
An initial bolus dose is delivered to fill V1 and provide rapid is achieved. The diffusion of the drug from plasma to the brain
induction of anaesthesia. If a Propofol bolus was not delivered it occurs exponentially initially until equilibrium is achieved 4e5
would take a constant Propofol infusion at 10 mg/kg/hr 45e90 half times. If Cpt is increased a bolus is delivered to V1 and the
minutes to achieve clinically useful plasma levels in an 85 kg infusion rate increases to match the additional transfer and
adult male.4 elimination at the higher concentration. When Cpt is decreased,
the infusion stops until the plasma concentration declines to the
Elimination (E) new target and is restarted at a lower rate, diffusion of the drug
To maintain a constant V1 concentration a final constant infusion from the brain occurs with the same half-time.
rate must match elimination of the drug when redistribution is
complete, and the drug has equilibrated between the peripheral Pharmacokinetic models
and central compartments.
Different pharmacokinetic models have been incorporated into
Transfer (T) the pumps and there is debate about which models most closely
An interim infusion rate is required to maintain the V1 concen- represent the match between calculated and actual Propofol
tration by matching the rate of transfer of the drug from central to concentrations. However, currently there is no evidence sup-
the peripheral compartments. Manual regimes risk excessive porting one over another and all have proved reliable in clinical
doses for some patients and inadequate doses in others. The practice. All models have similar limitations in terms of accuracy
pharmacokinetic and pharmacodynamics variability between and stability of plasma and effect site concentrations due to
patients dictate the clinical effect of the drug and a more accurate inherent assumption made when predicting target site levels and
technique is required to reliably deliver appropriate concentra- inter-individual variability.7 Close clinical monitoring of the pa-
tion in response to varying degrees of surgical stimulation. tient remains an important part of the anaesthetist’s role. Table 2
illustrates the main differences between the Marsh and Schnider
Target-controlled infusions (TCIs) Models.
The Marsh model assumes that V1 is directly proportional to
TIVA can be delivered by several methods (intermittent bolus,
weight only, therefore ignoring age. The age is entered but not
fixed rate infusion, infusion based on a manual algorithm, TCI
used directly in the calculation. However, the pump will not
and a mixture of these). By encompassing several techniques
function if an age less than 16 years is entered. The Marsh model
which may not produce an equivalent efficacy or safety profile it
utilizes total body weight.5
is not possible at present to recommend a standard technique.
The Schnider model is incorporated into the newer-generation
There are ongoing debates as to whether TIVA is associated with
TCI pumps. It is a three-compartment Propofol model where age
a higher incidence of awareness when compared to intravenous
and height are entered into the system. As it takes age into ac-
induction and volatile maintenance.
count it is considered more appropriate in the elderly population
The amount of Propofol in the blood and brain required to
allowing for reduced clearance. The Schnider model adjusts
ensure an appropriate level of anaesthesia is dependent on a
some of the pharmacokinetic parameters for age but this does not
multitude of factors and varies between individual patients;
necessarily prevent haemodynamic instability. A gender-specific
making it impossible to predict what is required in advance. The
lean body mass is calculated and used to adjust the elimination
variation is commonly witnessed in older patients requiring a
lower Propofol concentration than younger patients. The Pro-
pofol plasma concentration routinely required for maintenance of
anaesthesia will usually be between 1.5 and 6.0 mg/ml.6
Differences between the Marsh and Schnider models
In order to ensure that an adequate depth of anaesthesia is
achieved by TIVA, a dedicated pharmacokinetic pump should be Marsh model Schnider model
used. These pumps utilize complex algorithms which calculate
the distribution of agents between compartments and allow for Central compartment (V1) In 70 kg In a 70 kg
rapid adjustments of targets to achieve the desired clinical effect. person - larger person e smaller
The first commercially available TCI system was the ‘Diprifusor’ V1 (15.9 L) V1 (4.27 L)
in 1998 for the induction and maintenance of anaesthesia in Onset of clinical effects on Slower Faster
adults. The use of TCI pumps to deliver TIVA is now induction of anaesthesia
commonly used for anaesthesia in the operating theatre. Initial bolus dose (mg) Larger Smaller
Time to deliver dose Longer Shorter
Key components (seconds)
 User interface. Time to reach target Longer Shorter
 Microprocessors with pharmacokinetic software. concentration (minutes)
 Infusion pump which delivers up to 1200 ml/hour.
Table 2
 Visual and audible safety systems.

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Please cite this article as: McGrenaghan E, Wilson M, Total intravenous anaesthesia, Anaesthesia and intensive care medicine, https://doi.org/
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 PHARMACOLOGY

rate constant K10. Due to the small fixed volume of V1 in the when the remifentanil infusion is terminated as no postoperative
Schnider model it is recommended to use effect-site targeting to analgesia will be provided once the infusion is terminated and
ensure an adequate initial bolus.4 there is a risk of acute opioid tolerance.7
The major difference between the Marsh and Schnider model
is the volume of V1. The central compartment in Schnider is fixed Typical target concentrations in routine practice
in the sense that it is the same for each patient at 4.27 L in a 70 kg
If a rapid onset of anaesthesia is required, an initial Cpt (Marsh)
person which is smaller than that used in Marsh (15.9 L),
or Cet (Schnider) Propofol concentration 4e6 mg/ml will be
therefore varying the estimated concentration following a bolus.
appropriate in healthy young or middle-aged patients. Mainte-
This results in almost a fourfold difference in the peak plasma
nance of 3e6 mg/ml/min without opioids and 2.5e4.0 mg/ml/
concentration when a bolus is administered. When using Marsh
min with opioids are typical. If the patient is very anxious or
in the less robust patient it is advised to start at a low Cpt and
robust this may be higher, alternatively if they are elderly, frail or
gradually increase until the desired clinical effect is achieved.4
critically ill it will be lower.
In elderly frail patients an alternative technique of starting a
Remifentanil
slower induction at an initial Propofol concentration of 1 mg/ml
Opioids are a key component of a balanced TIVA technique as with gradual 0.5e1.0 mg/ml increases until there is loss of con-
they enable the response to noxious stimuli to be controlled. Due sciousness. This will help avoid hypotension on induction while
to its negligible CSHT, Remifentanil is an ideal co-agent to be allowing the anaesthetist to assess the target concentration
administered with Propofol. It has a synergistic interaction with required to prevent a response to noxious stimulus. The clinical
Propofol and rapid elimination. This enables a decreased Pro- calibration of the individual patient’s response to Propofol
pofol concentration intraoperatively and the rapid offset of should routinely take place at induction with the documentation
remifentanil avoids respiratory depression postoperatively. of the Cet when the patient experiences loss of response to
However, it is important to note that remifentanil will not pro- speech, and loss of movement in response to a noxious stimulus
vide postoperative analgesia. e.g. firm pressure on the angle of the mandible.
The Minto model is popular as it is applicable to a wide range The latter concentration can be used to guide the approximate
of patient characteristics. Age is used for calculation of its concentration likely to be required during the maintenance of
pharmacokinetic parameters but as in the Schnider model, its anaesthesia.3 Patients with a Propofol concentration greater than
adjustment does not alter pharmacodynamics response. A sex 1.5 mg/ml are unlikely to spontaneously ventilate and will
specific lean body mass is calculated and used to adjust the pa- require ventilation.
tient’s parameters.
Special considerations
Practical aspects
TIVA in paediatrics
Multiple approaches can be utilized for the simultaneous in- TIVA in paediatrics is a lot less routine than adults but has many
duction of Propofol and remifentanil TCI. If the targeted effect specific advantages to paediatric anaesthesia. These include
site is chosen in both then they can be commenced together. decreased emergence delirium, reduced airway reactivity and
However, there is an increased risk of apnoea if remifentanil is less postoperative nausea and vomiting. However, the pharma-
started prior to propofol or if plasma target is selected in both. If cokinetic and pharmacodynamics variability, the effect of pro-
effect site Propofol and plasma remifentanil are selected, the pofol metabolism in early life, specific issues in the critically ill
synergistic effect will be lost as Propofol will achieve target and the non-linear changes in volume of distribution and clear-
concentration much more rapidly, increasing the risk of hae- ance mean TIVA should be used with extreme caution in the
modynamic instability.5 neonatal and ex-premature infants.8
Due to the synergy between remifentanil and Propofol the Compartment volumes in children are about twice the size of
ability to choose high remifentanil/low Propofol effect site con- that of adults when compared to their respective body weight.
centration, or the converse, is enabled. This allows for a quicker This results in children being delivered a larger initial bolus dose
wake up for the patient if utilizing a high remifentanil combina- and infusion rate relative to body weights. This difference nor-
tion; however, it increases the risk of apnoea and bradycardia.5 malizes at the age of 16 years. There is also a greater rate of
If the pump battery fails intraoperatively when not connected clearance, peaking at 1 year of age resulting in a higher main-
to the main power supply most pumps will not recall the pro- tenance rate. Prolonged infusion will also accumulate peripher-
gramme, or the amount of drug previously delivered. The three ally to a greater extent when compared to adults producing a
options are to switch to a volatile-based technique, restart the slower patient wake up post termination of infusion. For average
pump in a manual mode or restart the pump in TCI mode. All of length procedures up to 50% more propofol will be used in
these options risk haemodynamic instability.5 paediatric models when compared to an adult utilizing the Marsh
Termination of infusions can be performed simultaneously at model.3
the end of the operation or the remifentanil can be continued at a The 2018 guidelines for the safe practice of TIVA have com-
lower dose, e.g. 1e2 ng/ml to facilitate a smoother wake up and mented that using TIVA in paediatrics requires specific training
avoid coughing.7 to allow for the pharmacokinetic and pharmacodynamics varia-
Delivery of longer-acting opioids should be administered 40 tion as well as practical differences across the various age ranges.
minutes prior to wake up to avoid increased postoperative pain Processed EEG (pEEG) feedback may be particularly useful for

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Please cite this article as: McGrenaghan E, Wilson M, Total intravenous anaesthesia, Anaesthesia and intensive care medicine, https://doi.org/
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 PHARMACOLOGY

titration of anaesthesia.3 The two most widely used and validated concentration continuously is a major factor. Monitoring the end
paediatric TCI programmes used in practice are Kataria and tidal anaesthetic gas concentration provides an ability to quickly
Paedfusor models. recognize inadequate anaesthesia. However, with TIVA the po-
The Kataria model is suitable for children between the ages tential for an interruption via disconnection of the infusion
of 3e16 years with a weight range between 15 and 61 kg in tubing or cannula creates a potential for it to go unrecognized
comparison to the Paedfusor, which is a variant of the Marsh and may result in the patient experiencing unintended
model that is appropriate in children aged between 1 and 16 awareness.1
years who weigh between 5 and 61kg. Paedfusor features non- The Safe Anaesthesia Liaison Group9 (SALG) produced rec-
linear scaling of V1 volume above the age of 12 years.8 Teenage ommendations in 2009 to minimize the risk of complications
children who weigh more than 61 kg can be managed using the with TIVA. These included the use of non-return valves on
Marsh adult model.3 intravenous infusion lines, clear labelling of connectors and
Pain is a common issue on induction of TIVA in paediatrics valves, cannula site visible at all times and that all relevant
and can be very distressing. This can be diminished by prior clinical staff are competent in the use and aware of the limita-
administration of intravenous lidocaine, opioids or nitrous tions of the equipment.4
oxide.8 However, regardless of these guidelines the fifth National
Simultaneous delivery of remifentanil TCI can be adminis- Audit Project (NAP5) found that of the 28 cases reviewed, 21
tered to children over the age of 12 and weighing more than 30 involved TIVA being utilized for the induction and maintenance
kg using the Minto model, but under this age and weight it is of anaesthesia in a theatre setting with 7 cases being reported
necessary to use a manual infusion e.g. 0.25e0.5 mg/kg/min as a when anaesthesia was being initiated or continued outside of the
TCI model is not yet available2 operating theatre. The most common cause of unintended
Propofol infusion syndrome is a very rare, but potentially fatal awareness was a result of a paralysed patient being administered
condition which has been associated with Propofol infusions in an inappropriately low dose fixed rate propofol infusion. More
the paediatric population. It results from interference with than three-quarters of these cases were considered to be
mitochondrial energy production resulting in rhabdomyolysis, preventable.1
acidaemia and multi-organ failure. The risk factors for this are
prolonged Propofol infusions, high delivery rates at 6 ml/kg/hr, TIVA outside of theatre
critical illness, low sugar intake and co-administration of cate-
The NAP5 report also highlighted the time delay when convert-
cholamines and steroids.2 It is rarer still in the context of TIVA
ing from inhalational anaesthesia to TIVA when transferring
for surgery.
patients to critical care and the failure of administering a bolus
dose of propofol to ensure adequate effect site concentration.1
TIVA in critical care Conversely however, TIVA minimized risk of unintended
Fixed rate propofol infusion are commonly used for sedation on awareness when transferring the patient from the anaesthetic
intensive care units but if procedures are required to be per- room to the operating theatre as there was no need to disconnect
formed or muscle relaxants are to be administered then care must from the breathing circuit and interrupt inhaled anaesthetic de-
be taken to avoid awareness. Due to organ dysfunction in the livery. There were relatively few reports of unintended aware-
critically ill patient the pharmacokinetics of TIVA will be altered, ness with TCI in contrast with non-TCI infusions, indicating the
decreasing the accuracy of the TCI model to predict plasma issue does not lie with the pharmacokinetic models delivered by
Propofol concentrations increasing the risk of haemodynamic these pumps.1
instability. The guidelines for the safe practice of TIVA recom- Out of theatre use of TIVA was identified as a higher risk
mend titration to clinical effect and the utilization of processed setting for unintended awareness. Most notable low dose fixed
EEG monitoring in these circumstances.3 rate infusions without a prior bolus dose of Propofol and an
absence of pEEG monitoring. In these settings when inhaled
TIVA and obesity anaesthesia is not available it is crucial for all anaesthetists to be
When using TIVA in obese patients there is a lack of evidence competent in the delivery of TIVA. The Guidelines for the safe
with regards to if it is better to use total body weight or adjusted practice of TIVA recommend the use of TCI and pEEG monitoring
body weight. The Marsh and Schnider models may be inaccurate when delivering a TIVA outside of theatre.3
in the obese patient. Marsh TCI pumps will only allow a It is crucial to ensure that the brain concentration of the
maximum of 150 kg and Schnider will only accept variables Propofol is adequate before the volatile anaesthetic agent falls
resulting in a BMI of less than 35 kg/m2 for females and 42 kg/m2 particularly when administering a neuromuscular blocking drug
in males. The Society for Obesity and Bariatric Anaesthesia prior to transfer as reported in NAP51.
(SOBA) has published guidelines on using TIVA in obese pa-
tients. The current advice is to be cautious, titrate to clinical ef- Monitoring the patient during TIVA
fect and continually clinically assess whilst utilizing processed
This inherent risk of accidental awareness under general anaes-
EEG to avoid awareness or haemodynamic instability.3
thesia (AAGA) when delivering TIVA has resulted in the National
Institute of Health and Care Excellence (NICE, 2012) recom-
TIVA and accidental awareness
mending the use of depth of anaesthesia monitoring; especially
When contrasting the safety profile of TIVA with an inhaled when neuromuscular blocking agents are used. The interpreta-
anaesthetic the ability to monitor end tidal anaesthetic gas tion of pEEG does have pitfalls that anaesthetists need to

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Please cite this article as: McGrenaghan E, Wilson M, Total intravenous anaesthesia, Anaesthesia and intensive care medicine, https://doi.org/
10.1016/j.mpaic.2018.12.010
 PHARMACOLOGY

appreciate as they can result in error of analysis. These can result 10. When TIVA is administered outside the operating room, the
from artefacts, poorly placed electrodes and electrical interfer- same standards of practice and monitoring should apply as
ence it is therefore very important anaesthetists receive appro- for anaesthesia in the operating room.
priate training in interpreting pEEG to ensure TIVA is performed
safely.10 Processed EEG monitors do not just provide a derived Conclusion
index value to the anaesthetist but a variety of information to
TIVA is an essential technique that all practicing anaesthetists are
assess for example the EEG waveform, signal quality, EMG ac-
required to perform confidently and competently for a variety of
tivity and degree of burst suppression which should all be
clinical situations. Following the publication of NAP5 it is clear
interpreted by the anaesthetist in combination with other patient
that a lack of training and education in the use of TIVA can result
monitoring and clinical experience.3
in unintended awareness. It is therefore crucial that all anaes-
thetists using this technique are familiar with the indications,
Recommendations from the guidelines for the safe
limitations and have an understanding of the underlying phar-
practice of TIVA 20181
macokinetic principles to ensure safe delivery in the appropriate
1. All anaesthetists should be trained and competent in the clinical settings. A
delivery of TIVA. Schools of Anaesthesia and training bodies
should provide teaching, training and practical experience of
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9. Use of a processed EEG (pEEG) monitor is recommended
when a neuromuscular blocking drug is used with TIVA.

ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 6 Ó 2018 Published by Elsevier Ltd.

Please cite this article as: McGrenaghan E, Wilson M, Total intravenous anaesthesia, Anaesthesia and intensive care medicine, https://doi.org/
10.1016/j.mpaic.2018.12.010