Features  |   August 2015
Total Intravenous Anesthesia: Present and Future
Author Affiliations
  • Girish P. Joshi, M.B.B.S., M.D., FFARCSI
    Educational Track Subcommittee on Ambulatory Anesthesia
Article Information
Ambulatory Anesthesia / Cardiovascular Anesthesia / Endocrine and Metabolic Systems / Pain Medicine / Pharmacology / Technology / Equipment / Monitoring / Features
Features   |   August 2015
Total Intravenous Anesthesia: Present and Future
ASA Monitor 08 2015, Vol.79, 10-57.
ASA Monitor 08 2015, Vol.79, 10-57.
The availability of short-acting sedative-hypnotics (i.e., propofol) and opioids (i.e., remifentanil) and smart delivery systems (e.g., target-controlled infusion [TCI] systems) have increased the popularity of total intravenous anesthesia (TIVA). TIVA techniques are increasingly being used in an ambulatory setting, particularly the office-based anesthesia (OBA) practice in which the office “operating room” may have limited space and minimal equipment,1  as administration of TIVA does not require an anesthesia machine and scavenging equipment. In addition, TIVA is associated with lower incidence of postoperative nausea and vomiting (PONV) and avoids the risk of malignant hyperthermia (MH). Although TIVA techniques are generally considered to be more expensive, the differences in costs between inhaled anesthetic and TIVA techniques are difficult to measure because of the many factors that may influence costs.2  Despite its advantages, TIVA has some limitations. TIVA lacks the muscle relaxant effects of inhaled anesthesia. Also, in contrast to inhaled anesthesia where the end-tidal concentrations can be used for prevention of recall, bispectral index (BIS) monitoring is recommended during TIVA.3 
1 Comment
September 21, 2016
Barry Friedberg
President and Founder, Goldilocks Anesthesia Foundation, a 501c3 non-profit corporation
TIVA, Present and Future

BIS without simultaneous EMG trending is not a useful tool. Real-time EMG is akin to real time EKG. Spikes in EMG are a warning of incipient arousal, readily ameliorated with additional propofol to return EMG to the baseline. For what it's worth, the 2015 factory default setting is now BIS/EMG.

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