Total Intravenous Anesthesia - TIVA

Today, we used TIVA to induce anesthesia on my patient instead of any inhaled anesthetics. TIVA is anesthesia administered entirely by the intravenous route eliminating the use of inhaled anesthetics. TIVA offers several advantages over the traditional volatile anesthetic method (isoflurane and sevoflurane). These advantages include reduced air polution, greater hemodynamic stability, decreased post-op nausea and vomiting and decreased pulmonary vasoconstriction. The reason why we used it on our patient today was that she had problems in the past with severe nausea and vomiting post anesthesia. 

Situations Where TIVA is Useful

• Pts at risk of post op nausea and vomiting
• Neurosurgical procedures
• History of Malignant Hyperthermia
• Bronchoscopy or ENT surgery
• Ambulatory setting
• Lobectomy via thoracotomy or pneumonectomy

Commonly Used Drugs for TIVA

Propofol-This is the only available intravenous hypnotic agent suitable for induction and maintenance of anesthesia. Propofol offers many advantages including rapid recovery of consciousness and psychomotor function and has a lower incidence of post-operative nausea and vomiting.

Remifentanil - This is an ultra short acting opioid. It has been established as the drug of choice for TIVA with propofol (we used this along with propofol today). The resident asked me how remifentanil was metabolized and since it is an opioid, I guessed that it was hepatically metabolized. I was wrong because I didn't think about the fact that it remifentanil is metabolized very rapidly which points more towards an enzyme. So, "some kind of enzyme" was my lame second guess. Remifentanil is metabolized by esterase and thus, it has a very short half life. Because of this, my resident told me that at the end of surgery, BEFORE we turn off the remifentanil drip, we will give a dose of fetanyl which hangs around in the body for a much longer time and will provide analgesia. After we give the fetanyl, we can turn off the remifentanil drip which will ensure that the patient will not be in pain once the remifentanil wears off.

Other medications that can be used include Sufentanil and Alfentanil