TIVA is a technique of anesthesia involving the induction and maintenance of anesthetic state with IV drugs alone. Shorter context sensitivity half time anesthetic agents like propofol is the universally accepted induction agent of choice widely used as a component of TIVA.
2. Objective of the presentation
To discuss :
• Update in TIVA and its practical aspects
• Journal Articles & Guidelines
• Clinical Uses and future practices of TIVA
2
3. Lecture Outline
• Introduction to TIVA Practice
• Drugs selection and its combination
• Methods of TIVA delivery
• Journal articles and guidelines
• TIVA in special population
• Promising of TIVA
• Summary 3
6. Introduction
• TIVA is technique of
Anesthesia given
exclusively by the IV
route/ without Gas
Anesthesia
Miller’s 9
edition
• Become Popular, Practical
and Possible due to:
1. The advance knowledge of Pk
and PD properties of newly
developing drugs
2. New concepts in PK modelling
coupled with advances in the
technology of infusion pumps
(Stoelting’s Basic anest 6th ed)
3. Current Global issues (WAG vs.
Health policy: carbon free footprint)
US Narrative Review . Anesth 2021
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7. TIVA...
• With/Without Airway Equipments
• With Single and/ or Combined drugs
• With/Without Regional analgesia ( MAC)
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8. 8
TIVA
INDICATIONS
Almost in all
surgical
procedures
MH susceptible
Remote
locations
Airway
procedures
PONV risk
Neurosurgery
Neuromonitoring
Short
procedures: CT,
MRI, Cardiac,
catheterisation
Daycare Surgery,
Patient Choice
9. Advantages
• Clinical Benefit of TIVA
• Predictable onset and offset of anesthetic effect
• More HD stability and shorter recovery
•
• Economic Benefits of TIVA
• Costs and Hospital stay
• Environmental friend! (Safe)
9
10. TIVA Drugs
• All most all IV
anesthetics but shorter
context sensitivity half
time agents are
preferred
• CSHT- Time taken
for plasma conc- of a
drug to decline by
50% after an infusion
designed to
maintained steady
state. (R.Eyres 2014) 10
13. TIVA Drugs combinations
• KETOFOL TIVA (Ketamine and Propofol) Amorytin,et.al 2014
• Higher Ketamine ratio 1:2 is useful for induction and lower for mtc.
• RP TIVA (Remefentanyl and Propofol)Ideal combination for TCI
• PDF TIVA (Propofol, Dexmedetomidine and Fentanyl)
• KPD TIVA (Ketamine, Propofol and Dexmedetomidine) Ragia et.al 2012
Best opioid free Tiva
• KETODEX TIVA (Ketamine and Dexmedetomidine) Vidya Sagar 2017
• Opioid free anesthesia, preferable to children, obesity
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14. Ketofol journal articles
• Amorytin S(2014) Ketofol:
A combination of ketamine
and propofol. J. Anesth
critical care open Access
1(5).00031 (Thailand)
• Conclusion: ketofol has
several benefits of HD
stability, lack of respiratory
depression, good recovery
and post op analgesia.
• The safety and efficacy of
ketofol as analgesics are
depend on dose and ratio of
mixtures .
• Saudi J Anest 2016
Aug4(2). 72-79
• Comparison of two drug
combination in tiva: ketofol
and propofol-fentanyl;
• Conclusion: the result of
this study suggest that both
ketamine-propofol and
fentanyl-propofol
combination produce rapid,
pleasant and safe anesthesia
with only few unwanted
side effects and minor HD
fluctuations
14
15. Ketodex Journal articles
• Comparison of ketamine and dexmedtomidine versus
ketamine propofol for procedural sedation in children
undergoing minor cardiac catetherasation.
Ann.Card. Anesth.Oct 2017;20(4).422-25
• Conclusion: use of Ketodex combination is safe
alternative, without any HD and respiratory effect during
cardiac catheterization procedure but with some delay
recovery
15
16. Propofol + Remifentanil (Remifol)
• Most widely used TIVA combination
• Adequate analgesia, satisfactory hemodynamic, rapid recovery
• Remifentanil concentration is 50 mcg/ml (1mg in 20 ml propofol)
• Synergism- Propofol dose reduction by 50%
• Delivered either by conventional pumps or by TCI systems or by
close loop systems
• Ideal agents for TCI model
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17. PR TIVA...
• Journal in article (Guener junior,et.al mixed use of propofol
remifentayl. Dovepress.2014;176(3)
• Conclusion: In health patient with orthopedic surgery, tiva
with simplified infusion rate of propofol -remifentanyl mixture
allowed satisfactory course of anesthesia fast awaking and
effective postoperative analgesa better than inhalational
techniques
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18. KPD TIVA (Ketofol and Dex)
Mixture in 1:1:1 Dose for TIVA
• Combination of all these drugs permit lower
dose of each individual agent for TIVA, rapid
recovery and reducing their adverse effects
• Excellent analgesia and anesthesia
T. Chokshi 2019
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19. Journal Articles...
• Effects of propofol-base TIVA on gastric cancer: a retrospective
study Xiaoyu Zheng. et.al 2019.
• These results indicate that TIVA may be associated with improved
survival in gastric cancer patients who undergo resection.
• Current Systematic Review & Meta analysis suggested that TIVA is
associated with lower all cause mortality after cancer surgery.
Zhaosheng Jin; 2020;11(3):83-94
• TIVA in ERAS/ERPs was understuding, but theoretically best option.
G. Joshi 2018
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20. HOWTO GIVE TIVA
1. Single Syringe TIVA (SSTIVA)
2. Manually Controlled Infusion (MCI)
3. Target Controlled Infusions (TCI)
4. Automated (ATIVA ) /Closed Loop Systems 20
21. 1. Single Syringe TIVA
• Only one syringe is used, with the
advantage of dose titration at a single level
& fixed dose mixtures
• Short procedures can be managed with
intermittent boluses, without a syringe
pump.
• It can be practiced in low set ups, and
NORA
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22. 2. Manually Controlled Infusion (MCI)
• Manual dosing with fixed infusion rate
• Regular syringe pump can be used to deliver
pre-calculated doses
• Bristol model: Propofol (10-8-6) rule
Bolus: 1mg/kg plus
10 mg/kg/hr for 10 minutes,
8 mg/kg/hr for next 10 minutes,
6 mg/kg/hr there after
Opioids or Opioid free Tiva (MMA)
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23. Ketofol +Dexmed (OFA)
• Dilute ketodex in (2mg/ml + 2ug/ml)
• Loading = 0.5-1ml/kg over 10'
• Maintenance = 0.25 ml/kg/hr
• Don't Adjust analgesic dose
• Depth Can adjust with propofol infusion only
• Switch Off 15' prior to complete of surger
NB: Fundamental rule for dilution is minimum conc should be
2mg/ml 23
24. With Opioids -MCI
Remifentanyl MCI
• Initial dose of 1 ug/kg
bolus
• * Maintenance 0.25-0.5
ug/kg/min IV
• Post-Op 0.025-0.2
mcg/kg/min IV
Fentanyl MCI
• Bolus 2-3 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
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25. 3. Target controlled infusion TCI
• A computer assisted drug infusion to achieve a pre set drug
concentration in the plasma or the effect site
• User is defining a desired conc- of drug rather than an
infusion rate.
• User interface to enter details and target blood conc.
• Software with pk model, validated for specific drug to control
infusion rate
• The rates necessary to reach and maintain that conc. are
calculated by the syringe pump using an algorithm based on a
three-compartment pharmacokinetic model.
A. Nimmo 2019
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28. TCI models
Models Fixed
parameter
Variable
parameter
Parameter
Marsh
(plasma
targeted)
All rates are
constant
V1,V2,V3 Weight
Schnider
(effect site )
V1=4.7, V3
k13 k31
V2 k12 k21
k10
Age, LBM,
Sex
Kataria
(plasma
targeted)
All rates are
constant except
k10
V13 k10 Weight
Pedfusor
(effect site )
All rates are
constant
V13 Weight
Minto For remifentanyl, can be used in Cet mode
Allometric
(Eleveld)
A new model (PK/PD) developed using BSI
for diverse populations
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29. Choice of TCI model
• Currently, there is no evidence to support the use of one model
in preference to another and all have proved reliable in clinical
practice.
• All models have similar limitations in terms of the accuracy
and stability of predicted plasma and effect-site concentrations.
• Determinant factors: programming available infusion devices,
age, and physical status of the pts.
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30. Selecting TCI Targets
• Highly effective drug synergy allows the choice of high
propofol/low remifentanil effect-site concentrations or the
converse to achieve a desired clinical effect.
• Recommended minimum effect-site propofol concentration of
2 - 3 μg/ml is maintained.
• Remifentanil effect-site conc. 1-2ng/ml
• Allowing remifentanil to equilibrate at the effect-site before
starting the propofol is a useful technique with risks and
benefits-
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31. Checklist for settingup TCI: SIVA2019
• Use only dedicated pk TCI
pumps
• Ensure that you are
trained in use of the
chosen model
• Ensure the pumps are
plugged and charged
• Ensure that the drug
dilutions are correct
• Ensure that the correct
syringe type and size data
are entered and mounted
correctly
• Ensure that the pump is
programmed for the drug
actually attached to it
• Ensure that the low and high
infusion pressure alarms are
set
• Ensure that the correct patient
data are entered
• Consider if the targets set are
appropriate to the patient's
status
• What is plan B if the pump(s)
fail? 31
32. 4. Closed Loop /AutoTIVA
• Ideal means of automated drug delivery
• The Input – Drug delivery (etc. Propofol, Opioids)
•
• The Output – Evoked Potential, BIS, and vital signs
• Any given moment at input to the systems is function of previous output
(measurable feedback signal)
• Use Newly developing drugs; Hyptiva ( Anesthetic + Narcotic ), Duzitol
( Anesthetic + Narcotic + Muscle Relaxant), and Remimizolam ( Narcotic
+ Benzodiazepine )
• icontrol RPR (Remi- prop-Relaxant)
T.Choski 2019; Eleveld et.al. (Anesth.2019)
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33. Guideline for safe practice of TIVA
• A.Nimmo.et.al. joint guideline from ASA and SIVA. (2019)
Recommendations (10) next slide
• Principles of TIVA practical aspects: Use TCI; Advanced PK
Model for TCI and Understanding of CSHT facilitate increase
use of TIVA in various clinical settings .
• Al.Rifai.et.al 2016. BJA Educ.16(8). 276-80
Different TIVA Societies: www.eurosiva.eu, www.worldsiva.org,
https://siva.ac.uk
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34. Monitoring in TIVA
1. Clinical judgements: response to noxious
2. Tiva trainer pk software
predict the necessary effect-site conc. real time
3. Use of processed EEG:
4. BIS & TOF If Neuromuscular paralysis
www.eurosiva.eu
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35. TIVAIN DIFFERENT GROUPOF PATIENTS
• TIVA IN PEDIATRICS
PATIENT
• MCI remain an important option
• The Kataria and Paedfusor
model used
• As far as avoid TIVA In
Neonates
• TIVA IN GERATRICS
PATIENTS
• Less effects on cognitive function,
Cardiopulm. depression
• Always start with a low
concentration/infusion rate and
slowly work upwards.
• TIVA IN OBESE PATIENTS
• The recommended drug dose
always lower than non-obese
patients,
• Aways secure airway to avoid
respiratory depression with
nasal or oral airways
• Opioid free anesthesia
• TIVA IN CRITICAL
PATIENTS
• There are no specific protocols
• Dose can be adopted, require a
lower concentration
• Multi Para monitoring and
Oxygen in all cases
T. Chokshi 2022, Egan et.al (2017)
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36. TIVA during covid-19
pandemic
• TIVA during covid-19 pandemic is far more
advantageous D. Gahlot 2022
• It Avoids deleterious effects of
immunosuppression and lack of respiratory
irritation, thus it providing edge of current
situation
• GAS= Gas Always Side-effects!
T. Chokshi 2020
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37. TIVA in low resource setup
• Opioids free anesthesia (OFA)
• Mixture of anesthetics + adjuvants
• The purpose is sympathetic block (perfect
anesthesia!)
• No TCI devices (single dose-dependent injection
and/or manual control infusion)
• E.g: ketamine/ ketofol + IV lidocaine +MgSo4
combination shows greater HD stability
37
38. Potential problems with TIVA
• Propofol related infusion syndrome: (rarely)
• evidence to support this view is very limited.
• Awareness Under Anesthesia mainly dueto
• Technical errors and poor application of knowledge
• 75% of these causes would have been preventable
• Deployment of a processed EEG device especially if muscle
relaxants were given
• Opioid induced hyperalgesia!
NICE & NAP5 (2019) recommendation
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39. Future of TIVAWork Station
• Auto TIVA (Work with
concept of Augmented reality
of Artificial Intelligence with
help of TCI and BIS)
• Use Different TCI models
• Like Vaporizers, the Syringe
Pumps and TCI systems
integrated into the Anesthesia
Work Station
• In built internet, NFC & BT
• Smartphone applications &
Remote controller!
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40. Summary
TIVA is viable, modern and safe anesthesia, with lots of
advantages
TCI pumps and advance monitors make TIVA easy and
precise
Ketofol is most common drugs used as combined and
also with other drugs
The newer TIVA agents with favourable pk properties
have made TIVA feasible in a wide array of varying
clinical scenarios and anaesthetic demands
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