Principles of total intravenous anaesthesia: practical aspects of using total intravenous anaesthesia

Abstract

### Key points Advanced pharmacokinetic models for target-controlled infusion (TCI) have facilitated an increasing use of total i.v. anaesthesia (TIVA) in various clinical settings. The technical complexity and labour-intensive methodology of TIVA can deter clinicians and lead to default use of a volatile agent. In theory, any combination of i.v. hypnotic(s) and opioid(s) can be used and opioid-free techniques are described. In practice, the synergy between TCI infusions of propofol and remifentanil proves highly effective at obtunding response to noxious stimuli1 and for this article constitutes ‘ideal’ TIVA. This drug combination achieves equilibrium between adequate depth of anaesthesia and rapid recovery. Intermittent boluses of agents or manually controlled infusions may produce an inadequate effect.2 The specific indications for TIVA are given in Table 1. TIVA is applicable to nearly all types of surgery but has particular value in clinical scenarios where a stress-free awake extubation free of laryngospasm is required. TIVA confers many advantages over a conventional volatile technique, particularly a better recovery profile with reduced risk of postoperative nausea and vomiting, and can facilitate intraoperative wake-up while retaining amnesia. The use of TIVA for cases requiring a rapid intubation sequence is controversial but is safely practiced. View this table: Table 1 Specific indications for …