TIVA practical approach and updates

1. Dr. Tushar Chokshi
Dr. Tushar M. Chokshi
Area of
Expertise
Other
Highlights
Affiliations
Current
Position
Consultant Private Practicing
Anesthesiologist in Vadodara
(Gujarat, INDIA)
 Sterling Hospital
 Urocare Hospital
 Dhwani ENT Hospital
 Baroda Hospital
30 Years of Experience
TIVA, OFA and NORA
 Uro Anaesthesia
 Lapro Anaesthesia
ENT Anesthesia
Paediatric Anesthesia
 Founder of TIVA and OFA
Face book Groups in INDIA
 National and State Level Speaker
Started Smartphone and Tele-
Anesthesia practice in INDIA
Started Infographics in Anaesthesia

9825062245
chokshitushar@hotmail.com
MD (Anaesthesiology)
https://sites.google.com/site/tusharchokshisite
National
Origami
Teacher
Visual
Storyteller
&
Vlogger
Happy Go To Lucky Fellow
Always believe in exchange of Knowledge
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2. Dr. Tushar Chokshi
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3. Dr. Tushar Chokshi
1) How many of you are giving TIVA ?
2) What is your definition of TIVA ?
3) What is your experience of TIVA ?
4) Will you give TIVA in your practice ?
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4. Dr. Tushar Chokshi
Lecture Outline
• History
– Definition
• Types of TIVA
– Indications
• Advantages and Disadvantages
– TIVA Drugs & Drug Combinations
• Methods of giving TIVA
– Syringe Infusion Pumps, Target Controlled Infusion(TCI)
Tushar Chokshi Infusion(TCI), and Closed Loop Systems
• TIVA in Different Groups of Patient
– Surgical Procedures
• TIVA Checklist & Monitoring
– TIVA Updates & TIVA Apps
• Future of TIVA
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* Take Home message
* What is your opinion

5. Dr. Tushar Chokshi
1656
IV injection of opium
with alcohol into a dog
in Oxford in
leading to anaesthesia
I665
Sigismund Elsholtz
first attempted
intravenous anaesthesia
by injecting a solution
of opiate in human
to obtain insensibility
I872
Ore, Myer, and Witzel
experimented with IV
chloral hydrate on animals
I905
Real Intravenous
anaesthesia started about
when Fedorow at
St. Petersburg,
reported his results on
530 cases in which he
used 0.75 per cent
Hedonal in a normal
saline solution
I92I
Advance in intravenous
anaesthesia began with
Daniel and Gabriel Bardet
1936
Pentothal changed the
IV anesthesia practice
of TIVA
Ketamine 1962
Propofol 1977
Remifentanil 1996
Dexmedetomidine 1999
Remimazolam 2020
TIVA > 350 yrs before
Inhalation > 175 yrs before
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6. Dr. Tushar Chokshi
2010
2020
IV
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In last 100 years

7. Dr. Tushar Chokshi
It is a technique of
general anesthesia
Totally through
Intravenous Lines
Anesthesia via
Intravenous agents only
No Gas (Even Nitrous Oxide)
or Volatile agents are used
except Oxygen
Given by IV boluses,
in drips, by syringes
or by infusion pumps
Total intravenous anaesthesia (TIVA)
It is a technique of general anaesthesia which uses a combination of
agents given exclusively by the intravenous route without the use of
inhalation agents (Gas Anaesthesia) including Nitrous Oxide, but oxygen,
compressed air or helium are exception
TIVA
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( TIVA is used in Induction as well as in Maintenance of Anaesthesia)

8. Dr. Tushar Chokshi
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TIVA is Becoming Popular
because

9. Dr. Tushar Chokshi
Gives
Always
Side effects
GAS?
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Aerosol Droplets

10. Dr. Tushar Chokshi
Types of TIVA
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11. Dr. Tushar Chokshi
With Endo Tracheal Tubes Without Endo Tracheal Tubes
With Supra Glottic Airways Without Supra Glottic Airways
With Nasal Airways With Oral Airways
Without ETT/SGD/Nasal/Oral Airways 11

12. Dr. Tushar Chokshi
TIVA
INDICATIONS
Almost in all
surgical procedures
Anaesthesia in non operative
locations where inhalational
anaesthetics are difficult
Airway procedures Remote locations
MH susceptible
Neurosurgery &
Neuro monitoring
PONV risk
Short procedures
CT, MRI,Cardiac
catheterisation
Daycare Surgery Trainee teaching Patient Choice 12

13. Dr. Tushar Chokshi
Except for a slight
prick in the arm, the
patient is unaware of
having an anaesthetic
No mask over the face
No sudden concentration
of gas or vapour
No risk of MH Less PONV
Patients wake up as it
from natural sleep
Very low incidence of
post operative delirium
Avoid distension air
filled spaces in the
patient’s body- so
better operating
conditions for surgeons
Reduced stress response
Better preservation
of cerebral auto regulation
Less chances of
emergence phenomena
Less operating room
pollution
There should be no smell
of volatile agents at all in
the room, and the patient
is usually most grateful for
not having had his system
saturated with such a drug 13
TIVA

14. Dr. Tushar Chokshi
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TIVA is favourable to almost all Body Systems

15. Dr. Tushar Chokshi
Injection is irreversible Shallow respirations
Possibility of not
finding the vein
Not having another
apparatus
to carry on the TIVA
Incidence of awareness
if not given properly
Risk of bacterial
contamination
Environmental effect
of plastic waste
Disposables may be costly
Caution in prolonged
procedures
or obese patients
Pain on injection
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16. Dr. Tushar Chokshi
TIVA completes Anesthesia Circle
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17. Dr. Tushar Chokshi
TIVA Drugs
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18. Dr. Tushar Chokshi
TIVA drugs
with their advantages
• Majority of drugs used for TIVA including benzodiazepines,
narcotics, propofol, ketamine, etomidate,
dexmedetomidine, muscle relaxants, and other drugs are
easily available in almost all the Operation theatres and
outside OT
• All these drugs can be given to any subset of population
from paediatric to geriatric patients in easily titratable
doses. 18

19. Dr. Tushar Chokshi
1957-1961 Dexamethasone
1886-1990 Magnesium Sulphate
1956 Paracetamol
1973-1988 Diclofenac Sodium
1961-1966 Clonidine
1980-1987 Esmolol
1920-1928 Ephedrine
1971-1985 Mephentermine
1860 Cocaine
1905 Procaine
193--1941 Tetracaine
1943-1949 Lidocaine
1950 Chloroprocaine
1960 Mepivacine
1957 Bupivacine
1980 Ropivacaine
1980 Levobupivacaine
1900 Tubocurarine Chloride
1906-1949 Suxamethonium
1947 Gallamine Triethiodide
1964 Pancuronium
1974-1983 Atracurium
1984 Vecuronium
1984 Mivacurium
1989-1995 Cisatracurium
1994 Rocuronium
1830 Chlorofom
1846 Ether
1920 Trichloroethylene
1956 Halothane
1963-1966 Enflurane
1979 Isoflurane
1970-1987 Desflurane
1971-1990 Savoflurane
1804 Morphine
1937-1943 Pethidine
1960-1968 Fentanil
1974 Sufentanil
1996 Remifentanil
1974 Carfentanyl
1961-1971 Naloxone
1930-1934 Sodium Thiopental
1962-1964-1970 Ketamine
1964-1972 Etomidate
1977-1989 Propofol
1999 Dexmedetomidine
1901 Atropine
1975 Glycopyrrolate
1964-1979
1981
Metoclopramide
Ranitidine
1980-1991 Ondansetron
1959-1963 Diazepam
1963-1977 Lorazepam
1987 Flumezenil
1975-1990 Midazolam
1772 Nitrous Oxide X
1774 Oxygen
1881 Cyclopropaine X
1898 Xenon X
1996 Atipamazole
1961-1971
1982
Naloxone
Doxapram
1987 Flumezenil
1931 Neostigmine
2007-2015 Sugammdex
1967 Dentrolene
2014-2020 Remimazolam
Anesthesia Adjuvant
IV Anesthetic
Local Anesthetic
Gas
Opioid
Premedication
Inhaltion Anesthetic
Benzodiazepine
Muscle Relaxant
Anti MH Agent
Benzodiazepine Reversal Agent
IV Reversal Agent
Opioid Reversal Agent
Relaxant Reversal Agent
Opioid with Benzodiazepine
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Total 66 Drugs
In Use 45 Drugs
Not
Used
In
TIVA
Not
Used
In
TIVA
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In TIVA 25 drugs

20. Dr. Tushar Chokshi
Rapid onset of action
Rapid and predictable
recovery
Potent and lipid-soluble
Water-soluble to minimize
toxicity associated with
the solvent
Stable in solution
Chemically compatible
with other drugs
No perivascular
sloughing if
extravasated
Not absorbed by
plastics
Does not promote
bacterial growth
Devoid of adverse
side effects
Low cost
Most important it can
be mixed with other
anesthetic agents without
any complication
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21. Dr. Tushar Chokshi
All
Benzodiazepines
Dexmedetomidine
Dexamethasone Magnesium Sulphate
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TIVA
DRUGS
TOOLBOX
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Opioids 21

22. Dr. Tushar Chokshi
IV Anesthetic Drugs
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23. Dr. Tushar Chokshi
Propofol In TIVA
• Prime drug in all TIVA
combination
• Initially TIVA dose is 2-2.5
mg/kg IV ( if use alone)
• In TIVA mixture 1 mg/kg IV
• In infusion 6 mg/kg/hr
for maintenance
• Co-administration of
Propofol and Remifentanil
by target-controlled
infusion (TCI) is highly
effective and constitutes
ideal total i.v. anaesthesia
Maintenance
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24. Dr. Tushar Chokshi
PROPOFOL
Invented in 1977 In Use 1989
Switch On & Switch Off Anaesthesia
Only Hypnosis, Anaesthesia & No Analgesia
Propofol 1 % (10mg/ml) Propofol 2 % (20mg/ml)
Milk of Amnesia Also used in Veterinary Medicine for anaesthesia
Addiction and
Propofol Infusion
Syndrome with
long-term use
Milky White Solution
WHO Essential Medicine
Only given by
IV Route Slowly
No other routes
are indicated
Pharmacodynamics
Three compartment linear model
with compartments representing
Plasma, Rapidly equilibrating tissues,
and Slowly equilibrating tissues
Indications
 Initiation and maintenance of
Monitored Anesthesia Care
(MAC) sedation
 Combined sedation and
regional anesthesia
 Induction of General
Anesthesia
 Maintenance of General
Anesthesia
 Intensive Care Unit (ICU)
sedation of intubated,
mechanically ventilated patients
 Lie Detector test
Compatibility with other Drugs
 Ketamine
 Midazolam
 Dexmedetomidine
 Fentanyl / Remifentanil
 Lidocaine / Dexamethasone
Compatibility with other fluids
 5 % Glucose
 5 % Dextrose Saline
 0.9 % NaCl
 Ringer Lactate
 Paracetamol Infusion
 Minimum Dilution 2 mg/ml
Different Doses ( IV)
Induction
Children – 3-3.5 mg/kg
 Adult – 2-2.5 mg/kg
 Geriatric – 1-1.5 mg/kg
 ASA III & IV - 1 mg/kg
Maintenance
 Children - 0.125-0.3 mg/kg/min
 Adult - 0.1-0.2 mg/kg/minute
 Geriatric - 0.05-0.1 mg/kg/min
 ASA III & IV - 0.05 mg/kg/min
Maximum Maintenance
 6-10 mg/kg/hr(Roberts regime)
ICU Patient (Maximum 10 days)
 0.01-0.05 mg/kg/minute
TCI Model : Marsh, Diprifusor
Schinder, Kataria and Paedfusor
Common Side Effects
Hypotension
 Apnea lasting 30-60 seconds
 Abnormal Movement
 Injection site burning/pain
 Respiratory acidosis
 Hypertriglyceridemia
 Rash and Itching
 Arrhythmia and Bradycardia
 Cardiac Output decreased
 Bronchospasm / Edema
 Phlebitis /Allergic Reaction
 Pancreatitis
Asystole/Cardiac Arrest
 Seizures
Contraindications
 Documented Hypersensitivity
 Egg allergy
 Soybean/Soy allergy
Cautions
 Bronchial Asthma
 Pt. with long term NSAIDs
 Severe Hypovolemia or Shock
 EF < 30 % with Cardiac Disease
 Severe hepatic dysfunction
 Severe renal Impairment
 Long term infusion
 GI bleeds, ulcers, perforation
 Pregnancy and Lactation
Mechanism of Action
 Works by increasing GABA
mediated inhibitory tone in the CNS
 Decreases the rate of dissociation
of the GABA from the receptor,
thereby increasing the duration of
the GABA-activated opening of the
chloride channel with resulting
hyper polarization of cell membrane
The endocannabinoid system
may contribute significantly to
propofol‘s anesthetic action and
to its unique properties
 Causes a prominent reduction in
the brain's information
integration capacity
Pharmacokinetics
 Formula : C12H18O
 Molar mass : 178.275 g·mol−1
 Protein binding : 95–99%
 Metabolism :
Liver glucuronidation
 Onset of action : 15–30 seconds
 Elimination half-life: 1.5–31 hr
 Duration of action : 5–10 min
 Excretion: Renal
 Renal clearance : 120 ml/min
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Pre filled Syringes 10 ml/20 ml
10 ml/20 ml 1 % as Bulb/Ampoule
50/100 ml 1 % or 2% Bulb MCT/LCT
Propofol contains Soya oil, MCT,
glycerol, egg lecithin, sodium hydroxide,
oleic acid and water for injections
Changed
Anesthesia
Practice
Over
Dose
Death
Main Drug in TIVA
Most
widely
used
drug
In
world
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25. Dr. Tushar Chokshi
Ketamine
NMDA antagonist
- Key role and main drug in TIVA
- Best analgesic, amnesic and opioid sparing effect
- Dose less than 0.5 mg/kg reduces postoperative analgesic needs and especially seen in
opioid-tolerant patients
- It has anti-hyperalgesic and anti-tolerance effects.
Most popular drug for anesthesiologist across globe since 50 years
Brahmashtra
for anesthesiologist in TIVA
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26. Dr. Tushar Chokshi
Ketamine in TIVA
• Only intravenous anaesthetic with hypnotic, analgesic and
amnesic properties
• Produces rapid hypnosis with profound analgesia and
amnesia after intravenous administration of 0.5-2.0
mg/kg
• It can be mixed with all types of anaesthetic and narcotic
agents in single syringe
• Ketamine with Medazolam (Ketomed), Ketamine with
Propofol (Ketofol) and ketamine with Dex
(Ketodex/ketdex) are established TIVA mixtures
• One of established drug for TIVA mixture
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27. Dr. Tushar Chokshi
Main Features
 Rapid-acting general anesthetic
 Produce profound analgesia
 Normal pharyngeal-laryngeal reflexes
 Slightly enhanced skeletal muscle tone
 Cardiovascular and respiratory stimulation
 Transient and minimal respiratory depression.
Contraindications
> Angina, Stroke and very high blood pressure
Psychiatric disorders, Uncontrolled Epilepsy
In raised intraocular pressure & Eye injury
Acute Porphyria
 Age less than 3 months
 Traceal and Laryngeal Surgery
- Bioavailability – 93 -100 %
- Protein binding - 53.5%
-Distribution half-life 1.95 min
- Half Life - 186 minutes
- Elimination - urine 91 % , 3 %
in feces and 6 % unchanged
- Clearance rate - 95 L/h/70kg
Mechanism of action
 Interacts with N-methyl-D-aspartate (NMDA) receptors,
opioid receptors, monoaminergic receptors, muscarinic
receptors and voltage sensitive Ca ion channels
 Does not interact with GABA receptors
 Selectively depress the thalamoneocortical system before
significantly obtunding the more ancient cerebral centers and
pathways (reticular-activating and limbic systems)
- Water and Lipid Soluble
- Oral ketamine broken down by
bile acids
- Undergoes hepatic Metabolism
- It can be mixed with any TIVA
drugs
- Compatible with all IV fluids
Other uses
> Emergency Dept.
> Asthma
> Seizures
>Pain management
> Depression
> Vet Anesthesia
Invented in 1962 ---- NMDA receptor antagonist with Dissociative Anesthesia ---- Approved in 1970
Most Popular Anesthetic Drug of Anesthesiologists
Ketamine
• I V Effect
Starts -2 min
Last – 25 min
• IM Effect
Starts – 5 min
Last – 4-6 hrs
• Oral – 30 min
C13H16ClNO More
Analgesia
&
Less
Anesthesia

M/A
Main Actions
 Increase BP
 Increase Salivation
 Bronchodilation
 Hallucination
 Agitation
 Catatonia
 Prevent opioid
induced
Hyperalgesia
 Best agent
in Post anesthetic
shivering
Post
Ketamine
Double vision
& Nystagmus
are very
common
Dose Schedules
0.1-0.3 mg/kg – Analgesia
0.2-05 mg/kg – Recreational
0.4-0.8 mg/kg -- Partially dissociated
1-2 mg/kg – Fully Dissociated
1-2 mg/kg /IV – Procedural Sedation
4-8 mg/kg/IM – Procedural Sedation
0.1-0.2 mg/kg/hr – Postop Pain Relief
(Infusion maximum 3 days only)
IV Bioavailability -100 %
IM Bioavailability – 93 %
Dose Schedules
10 mg/kg /Oral – As Sedative
Premedication(Bioavailability – 20 %)
0.7-0.9 mg/kg – Intrathecal (S/A)
0.2 mg/ml – Epidural for Postop pain
Intra nasal 0.5-1 mg/kg (Bio-50%)
Intrarectal 0.5-1 mg/kg (Bio-30%)
Sublingually 0.5 -1 mg/kg (Bio-30%)
Inhalation 0.5-1 mg/kg
Topical Gel – 1% ketamine with
other drugs
Ketamine is
the only
drug which
Is given by
all routes
In body
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•Increase HR, high BP(20 %)
•Increased intracranial pressure
• Transient reddening of the skin
• Reduced appetite, nausea
• Increased salivation, vomiting
•Pain, eruptions or rashes at the injection site
• Tonic-Clonic movements
• Double vision , involuntary eye movements,
• Increased bronchial secretions
• Anaphylaxis and Dependence
• Cognitive Deficits
• Emergence reaction
Side
Effect
Pharmacokinetics
•Rapid onset and short duration of action
• Initially distributed to highly perfused brain tissues
• Crosses Blood Brain barrier
• Undergoes extensive redistribution
• Major metabolite are norketamine
and dehydronorketamine
Combination
• Ket+Propofol(Ketofol)
• Ketamine+Dex(Dexket)
• Ketamine+Fentanyl
• Ketamine+Midazolam
• Ketamine+Diazepam
• Ket+Prof+Dex (KPD)
WHO List of Essential Medicine
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28. Dr. Tushar Chokshi
Dexmedetomidine
• Dexmedetomidine has hypnotic,
sedative, and analgesic
properties and is estimated to be
7-10 times more potent than
clonidine
• Most ideal anesthetic agent with
all the properties of anesthesia
• Has got opioid sparing effect
• Dexket/Ketodex combination is
becoming very popular in Pediatric
OFA
• Patients sedated, but, arousable,
alert and respond without
uncomfortable
• They may quickly return to
sedation again
• Conscious Sedation as natural
sleep
• This drug is becoming widely
popular in all part of world in all
anesthesia techniques
• Dose ranges from 0.5 to 1 mcg per
kg according to patient status and
surgery needs
• Maintenance infusion is generally
initiated at 0.6μ/kg/hour and
titrated to achieve desired
anaesthesia effects
• In pediatric TIVA dex with
ketamine (Ketodex) combination is
mostly preferred for Endoscopic
and Radiological procedures
An alpha-2 agonist
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29. Dr. Tushar Chokshi Sedation
Anxiolysis DEXMEDETOMIDINE
Analgesic
Anaesthetic
FDA
December 1999
Market
August 2000
 Agonist of α2-adrenergic receptors 
 Most ideal anesthetic agent available 
M/A
Induces sedation by decreasing
activity of noradrenergic neurons
in the locus ceruleus in the brain
stem, thereby increasing the
activity of inhibitory gamma-
aminobutyric acid (GABA) neurons
in the ventrolateral preoptic
nucleus
 Popular in pediatric TIVA with ketamine 
 Patients sedated, but arousable, alert and respond without
uncomfortable like conscious sedation 
No effect on
Respiratory
System
 Transient Hypertension followed by Hypotension 
No Direct
effect on
Myocardium
IOP
Insulin Release
 Overdose may cause 1st or 2nd degree AV Block 
- Nasal - ~ 84 % bioavailability
Indications
Pre Anaesthetic sedation (IM/IV)
As Induction Agent
In maintenance of Anaesthesia
As adjuvant in TIVA
Intra thecal with Regional Ane.
In Post Operative Analgesia
As ICU sedation(only for 24 hrs)
Relative Contraindication
 Infusion over 24 hours
 In pre existing severe bradycardia
 Brady dysrhythemia
 Patient with < 30% EF
 Partial or Complete AV block
 In patients more than 65 y of age,
a higher incidence of bradycardia and
hypotension
Compatibility
- 0.9% sodium chloride in water
- 5% dextrose in water
- 20% mannitol
- Lactated Ringer's solution
- 100 mg/ml MgSo4 solution
- 0.3% potassium chloride solution
- With other Anesthetic agents e.g.
Propofol, Ketamine, Etomidate
Available as Ampoules or Bulb
50 mcg / 0.5ml
100 mcg / 1 ml
200 mcg / 2ml
Sileo Gel for Dogs
(Dexmedetomidine Oromucosal Gel)
0.09 mg/ml, 3 ml syringe
(BIPHASIC BLOOD PRESSURE RESPONSE) (BRADYCARDIA IS BECAUSE OF DOUBLE EFFECT)
(DECREASE OPIOID REQUIREMENT BY 50 %)
(BETTER THAN CLONIDINE IN ALL ASPECTS)
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30. Dr. Tushar Chokshi
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31. Dr. Tushar Chokshi
Etomidate
• Excellent Cardio stable drug
• Use mainly in Hemodynemically compromise patient as
TIVA induction agent
• For Sedation : 0.1 mg/kg up to three doses
• For TIVA : 0.3 to 0.4 mg/kg IV over 30-60 seconds
• In ICU : As continuous infusion 0.04 to 0.05
mg/kg/hr with continuous monitoring
• In Cushing Syndrome or law Cortisol level patient 0.2
mg/kg
• In Geriatric patients : 0.2 mg/kg
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32. Dr. Tushar Chokshi
Etomidate decrease in level of
circulating cortisol
IV 100 to 200 mg hydrocortisone
is given before etomidate
Pharmacokinetics
Onset of Action : within 30 to
60 seconds
Peak Effect : In 1 minute
Duration : 3 to 5 minute and
terminated by redistribution
Protein Binding : 76 %
Metabolism : Hepatic &
Plasma Esterase
Half-Life Distribution : 3
Minutes ( Anesthesia )
Half-Life Redistribution : 30
Minutes ( Sedation )
Half-Life Elimination : 3 hours
( Drowsiness )
Etomidate + Ketamine Mixture
Most suitable mixture for short procedure
Best combination for RSI in trauma and sepsis patients
Good alternative in pediatric patients compare to ketofol and ketodex
Both counter act each other adverse effects like myoclonus, nystagmus, injection site pain
Dose is 0.1mg/kg etomidate + 1 mg/kg ketamine
Mechanism of Action
• Carboxylated Imidazole agent
• Imidazole agent in IV anesthetic drugs
• R-1-(1-ethylphenyl)imidazole-5-ethyl ester
• Acts directly on the (GABA)
receptor complex blocking neuroexcitation
producing sedation/hypnosis/
anesthesia without analgesia
• Acidic pH - 6.9, pKa – 4.2,
• poorly water soluble
• soluble in 35 % propylene glycol
History
- Janssen Pharma in 1964 at Belgium
First introduced as Anti-Fungal agent
- Introduced as IV Anesthetic agent
(due to potent sedative properties )
- In Europe 1972
- In USA 1983
- In India 2013
Doses in different situations
• For Sedation : 0.1 mg/kg up to
three doses
• For G/A 0.3 to 0.4 mg/kg IV over
30-60 seconds
• In ICU : As continuous infusion 0.04
to 0.05 mg/kg/hr with continuous
monitoring
• In Cushing Syndrome or law
cortisol level patients 0.2 mg/kg
• In Geriatric patients : 0.2 mg/kg
• In Pregnancy : 0.2 mg/kg
• In Pediatric Patients : 0.1-0.3 mg/kg
Available as Milky White and Clear Solution in 2 mg/kg 10 ml Bulb or MCT/LCT preparation
Etomidate is most preferred drug
in Hemodynamically unstable
patients then any other anesthetic
agents for induction of anesthesia
Indications
• As Sedation
• As Conscious Sedation
• As Hypnotic Agent
• Etomidate Interview in Lie Detector
Test
• As Anesthetic Agent ( preferred in
cardiac patients)
• In Rapid Sequence Intubation (RSI)
• In Cardio version as Premedication
• In ICU as infusion in ventilated or
nonventilated patient
• As eSAM ( Etomidate Speech And
Memory Test)
Contra-Indications
• Proven sepsis with unstable
hemodynamic patients
• Abnormally Low Blood Pressure
even with Rx
• Decreased Function of the
Adrenal Gland
• Hypersensitivity of Etomidate
• Pediatric Patients less than 10
years age (but people have started
using etomidate up to 2 years age
with risk-benefit profile)
• In Pregnancy try to avoid as
induction agent if other anesthetic
agents are available
• In Geriatric Patients with caution
Adverse effects
• Transient Injection site pain up
to 80 % patients
• Skeletal Muscle movements
mainly myoclonic ( peripheral
limb movements ) up to 30 %
patients
• Opsoclonus ( uncontrolled eye
movements )
• Adrenal Suppression up to 10 %
patients
• Hiccups
• Apnea up to 90 seconds
• Less frequently nausea vomiting
laryngospasm, snoring,
arrhythmia & increase in PaCO2
CNS – Decrease ICP, Cerebral Blood
flow and Cerebral Metabolism
But cerebral perfusion pressure
maintained
CVS -- No or Minimal changes in
Heart Rate, Blood Pressure and
Cardiac Output
No hemodynamic changes in
response to pain
No effect on Sympathetic tone
RS – Minimal changes in Respiratory
Rate and Tidal Volume
Slight elevation in arterial carbon
dioxide tension (PaCO2)
Transient apnea up to 90 seconds
- No histamine release
- Very rare allergic reactions
- Hepatic and Renal blood flow
decreased
Administration of Drug
• Never dilute Etomidate with DW in same Syringe
• Preferably Large Vein for IV administration
• Pre administration of lidocaine if possible (2 ml)
• First dose to be completed within one arm-brain circulation (60-90 seconds )
• All muscle relaxants, benzodiazepines, narcotics and ketamine are compatible
with etomidate in same syringe except vecuronium and Vit-C
Different Effects
ETOMIDATE
In Pregnancy with Heart Dz.
etomidate is drug of choice 32

33. Dr. Tushar Chokshi
Opioids
33

34. Dr. Tushar Chokshi
Fentanyl in TIVA
• Bolus 3 μg/kg over 30 sec
• Followed by 2 μg/kg/hr for 30 min
• 1.5 μg/kg/hr from 31-150 min
• 1 μg/kg/hr until 30 min before skin closure
Remifentanyl in TIVA
* 1mg/vial, 2mg/vial, 5mg/vial
* Initial dose of 1 mcg/kg
* TIVA Maintenance 0.25-0.5 mcg/kg/min IV
* Post-Op Period 0.025-0.2 mcg/kg/min IV 34

35. Dr. Tushar Chokshi
- FENTANYL -
Bioavailability
92% (transdermal)
89% (intranasal)
65% (buccal)
54% (sublingual)
100% (intramuscular)
100% (intravenous)
55% (inhaled)
Protein binding : 80–85%
Metabolism : Liver(CYP3A4)
Onset of action : IV within 5 minutes
Elimination half-life Formula C22H28N2O
Intravenous Molar mass : 336.479 g·mol−1
6 mins (T1/2 α) Melting point : 87.5 °C
1 hours (T1/2 β) Crosses BBB & Placenta
16 hours (T1/2 ɣ)
Intranasal : 6.5 hrs.
Transdermal : 20–27 hrs.
Sublingual/buccal
(single dose) : 2.6–13.5 hrs.
Duration of action IV : 30–60 minutes
Excretion : 75% Urine, 10% feces, 10% unchanged
Routes of Administration
Buccal
Epidural/Spinal
IM
IV
Nasal
Nebulizer
Sublingual
Skin patch
Oral
Used as Recreational drug &
also in Veterinary Anesthesia
Side Effects
Vomiting, Constipation, Sedation, Urinary
retention, Confusion, Hallucinations
Injuries related to poor coordination
Symptoms of Overdose
Respiratory depression, Somnolence,
Stupor, Coma, Skeletal muscle flaccidity,
Cold and clammy skin, Pupillary
constriction, Pulmonary edema,
Bradycardia, Hypotension, Airway
obstruction, Atypical snoring, and Death
A potent OPIOID agonist
100 times more stronger than Morphine
Fentanyl invented by Paul Janssen in 1960
and approved for medical use in 1968
Most widely used synthetic opioid
Hyperalgesia is common with Fentanyl
Fentanyl patches for cancer pain is
WHO List of Essential Medicines
Mechanism of Action
Fentanyl binds to opioid receptors, especially
the mu opioid receptor, which are coupled to
G-proteins. Activation of opioid receptors
causes GTP to be exchanged for GDP on the G-
proteins which in turn down regulates
adenylate cyclase, reducing concentrations of
cAMP. Reduced cAMP decreases cAMP
dependant influx of calcium ions into the cell.
The exchange of GTP for GDP results in
hyperpolarization of the cell and inhibition of
nerve activity
Fentanyl Antagonist
-Naloxone-
-Nalmefene-
-Naltrexone-
Doses
-Loading dose: IV 25-100 mcg or 1-2 mcg/kg
-Maintenance dose: IV 25-50 mcg or 0.35-0.5
mcg/kg every 30 to 60 minutes
-Continuous infusion: 50-200 mcg/hour (Ane.)
-TIVA : 0.5 to 2 mcg/kg
-NORA : 0.5 to 1 mcg/kg
-Rapid sequence intubation : 1 to 3 mcg/kg
-Continuous infusion : 50-100 mcg/hour (ICU)
-Epidural : 0.5-1 mcg/kg/hr
-Never exceed single doses of 3 mcg/kg  
(IM : 1-2 mcg/kg)
Uses of Fentanyl
1) As analgesic with other anaesthetic drugs
2) For maintenance in all anesthesia
technique (TIVA, NORA, Volatile, Regional)
3) In post operative pain relief
4) Management of chronic pain e.g. cancer
5) In Palliative Care
6) In ICU for mechanically ventilated patient
7) In Breakthrough pain
8) In Combat medicine in Military
9) Suppression of the cough reflex
Available Strengths of Fentanyl
(schedule II drug)
IV injection : 0.05 mg(50 mcg)/ml
2ml, 10ml and 50 ml vials
Transdermal Patch
12.5,25,37.5,50,62.5,75,100 mcg/hr
Fentanyl Buccal Tablet : 100 mcg
Intranasal Spray :
100mcg, 300mcg, 400mcg/100mcL spray
Given from Neonates to Geriatric patients
Extra Shots
-Dose reduction is 50 % in acute renal and hepatic
impairment
-Do not abruptly discontinue fentanyl in patient
-It can be mixed with propofol, ketamine,
lidocaine, etomidate and midazolam
-It also can be mixed in 5% dextrose, RL and 0.9 %
normal saline for continuous infusion
-No histamine release, thus preferred narcotic for
asthmatic patients
Extra Shots
-Fentanyl is contraindicated in patients who are on
MAO-Inhibitors
-Rapid administration cause muscle rigidity, so
always give IV injection slowly
-Fentaketacaine (Fentanyl + Ketamine + Lidocaine)
drip is used for postoperative analgesia
-Fentanyl is also used in Neuroleptanalgesia
-Recently fentanyl use extend in treatment of
epilepsy
-Narcotic delirium is common with fentanyl
Opioid
epidemic
with
fentanyl
is very
common
Fentanyl is high
potential for addiction

36. Dr. Tushar Chokshi
REMIMAZOLAM
New TIVA Drug
Benzodiazepine with
Opioid Property
History
1990 – Glaxo Discovered
2008 – Payon (Japan) Acquired drug
2020 – Japan approved named Anerem
2020 – USA approved named Byfavo
2020 – China approved named Ruima
2020 – Europe/Canada/ S. Korea under
approval named Aptimyda
Types of Drug
* Ester based Ultra Short Acting
* Soft Drug
* Properties of Midazolam
and Renifentanyl
* Sedative Anaesthetic
Mechanism of Action
*Acts on GABA receptors
*Potentiate effect of GABA receptor
which allows passage of chloride
ions
*And suppress and control the pain
Water Soluble product
Weight
Average: 439.313
Monoisotopic: 438.069139
Chemical Formula
C21H19BrN4O2
Protein bound:
>91% (primarily to albumin)
Pharmacodynamics
*Enhance the effects of
GABA
*Sedation within 3-3.5 m
*Ultra Short Acting
*Not a Schedule drug
*Careful in hepatic
impairment
*Caution in Patients of
abuse or dependence
Pharmacokinetics
* Half Life – 37 to 53 min
* Distribution Half-Life
0.5 to 2 Min
Clearance - 54 to 75 L/Hr
* Excretion – 80 % as
inactive metabolites
In renal failure no change
in drug pharmacokinetics
* Age, Sex, Race, weight
has no effect on drug
Strength
* Single-patient-use
vial for IV
* Each glass, injection
contains 20 mg white to
off-white lyophilized
powder, equivalent to
27.2 mg Remimazolam
Besylate ready for
reconstitution
* Storage 20°C to 25°C
* Reconstituted
Remimazolam can be
stored in the vial for up
to 8 hours under
controlled room
temperature at 20°C to
25°C
* Protect vials from
light
* Discard unused
portion.
* Contains 2.5 mg/ml
after adding 8.2 ml of
NaCl
Compatible with
* 0.9% NaCl Inj
* 5% Dextrose Inj
* 20% Dextrose Inj
* 5% & 0.45% DNS
* Ringer’s Solution
* Do not mix with other
drugs or fluids
Preparation of Drug
* Strict aseptic technique
* Not contain preservative
* Prepared immediately
before use
* To reconstitute, add 8.2 mL
sterile 0.9% NaCl Injection
which contains 2.5 mg/ml of drug
Indication
* Single dose for premedication
* Bolus dose followed by
Supplemental dose for Sedation
* Intravenous anesthetic with
opioids as a part of TIVA
• Intensive care unit sedation
• In short procedure < 30 min
Contraindication
* Remimazolam contains dextran 40
can cause hypersensitivity reactions
* History of severe hypersensitivity
reaction to dextran 40
* Avoid in clinically notable hypoxia,
bradycardia, and hypotension
* Oral Bioavailability is zero
Overdose ( Rx - Flumazenil )
* CNS depression with drowsiness
* Confusion and lethargy
* Progression to ataxia
* Respiratory depression
* Hypotension
* Abuse and Dependence
Adverse Reactions
* Hypotension (33-58%)
* Hypertension (20-42%)
*Diastolic HT(10-25%) Systolic HT(6-22%)
* Hypoxia (22%), Bradycardia (3-11%)
* Respiratory Acidosis (19%)
* Increased RR(14%), Nausea, Headache
Dose
* Induction
5 mg IV over 1 min
* Maintenance
2.5 mg over 15 seconds
* Half dose in ASA 3 & 4
* Ideal Dose 0.075 mg/kg
* Intra Nasal 0.075 mg/kg
Specific Populations
of Patient
* Pregnancy
cross the placenta and may
produce respiratory
depression and sedation in
neonates
* Lactation:
discard breast milk for 5
hours after treatment with
Remimazolam to avoid
Neonatal Sedation:
* Pediatric :
Remimazolam should not
be used in patients less
than 18 years of age
* Geriatric Use:
may cause confusion and
over-sedation in the
elderly; elderly patients
generally should be
observed closely
* Severe Hepatic
Impairment:
carefully titrated and
reduced doses indicated
* Renal Impairment:
Not altered renal failure
Pharma Co. Produced
* Acacia Pharma (USA)
* Mundipharma (Japan)
* Hana Pharm (S. Korea
and Southeast Asia
* R Pharma (Russia,
North Africa and Turkey)
*Humanwel Pharma(China)
Price of Remimazolam
(20 mg one bulb)
25 Dollars in USA
1800 Rs in India
Advantages
Over Midazolam
* Faster acting
* Shorter lasting
* Faster recovery
* Predictable recovery
* Conscious sedation
* Remimazolam TCI
pumps are under
development stage
* Called as “Soft-Drug”
because of self
metabolizing and organ
independent properties
Most Ideal
Sedative Drug
36

37. Dr. Tushar Chokshi
Adjuvant TIVA Drugs
37

38. Dr. Tushar Chokshi
Midazolam
• 0.05 mg/kg
• Co-administration of midazolam in TIVA reduce
the induction dose and the total dose of any
other anaesthetic drug
• Total dose: < 10 mg
38

39. Dr. Tushar Chokshi
MIDAZOLAM

 



 




 
 
Pharmacokinetics
 Bioavailability : By IV 100% , mouth
40%, IM 90%, Nasal 78% and Buccal 90%
 Protein binding : 97%
 Onset of action : Within 5 min (IV), 15
min (IM), 20 min (oral), 10 min (Bucal)
 Elimination half-life : 1.5 – 2.5 hours
 Duration of action : 1 to 6 hrs
 Excretion : Kidney
 Metabolism : Hepatic Hydroxylation
by (CYP) 3A4 enzyme system
Mechanism of Action
Midazolam binds to the GABA receptor but
does not displace GABA; rather, it enhances the affinity
of GABA for its receptor site on the same receptor
complex. The pharmacodynamic consequences of
benzodiazepine agonist actions include antianxiety
effects, sedation, and reduction of
seizure activity
 Patented in 1974 medical use in 1982
 Benzodiazepine class of drug
 Chemical name is C18H13ClFN3
Available as a generic medication
Most commonly used benzodiazepine
in anesthetic medicine
It is shorter lasting, more potent, and
causes less pain at the injection site
In 2018 Midazolam approved as a
"truth serum“ "Medication
Side Effects
 Apnea / Bradypnea / Myoclonic jerks
 Variable blood pressure readings
 Drowsiness/Headache/Hiccups
 Nausea/Vomiting/Confusion
Overdose
 It is medical Emergency
 Cautious with elderly patients
Increase with CNS depressants, alcohol,
opioids, or tricyclic antidepressants
 Antidote is Flumazenil (0.01 mg/kg IV)
Indications
For preoperative
sedation/anxiolysis/amnesia
 In Non Operating Room Anesthesia
(NORA) procedure
 An adjuvant to TIVA and OFA
 IV for induction of general anesthesia
 Continuous IV infusion for sedation of
intubated and mechanically ventilated
patients in ICU
 As oral/nasal/rectal premedication in
pediatric patients
 For the acute management of
seizures and schizophrenia
 In palliative care
Caution to use
 In Geriatric and Paediatric patients
 During pregnancy and lactation
 In alcohol- or other drug-dependent individuals
 Those with comorbid psychiatric disorders
 In critically ill patients
 In hepatic and renal impairment
 Hypersensitivity
Dose Schedules
 Available as injection,
Syrup, Tablet & Buccal form
IV/IM inj available as 1 mg/ml,
5 mg/ml & Syrup 2 mg/ml
Oral pediatric dose : 0.25 to 0.5 mg/kg
For Sedation : 0.01 to 0.05 mg/kg IV
IM: 0.02 to 0.05 mg/kg IM,Rectal o.4 mg/kg
 Maintenance dose: 0.05 to 0.1 mg/kg via
IV infusion per hour
For GA : 0.25 to 0.35 mg/kg IV
 Nasal : 5 mg (1 spray) in 1 nostril
 Geriatric : 0.01 to 0.02 mg/kg IV
ICU patients : 0.03
mg/kh/hr
 As a versatile drug, it is used for the management
of palliative sedation and terminal restlessness in Ca
It is more potent and has a shorter duration of
action than diazepam, and replaced the diazepam
Midazolam nasal spray is the first and only FDA-
approved nasal option for treating seizure clusters
Midazolam is also commonly used as a pre-
anesthetic agent to provide sedation and muscle
relaxation in Veterinary Anaesthesia
Given by Oral, IV, IM, Nasal, Buccal and Rectal route
Midazolam, at a concentration of 0.5 mg/mL,
is compatible with 5% dextrose in water and 0.9%
sodium chloride for up to 24 hours and with lactated
Ringer's solution for up to 4 hours
Compatible with Propofol, Ketamine, Etomidate,
Dexmedetomidine, Fentanyl and Remifentanyl
Midazolam provides no pain relief
39

40. Dr. Tushar Chokshi
Magnesium Sulphate
• As an analgesic adjunct
• Useful in patients
receiving total
intravenous analgesia
(TIVA)
• Reduce propofol, Dex,
atracurium and
postoperative narcotic
consumption
• Improves the quality of
postoperative analgesia
during TIVA
• Bolus dose is 30-50
mg/kg with other
anesthetic agents and
maintenance dose is 6-
10 mg/kg/hr as
continuous infusion
• Very cost effective for
TIVA
Available as 2 ml amp with 500 mg/ml and total 1 gm
40

41. Dr. Tushar Chokshi
41

42. Dr. Tushar Chokshi
In spinal Anesthesia
Dose : 50 -100 mg
Old Wine in New Bottle Best Adjuvant in TIVA
Intravenous Oxygen for Anaesthesiologist
OMg OMg
As Anesthesia Adjuvant
Dose : 30-50 mg/kg
Direct depressant on myocardial
and vascular smooth muscles
Anti-arrhythmic
Reduces systolic blood pressure
Decrease pulmonary vascular
resistance
Bronchodilator
Reduce excitability of nerves
As an Anticonvulsant
Reverse the cerebral vasospasm
Reduces the release of
acetylcholine at NMJ
Terminates muscular contraction
Causing skeletal muscles relaxation
(Versatile Drug)
Friend
Philosopher
Guide
For
Anesthesiologist
Potassium levels must be normal
Extreme caution in patients
with myasthenia gravis or other
neuromuscular disease
In renal impairment
In digitalized patients
Monitor renal function,
blood pressure, respiratory rate,
and deep tendon reflex
In Local Anesthetic Block
Dose : 50 – 250 mg
Pre-Emptive
Analgesic
Analgesic effect of
MgSO4 is due to
inhibition of calcium
channels and
NMDA receptors
Reduce the dose
requirement for
opioids, anaesthetics
and muscle relaxants
and part of MMA
Both in hypo and hyper
Magnesemia
Hyperventilated patients
Avoid in Geriatric and
Pediatric patients as far as
possible
In electrolyte disturbance
Avoid excessive use of
volatile agents with MgSO4
(500 mg /ml)
BURP
Antidote for Magnesium is
Calcium
42

43. Dr. Tushar Chokshi
Dexamethasone
• Dexamethasone is used widely in TIVA as an
adjuvant
• As anti-inflammatory agent, prevents and treats
post-operative nausea and vomiting (PONV),
suppress inflammation, good analgesic agent
• Provides a sense of well-being
• Good quality of recovery and early discharge in
patients from TIVA anaesthesia
• Single prophylactic dose of dexamethasone 8 mg
can be given irrespective of sex, disease or ASA risk
43

44. Dr. Tushar Chokshi
Universal Weapon
For
Anesthesiologist
Anti-Emetic and Anti-Nauseatic
Anti-Inflammatory
Analgesic Effect
Anti Shivering
Increase Quality of Recovery
No effect on sepsis and sugar in single dose 44

45. Dr. Tushar Chokshi
DEXAMETHASONE
 Universal Friend 
Anti Nauseatic & Anti Emetic
Early Discharge from Anaesthesia
Anti Inflammatory
Weak anti pyretic effect
Anti Edema drug
Anti Shivering
Systemic Analgesic Effect
Increase Quality of Recovery
 Synthetic
Glucocorticoids with
minimal mineralocorticoid
activity
 Most potent anti
inflammatory than
Hydrocortisone and
prednisolone
 Biological half-life is 3 hours
 Metabolism in liver with
inactive metabolites
 Renal excretion upto 65%
in urine within 24 hours
Readily available
 Price is very cheap 
 Most ideal perioperative agent 
 Superior to ondensetron to reduce PONV 
 Reduce opioid Consumption 
 Decrease Analgesic effect upto 24 hours 
 Always to be given prior to surgery 
 Best TIVA and OFA adjuvant 
 Great psychological effect 
 Prevents any allergic reaction 
Dose Schedule
 PONV – 0.1 mg/kg (IV) 
 Anti Inflammatory – 0.2 mg/kg(IV) 
 Analgesic – 0.1 mg/kg(IV) 
 Epidural -- 8 to 10 mg 
 Blocks – 0.1 mg/kg 
 S/A - 8 mg 
Mechanism of Actions
 Depletion of γ-aminobutyric acid (GABA)
stores and reduction of blood brain barrier
to emetogenic toxins,
 Inhibition of central prostaglandins and
serotonin
 Membrane stabilizing effect on nerves and
on spinal cord
Dexona IN DM
 4 mg is
ideal dose
8 -10 mg dose
Increase around
25 mg/dl
glucose postop
upto 24 hrs
Dexona in Sepsis
Does not
increase any
risk of wound
infection with
or without DM
in any surgical
procedure
Acute Side Effect
Flushing
Perineal Itching
Dexona
Is the only
adjuvant in
anesthesia
given
irrespective of
age, sex,
disease or ASA
status
Safe in
Onco Anesthesia
Avoid in
Psychiatric patients
Be careful in
Immuno compromised
patients
Improves
Cognitive function
In Elderly
8
8 8
8
8
8 8
8
45

46. Dr. Tushar Chokshi
Best Companion of Anesthesiologist
Lidocaine
Analgesic & Anti Hyperalgesic
Anti Inflammatory
Reduced opioid analgesic consumption
Anti Arrhythmic
Improvements in patient’s outcomes
Decrease Aerosol and Droplets during Extubation
46

47. Dr. Tushar Chokshi
Intravenous
Lidocaine
(Magic Drug)
Best Adjuvant in TIVA
Lidocaine is metabolized in the liver and excreted by the kidneys
Permanent member of Multi Model Anaesthesia & Analgesia
Analgesic
 Anti Arrhythmic
 Anti Cancer drug
 Anti Hyperalgesic
 Anti Inflammatory
 Reduces the release of cytokines
 Improvements in patient’s outcomes
 Reduced opioid analgesic consumption
 Reduce Volatile anesthetic consumption
 Decrease Laryngospasm and Laryngeal Edema
Decrease Aerosol and Droplets during Extubation
Class-1b Antiarrhythmic Amide Local Anesthetic
Most beneficial
 In painful Propofol/Etomidate Inj.
 Both in Acute and Chronic pain
 Abdominal Surgery
 Neuro surgery
 TIVA and OFA
 Onco surgery
 ENT surgery
 In ERAS
Most ideal drug to blunt airway reflexes
and sympathetic responses to
laryngoscopy and tracheal intubation
Mechanism of Action
 Blocks sodium ion channels on
the cell membranes and stabilizes
the membrane
 In neural tissues, lidocaine inhibits
the generation, transmission and
propagation of neural impulses
 At the level of the spinal reflex,
it blocks the afferent and/or
efferent parts of the reflex arc
The pharmacological effect of IV lidocaine
involves multiple pathways (peripheral
and central) and mechanisms (direct and
indirect) for pain relief
Dose Schedule
 A bolus of 1–2 mg/kg followed by
an infusion of 1–2 mg/kg/h with IBW
 From Pediatric to Geriatric
 Do not exceed a maximum dose
of 100 mg bolus or 100 mg/h
The target plasma concentration for
therapeutic effect is between 2.5 and
3.5 μg/ml
 CNS toxicity occurs in > 5 μg/ml
 CVS toxicity occurs in > 10 μg/ml
Post Operative IV Lidocaine
Use of lidocaine for up to 24 h
has significant decrease in pain
 Reduced analgesic requirements
 A faster return of GI function
An overall reduction in side effects
 Maximum post op infusion can be
given upto 3 to 5 days till the bowel
function returns normal and pain is well
Controlled
 Multi Para monitoring is must
during post op IV lidocaine
Practical Consideration
The concomitant use of IV lidocaine
with another regional anaesthesia
technique (e.g., epidural, TAP block)
requires careful consideration and is
probably best avoided because of
possible local anaesthetic toxicity
IV lidocaine is a component of every
laparoscopic procedure, irrespective of
its duration, invasiveness and desired
outcomes
 IV lidocaine is Useful to relieve PDPH
IV
lidocaine
always,
to
ordered
by
Anesthesiologists
In
High-Risk
Patients
IV
Lidocaine
dose
must
be
reduced
Invention
1943
First Marketed
1949
47

48. Dr. Tushar Chokshi
Paracetamol
• Preemptive analgesic
• Has got opioid sparing
effect
• Loading dose is 30 mg/kg
and maximum not to
exceed 2 gm
• Very innocent drug in TIVA
and can be repeated at
every 6 to 12 hours interval
in dose of 1000 mg
• Excellent adjuvant in
Pediatric TIVA
Diclofenac Sodium
• Powerful NSAID in TIVA
with analgesia and anti-
inflammatory action
• Best is given in single dose
of 1.5 mg/Kg IV slowly and
maximum is 150 mg
• Use aqueous solution only
• Caution with renal, hepatic,
pulmonary and heart
failure patients
Always give both drugs before surgical
incision to inhibit prostaglandin receptors 48

49. Dr. Tushar Chokshi
It is an effective analgesic, especially when
administered IV, useful in a broad range of clinical
conditions. Also known as Acetaminophen
Synthesized in 1878 by Morse, medical usage in
1883 & available without prescription since 1959
Nonsteroidal anti-inflammatory group drug
Routes of administration
Mouth and Buccal
Rectal
IV and IM
Onset of action
Mouth – 37 minutes
Buccal – 15 minutes
Rectal – 40 minutes
Intravenous– 8 minutes
Pharmacokinetic
Protein binding : 10–25%
Metabolism : Mainly liver
Excretion : Urine (85–90%)
Bioavailability : 63–89%
Protein binding : 10–25%
Elimination half life : 2–2.5 hours
Formula : C8H9NO2
Molar mass : 151.165 g·mol−1
Boiling point : 420 °C
Dose Schedule
Infusion 10 mg/ml available 100 ml pint & 150 mg/ml amp
 < 10 kg : 7.5 mg/kg, maximum daily dose 1 gm
 10 kg to 33 kg : 15 mg/kg, maximum daily dose 2 gm
 33 kg to 50 kg : 15 mg/kg, maximum daily dose 3 gm
 > 50 kg without any renal/liver dz : 1 gm and maximum 4 gm
 > 50 kg with any renal/liver dz : 1 gm and maximum 3 gm
The minimum interval between each IV administration
must be at least 4 hours and no more than 4 doses to be
given in 24 hours
Contraindications
Hypersensitivity to paracetamol
 In cases of severe hepatocellular insufficiency
 Pre-term newborn infants
Indications
 Short term treatment mild to moderate pain
Short- term treatment of fever
As adjuvant in TIVA and OFA
Precautions for use
 Chronic renal and liver disease
 Malnutrition
 Dehydration
Overdose
 Risk of Liver injury particularly elderly subjects
& young children with overdose of 7.5 g
 Nausea/Vomiting/Anorexia/Pallor/Abdo. Pain
Storage
Store below 25°C.
Do not Freeze
Available in 100 ml
Glass Bottle and
Non PVC Bag
Shelf life
2 years
The pharmacokinetics and the metabolism of
paracetamol are not modified in elderly subjects,
so, no dose adjustment is required
Antidote (IV/Oral) is
N-acetylcysteine (NAC)
Mechanism of Action
Paracetamol has a central
analgesic effect that is mediated through
activation of descending serotonergic pathways
 Its primary site of action, which may be,
weak inhibition of prostaglandin (PG) synthesis
or through an active metabolite influencing
cannabinoid receptors
Paracetamol never reduce tissue
inflammation like other NSAIDs
Has got opioid sparing effect
 Paracetamol combined with NSAIDs more effective for treating postoperative pain than either paracetamol or NSAIDs alone
It is safe to use during pregnancy and when breastfeeding  Paracetamol can be safely taken both with food and on an empty stomach
PCM cause rare and possibly fatal skin reactions such as Stevens–Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
Extra Shots
An association exists between paracetamol use and asthma
so avoid in children with asthma
In contrast to aspirin, paracetamol does not prevent blood
from clotting (it is not an antiplatelet), thus it safely used in
people who have concerns with blood coagulation
Paracetamol hepatotoxicity is by far the most common
cause of acute liver failure and death within days
Combinations of oral paracetamol and opioid analgesics
and intramuscular paracetamol would be avoided
It is weak analgesic and mainly
antipyretic drug
 Some studies have found an
association between paracetamol and
a slight increase in kidney cancer, but
no effect on bladder cancer risk
It is also available in liquid
suspension and effervescent forms
It is the firs t Over The Counter
(OTC) drug in the world
Diclofenac Sodium and
Paracetamol combination is most
widely used for postoperative
analgesia, but thumb rule is that
they should be given before any
surgical incision
There are no haemodynemic
changes with paracetamol but
repeated use causes hypertension
No sedative effect
Pet Name
PCM








During IV regional anaesthesia, adding PCM to the
injected lidocaine was shown to improve the overall
quality of the block & onset is sooner

50. Dr. Tushar Chokshi
 DICLOFENAC SODIUM 
 Introduced By Ciba-Geigy in 1965
 Nonsteroidal anti-inflammatory drug
 Available worldwide
 Generic Medication
 Available as both a sodium and a
potassium salt
 Given by Mouth, Rectally, IM, IV
injection and Topical Skin Gel/Spray
Pharmacokinetic
 Formula C14H11Cl2NO2
 Protein binding More than 99%
 Metabolism Liver, oxidative, primarily by CYP2C9
 Onset of action Within 4 hours Topical,30 min Oral,
15 minutes IM, 5 minutes IV and 30 minutes Rectal
 Elimination half-life 1.2–2 hr
 Excretion 40% bile duct and 60% urine
 Molar mass 296.15 g·mol−1
Mechanism of action
 The primary mechanism responsible for its anti-
inflammatory, antipyretic, and analgesic action is
thought to be inhibition of prostaglandin synthesis by
inhibition of the transiently expressed prostaglandin-
endoperoxide synthase-2 (PGES-2) also known
as cycloxygenase-2 (COX-2).
 Blockage of voltage-dependent sodium channels
 Blockage of acid-sensing ion channels
It also appears to exhibit
bacteriostatic activity by inhibiting
bacterial DNA synthesis
Avoid use of multidose bulb/vial
 Positive allosteric modulation of KCNQ- and
BK-potassium channels
 It inhibits the lipoxygenase pathways, thus
reducing formation of the leukotrienes
 It also may inhibit phospholipase A2 as part of
its mechanism of action
 These additional actions may explain its high
potency – it is the most potent NSAID on a broad
basis
Contraindications
Hypersensitivity against diclofenac
 History of allergic reactions (COPD,
bronchospasm, shock, rhinitis, urticaria)
Active stomach and/or
duodenal ulceration or GI bleeding
Severe congestive heart failure
Severe liver insufficiency
Severe chronic kidney disease
Pre-existing hepatic porphyria
Avoid during dengue fever
Patients with fluid retention
In worsening of pre-existing hypertension
Inflammatory bowel disease such as Crohn's disease
or ulcerative colitis
Serious skin adverse events e.g. exfoliative dermatitis,
Stevens–Johnson syndrome, toxic epidermal necrolysis
Powerful NSAID in TIVA/OFA
with analgesia and
anti-inflammatory action
 Use aqueous solution only
Best is given in single dose of 1.5
mg/kg IV slowly and maximum is
150 mg
 It is opioid sparing drug
 Always give before surgical incision
to inhibit prostaglandin receptors,
which control the haemodynamic
response to surgical stimulation
 Diclo should not be mixed with
any drug except paracetamol in
same syringe
 Given with any IV Infusion
Always dilute diclo with DW and
give slowly to avoid injection pain
Dose
 Oral 50 mg 2 or 3 times a day
 Extended-release tablets 100 mg once a day
 Potassium immediate-release tablets 50 mg
orally 2 or 3 times a day
 Sodium enteric-coated tablets 75 mg orally 2
times a day
 IV/IM 1 to 1.5 mg/kg, repeat after 8 hours
 Rectally 1 to 1.5 mg/kg ( Paediatric patients)
Diclo is better than paracetamol
to control post operative fever & pain
In anaesthesia practice Diclo
Is used as an adjuvant for
perioperative acute pain
management
 Diclofenac is an effective analgesic for acute pain in children as part of the analgesic regime in the peri
operative period with dose range from 0.5 to 2.5 mg/kg
 Infusion line pain or irritation to vein is very common during IV Diclo, so better prefer large venous line
Major side effects of diclo are 1) abdominal or stomach pain, cramping, or burning 2) bloody or black, tarry
stools 3) bloody urine and decreased frequency or amount of urine 4) heartburn or indigestion 5) diarrhea
6) increased thirst and loss of appetite 7) vomiting of blood or material that looks like coffee grounds
7) very rare anaphylactic or anaphylactoid reaction
Some time single dose or overdose of Diclo may cause acute renal failure
 As far as avoid diclo in geriatric age group of patients ( paracetamol is preferred )

51. Dr. Tushar Chokshi
(Opioid sparing adjunct) (Gives central analgesia)
51

52. Dr. Tushar Chokshi
ESMOLOL
 Emergency friend of
Anaesthesiologist
 Cardioselective beta1 receptor
blocker
 Shortest acting beta blocker
Class II Antiarrhythmic
Safely given in broncho-
spastic and vascular dis.
 Gives central analgesia
Opioid sparing adjuvant
in OFA and TIVA
Mechanism of Action
Esmolol decreases the force and
rate of heart contractions by blocking
beta-adrenergic receptors of the
sympathetic nervous system, which are
found in the heart and other organs of the
body
 Esmolol prevents the action of two
naturally occurring substances:
epinephrine and norepinephrine
No significant intrinsic
sympathomimetic or
membrane stabilizing
activity at therapeutic dosages
Dosages forms and Strengths
Infusion bags
2 g/100 ml, 2.5 g/250 ml, 5 g/500 ml
Injectable solution
10 mg/ml and 20 mg/ml
Compatible with all common solvents
Incompatible with NaHCO3
Never infuse in small veins or by butterfly
 Never stop abruptly due to
withdrawal effect
Side Effects
10 % or more
Hypotension asymptomatic ( 25%)
Hypotension symptomatic (12%)
Bradycardia (15 %)
1 – 10 %
Injection site pain (8%)
Agitation (7%)
Dizziness(3%)
1 % or less
Chest pain
Anxiety/Depression
Dry Mouth/Dyspepsia
Redness of the face and neck
Headache
Pharmacokinetic
Bioavailability 90 %
Protein binding 55-60%
Metabolism Erythrocytic (in blood
by hydrolysis of its methyl ester)
Elimination half-life 9 minutes
Distribution half life 2 minutes
Duration of action 10-30 minutes
Excretion Kidney (73-78%)
Vd 3.4 liter/kg
Storage at room temperature
Safely given in pediatric
Patients ( > 2 Years)
Careful in Pregnancy
Uses
To terminate supra-
ventricular tachycardia
In episodic atrial fibrillation or
flutter
Arrhythmia during perioperative period
To reduce HR and BP during and after
cardiac surgery
In early treatment of myocardial
infarction
In blunting the haemodynemic
response to laryngoscopy and
intubation
To reduce intra and post
operative hypotension
Brady
is
less
Intraoperative Tachycardia
and Hypertension
Immediate control
1 mg/kg over 30 sec then
0.15-0.3 mg/kg/min infusion
Postoperative control
0.5 mg/kg iv for 1 min then 0.1 mg/kg/min
infusion
If not control then repeat bolus doses
For supraventricular tachycardia
0.5 mg/kg over 1 min then
0.05 mg/kg/min infusion
Hypo
Is
more
PONV
is
less
Best
adjuvant
in
Ane
Contraindication
Sinus bradycardia, Sick sinus syndrome
AV heart block, Heart failure
Pulmonary hypertension
Hypersensitivity

53. Dr. Tushar Chokshi
TIVA Drug Combinations
53

54. Dr. Tushar Chokshi
54
What to understand before
mixing any drugs for anesthesia

55. Dr. Tushar Chokshi
Anesthesia Triangle
The concept of the anesthesia triangle works with Hypnosis, Analgesia, Relaxation –
and their interactions
Any medications entering this prism may result in different interactions:
Pharmaceutical, Pharmacokinetics, Pharmacodynamics, and Thermodynamics by combo
A larger number of incoming drugs leads to increased complexity and more interactions
So, the rule is not mix more than three drugs at time 55
Anesthesia Triangle
• Hypnosis
• Analgesia
• Relaxation
Hypnosis
Analgesia
Relaxation
Anesthesia
Triangle

56. Dr. Tushar Chokshi Red
Not compatible
Green
Compatible
Yellow
Non-conclusive
The hidden world of
drug interactions in
anesthesia
Colombian Journal of
Anesthesiology
Volume 45, Issue
3, July–September
2017, Pages 216-223
Alberto
Tafur Betancourt
Conclusion
Drug interactions are
the corner stone of
the anesthesia triangle
and being aware of
those interactions may
contribute to safe
anesthesia
White
Not tested

57. Dr. Tushar Chokshi
TIVA
KINGDOM
Anaesthesiologist
Fentanyl
Remifentanyl
MgSO4
King
Commanders
Oxygen
Soldier
Here King will decide
their military in battle of
anesthesia whom to
send in combination
Prince is most common
warrior and goes in
every battle
of anesthesia
Prince with one or two
supreme commander
are the best military of King
In absence of prince
two supreme commanders
go to win small battles

58. Dr. Tushar Chokshi
KPD
Ketamine
Propofol
Dexmedetomidine
KETOFOL
Ketamine
Propofol
KETODEX
or
DEXKET
Ketamine
Dexmedetomidine
FP/RP
Fentanyl
or
Remifentanil
Propofol
PDF
MDF
KETOMED
Propofol
Dexmedetomidine
Fentanyl
Midazolam
Ketamine

59. Dr. Tushar Chokshi
Ketofol
• First established TIVA
combination in 1990
• Physically compatible
chemically stable 1:1 mixture
in capped syringe 3 hrs at
room temperature with
exposure to light
• No significant change in pH
up to 3 hrs
• No separation, cracking,
color change, gas formation
• Widely used by all
anesthesiologist across
globe
Ketodex/Dexket
• Ketamine 1mg/kg and
Dex 1 mcg /kg
• Useful in Pediatric patients
Ketomed
• Ketamine 1mg/kg and
Midazolam 0.1 mcg /kg
• Useful in outside OT
procedures
59

60. Dr. Tushar Chokshi
KPD TIVA (Ketamine, Propofol and Dex)
Mixture in 1:1:1 Dose for TIVA
Combination of all these drugs permit lower dose
of each individual agent for TIVA and reducing
their adverse hemodynamic and respiratory
effects which is very safe and important for
patient and anesthesiologist
The advantage is low dose of each agent as
compared to full dose
Excellent analgesia and anesthesia
 dose of individual
agents
 airway complications
Stable haemodynamics Rapid recovery 60
Used as Bolus, Maintenance and Short case < 30 minutes

61. Dr. Tushar Chokshi
PROPOFOL & FENTANYL
Combination of Propofol (1% &
2%) with Fentanyl (10 & 50
mcg/ml) showed no significant
degradation of emulsion within
20 hrs
Propofol dose reduction by 50%
61

62. Dr. Tushar Chokshi
RP TIVA (Remifentanyl and Propofol)
Can be mixed in polypropylene syringes and used for up to 36
hours- remifentanil concentration is 50 mcg/ml (1mg in 20 ml
propofol)
Color and clarity good with pH stable at 3.9 - 4
Very short acting
Adequate analgesia, satisfactory hemodynamic, rapid recovery,
shorter PACU stay, excellent patient acceptance
Ideal agents for TCI model
Synergism- Propofol dose reduction by 50%
Most widely used TIVA combination with TCI in the world
62

63. Dr. Tushar Chokshi
Methods
63

64. Dr. Tushar Chokshi
give TIVA
• Either with a single drug or with a combination
of drugs
• By Single Syringe Technique with mixture of
drugs or with only one drug
• Continuous IV infusion through drips
• With Syringe infusion pumps
• With TCI ( Target Controlled Infusions) machines
• Automated drug delivery through Closed Loop
Systems 64

65. Dr. Tushar Chokshi
Single Syringe TIVA (SS TIVA)
1) No additional investment for TCI
or Closed Loop Systems and no
need for expertise in it.
2) Simple syringe or pump can be
made use of.
3) Only one syringe is used, with the
advantage of dose titration at a
single level & fixed dose mixtures
4) Short procedures can be
managed with intermittent
boluses, without a syringe pump.
5) It can be practiced in low
dependent set ups, and outside
the operating rooms
Explores the feasibility and conduct of combining intravenous agents in a single
syringe technique to provide balanced anesthesia
65

66. Dr. Tushar Chokshi
Manually Controlled Infusion (MCI)
Manual dosing of anaesthetic agents during
TIVA
With fixed infusion rate
With syringes or with IV drips
66

67. Dr. Tushar Chokshi
67

68. Dr. Tushar Chokshi
Target Controlled Infusion (TCI)
A target
controlled
infusion is an
infusion
controlled to
achieve a pre
set drug
concentration
in the plasma or
the effect site
Key components of a TCI
infusion
User interface to enter details and
target blood concentration
Software with
pharmacokinetic model, validated
for specific drug to control infusion
rate
Communication between ‘control
unit’ and pump hardware
68

69. Dr. Tushar Chokshi
Single Syringe TCI
Double Syringe TCI Three Syringe TCI
69

70. Dr. Tushar Chokshi
John Baird Iain Glen
He is
Father
of Modern TIVA Technique
He has developed first established
TCI system ‘Diprifusor’
for Propofol TIVA
First time in 1996
70

71. Dr. Tushar Chokshi
Clinical benefits of TCI ( >2000 publications)
* More predictable onset of anaesthetic effect
* Higher stability during maintenance
* More predictable offset of anaesthetic effect
* Short time to recovery
* Low incidence of PONV
* Short time to discharge
Economic benefits
* Saves nursing time in the recovery room
* Limits the need for anti-emetic therapy
* Allows patients an early return to work
71

72. Dr. Tushar Chokshi
TCI Models Overview
72

73. Dr. Tushar Chokshi
73
Tushar Chokshi Infusion (TCI)
Three Styles
1) KPD Infusion ( Ketamine + Propofol + Dexmedetomidine )
0.5 mg : 0.5 mg : 0.5 mcg / kg/ hr ( In 500 ml RL )
2) Dexmedetomidine Infusion ( In 500 ml RL )
1 mg/ kg / hr
3) Propofol Infusion ( In 100 ml NS)
6 mg / kg / hr
(As maintenance infusion during TIVA)
Without TCI Machine

74. Dr. Tushar Chokshi
Closed Loop Anaesthesia Delivery Systems
or
Automated Total Intra Venous Anaesthesia
A closed-loop system is the ideal
means of automated drug delivery
• The Input – Drug delivery (etc. Propofol, Opioids)
• The Output – Evoked Potential, Bispectral
Index (BIS), Blood Pressure, Pulse Rate.
ATIVA/CLADS
74

75. Dr. Tushar Chokshi
D
Input
Output
75
Computer
Drugs Delivery
Vital Signs

76. Dr. Tushar Chokshi
Closed Loop Anaesthesia Models
76

77. Dr. Tushar Chokshi
Clinical Benefits of Closed Loop Anesthesia
• Automatic delivery of anaesthetic
drugs to the patient at the time of
induction of anaesthesia using IV
anaesthetic agents depending
upon the patient’s condition or
choice of anaesthetist.
• Frees the anaesthetist from the
repetitive task of looking at the
anaesthetic depth and altering the
drug delivery manually.
• Frees anaesthetists hands to allow
him/her for other activities while
keeping a watch on the monitor.
• Anaesthetist is warned of the
abnormal rates of drug delivery as
well as abnormal response of the
patient through visual and audio
warning
• Fine-tuning of the drug delivery
according to the requirement of
the patient as well as the surgical
stimulus requirement.
• Safety of patient by cutting off
anaesthetic drug delivery in case
of severe drop in blood pressure or
heart rate.
• The anaesthetist to define the
safety limits of blood pressure as
well as heart rate and blood gas
levels for not only warning the
anaesthetist but also stopping
delivery of the anaesthetic agents.
• The anaesthetist to define the
inspired and expired
concentrations of anaesthetic
agent beyond which the system
stops delivery of anaesthetic
agent. 77

78. Dr. Tushar Chokshi
iControl-RP (Remifentanyl-Propofol)
iControl-RPR (Remifentanyl-Propofol-Relaxant)
• Auto Robotic TIVA CLADS
• US FDA approved
• Developed in Vancouver at University of British
Columbia in 2015
• By Team of Dr. Ansermino(Pediatric
Anesthesiologist) & Dr. Dumont(Professor of
electrical and computer engineering)
78

79. Dr. Tushar Chokshi
TIVA
in Different
Groups of
Patient
Pediatric Geriatric
Obese
ASA III
79

80. Dr. Tushar Chokshi
TIVA in Pediatric Patients
• Paediatric total IV anaesthesia (TIVA)
can facilitate surgery, reduce airway
responsiveness, and minimize
complications such as postoperative
nausea and vomiting and emergence
agitation
• Manual infusions remain an important
option in clinical practice due to
variability of dose regime
• Kataria and Paedfusor TCI models are
used. The Kataria model used in
children aged 3-16 yr and weighing 15-
61 kg, and the Paedfusor in children
aged 1-16 yr and weighing 5–61 kg
• Propofol, Ketamine, Remifentanil and
dexmedetomidine play important role
in TIVA
• For obese children use the total body
weight (TBW) to calculate the dose
needed for infusion
As far as avoid TIVA in
Neonates
80

81. Dr. Tushar Chokshi
TIVA in Geriatric Patients
• Compared with inhalation anaesthesia, TIVA is
more suitable as it has less observable effects
on cognitive function in elderly patients after
surgery
• Comparing with TIVA, inhalational
anaesthetics may augment complications
related with reduced lung blood flow and
circulatory depression. Inhalational
anaesthetic agents may further reduce cardiac
output and cause potentially lethal increase in
alveolar concentration
• Always start with a low
concentration/infusion rate and slowly work
upwards. Go Low, Go Slow and Always Follow
• Most important is to avoid hypotension.
Consider intravenous fluids and vasopressors
when appropriate
• Multi Para monitoring and Oxygen is must
during TIVA in geriatric patients 81

82. Dr. Tushar Chokshi
TIVA in Obese Patients
• TIVA is an excellent method of
administering general anaesthesia
to obese patients
• The recommended drug dose in
obese patients always lower than
non-obese patients, the actual
blood concentration is higher than
the calculated target dose of drugs.
• The “no-relaxant” technique (for
intubation) is not advisable for
obese patients and Suxamethonium
for intubation in TIVA is ideal choice
• In Obese patient always secure
airway to avoid respiratory
depression with nasal or oral
airways
• Multi Para monitoring and Oxygen
is must during TIVA in Obese
patients 82

83. Dr. Tushar Chokshi
TIVA in ASA III Patients
• TIVA can be given to seriously ill
patients in whom their systemic
disease is not a threat to their life
(ASA III)
• There are no specific protocols for
TIVA in ASA III patients but dose of
TIVA of elderly patients can be
adopted, require a lower
concentration to produce
anaesthesia
• Multi Para monitoring and Oxygen is
must during TIVA in these patients
• Choose the most appropriate TIVA
drugs according to the patient’s
physical condition:-
# Whether the patient is elderly or
young
# Whether the patient is obese or
non-obese 83

84. Dr. Tushar Chokshi
Surgical Procedures under TIVA
in
COVID Pandemic
• From OT to Outside OT
• From Pediatric to Geriatric patients
• From any Surgical to Medical Specialty
84

85. Dr. Tushar Chokshi
TIVA
• All anesthesia drugs, Airway Equipments, Oxygen and Multipara
Monitor are must before giving TIVA
• Ensure no leakages from cannula and patient’s IV cannula is always
visible during the surgery (if possible)
• Syringes should be labelled with the drug name, date and
concentration
• Infusion lines should be checked every 15 minutes during surgery
• The infusion set through which TIVA is delivered should have a Luer-
lock connector at each end
• If BIS is used, check placement before and after surgical draping
• At end of case, ensure all tubing/IV cannulae which had TIVA drugs
by any method are flushed to prevent inadvertent boluses in the
ward
85

86. Dr. Tushar Chokshi
TIVA Monitoring
• Anesthesiologist
• Loss of response to shaking and
shouting
• Loss of hemodynamic response
or limb movement with
vigorous jaw thrusting
• Absence of tachycardia or even
bradycardia with laryngoscopy
and intubation
• Multipara monitoring
• Bispectral Index Monitor
• Evoked Potentials
• pEEG monitor is recommended
when a neuromuscular
blocking drug is used with TIVA
Visual
Machine
86

87. Dr. Tushar Chokshi
TIVA
TIVA has become more Popular, Practical and Possible
due to two main reasons –
First
The advance knowledge of pharmacokinetic and
pharmacodynamic properties of drugs such as Propofol,
Ketamine, Dexmedetomidine and newer short-acting opioids,
making them suitable for intravenous administration
Second
New concepts in pharmacokinetic modeling coupled with
advances in the technology of infusion pumps which allow the
use of algorithms such as Syringe Infusion Pumps, Target
Controlled Infusion (TCI) & Closed Loop System
Propofol with Remifentanil seems to be the dominating TIVA
technique all over world, delivered either by conventional
pumps or by target control systems or by close loop systems
87

88. Dr. Tushar Chokshi
TIVA APPS
88

89. Dr. Tushar Chokshi
Do TIVA with your Smartphone and volumetric pumps,
in a pharmacokinetic manner 89

90. Dr. Tushar Chokshi
90

91. Dr. Tushar Chokshi
The easiest and best drug
infusion calculator for
anaesthesia or anywhere
else
91

92. Dr. Tushar Chokshi
92

93. Dr. Tushar Chokshi
TIVA
Textbook
93

94. Dr. Tushar Chokshi
So TIVA in Fact
• Patient Friendly
• Surgeon Friendly
• Anaesthesiologist
Friendly
• Economically Friendly
• Environmentally Friendly
• Productivity Friendly
TIVA will be a norm in Future Practice
This is how it is used
94

95. Dr. Tushar Chokshi
Future
 Auto TIVA through Artificial Intelligence(AI) with
help of TCI and BIS
 Dexmedetomidine TCI model Hannivoort and Dyck
will be launched in 2021
 Like Vaporizers, the Syringe Pumps and TCI systems
will be integrated into the Anesthesia Work Station
 TIVA will be a Norm and New Normal
 TIVA will rule in all anaesthesia techniques by 2030
95

96. Dr. Tushar Chokshi
ALL-IN-ONE TCI and CLA
96

97. Dr. Tushar Chokshi
Secret Project for long TCI TIVA
Asena P&P
97

98. Dr. Tushar Chokshi
Instead of This complex Anesthesia machines with Monitors
98

99. Dr. Tushar Chokshi
AI
Monitor
In 2030
Switch On
&
Switch Off
Anaesthesia
Machine
Tusha
Future TIVA Anaesthesia Work Station

100. Dr. Tushar Chokshi
Newer Drugs in TIVA
• Remimazolam ( Narcotic + Benzodiazepine ) 2020
• Suggamdex ( Reversal Agent) 2015
• Hyptiva (Anesthetic + Narcotic) combines the
pharmacodynamics of Propofol with the
pharmacokinetics of Remifentanil
• Duzitol (Anesthetic + Narcotic + Muscle Relaxant)
combines hypnosis, amnesia, analgesia, muscle
relaxation and aphrodisiac
100

101. Dr. Tushar Chokshi
Take Home Message
Total Intravenous
anaesthesia is
viable and
safe alternative to
the Inhaltion
Anaesthesia , with
lots of advantages
over the latter
The newer intravenous
hypnotics and analgesic
agents with
favourable
pharmacokinetic
properties
have made TIVA more
popular in a wide array
of varying clinical
scenarios and
anaesthetic demands
Manual Controlled
Infusions using regular
syringe pump can
be used to deliver pre-
calculated doses
TCI pumps and
advance monitors
make
administration of
TIVA easy and
precise
&
STEP IN YOUR
COMFORT ZONE
with TIVA
for
Safe Anaesthesia
Safe Surgery
Safe patient
Safe Yourself 101

102. Dr. Tushar Chokshi
Patient wants more than Gas Anesthesia

103. Dr. Tushar Chokshi
103
I
I won’t use TIVA
I can’t use TIVA
I won’t to use TIVA
How do I use TIVA
I will try to use TIVA
I can use TIVA
I will use TIVA
Yes, I have used TI

104. Dr. Tushar Chokshi
GROUP 104

105. Dr. Tushar Chokshi
Different TIVA Societies in the World
www.eurosiva.eu
www.worldsiva.org
https://siva.ac.uk
105

106. Dr. Tushar Chokshi
106