What is tiva?

Definition (core concept)

• TIVA = Total Intravenous Anaesthesia: general anaesthesia delivered using IV drugs (for hypnosis ± analgesia), without using volatile (inhaled) anaesthetic agents.
• Usually delivered using an infusion pump (often a target-controlled infusion, TCI) rather than repeated boluses.
• Common drug combination: propofol (for unconsciousness) + an opioid such as remifentanil (for analgesia and blunting responses).
• You may still use oxygen/air via a breathing circuit and ventilator; “TIVA” refers to the anaesthetic drugs, not the gases.

Why use TIVA? (common indications)

• High risk of postoperative nausea and vomiting (PONV) or previous severe PONV: TIVA (propofol-based) reduces PONV compared with volatiles.
• Airway surgery or shared airway (e.g., ENT): avoids volatile contamination and can be smoother in some setups.
• Malignant hyperthermia susceptibility: avoid triggering agents (volatile agents and suxamethonium); TIVA is part of a trigger-free technique.
• When stable depth control is desired (e.g., some neurosurgery cases) or where volatile delivery is impractical.

What you need to run TIVA safely (minimum essentials)

• A reliable IV cannula (ideally a large-bore cannula in a good vein) and a plan for what to do if IV access fails.
• A dedicated infusion pump for propofol (and a second pump for opioid if used). If using TCI, confirm correct model and patient details (age, weight, height).
• Standard monitoring: ECG, non-invasive BP, pulse oximetry, capnography, temperature; consider depth of anaesthesia monitoring (e.g., processed EEG) where appropriate/available.
• A clear labelling system: label syringes and lines; keep propofol and opioid lines separate and traceable to the patient.
• A plan for airway management and ventilation as per any general anaesthetic (TIVA does not remove the need for airway vigilance).

How TIVA is typically delivered (new-starter overview)

• Induction: often a propofol bolus (plus opioid) to induce unconsciousness, then start/continue propofol infusion (and opioid infusion if used).
• Maintenance: propofol infusion provides hypnosis; opioid infusion provides analgesia and helps control responses to surgery.
• Emergence: stop/step down infusions in time for wake-up; anticipate that remifentanil wears off very quickly, so ensure a plan for postoperative analgesia.
• Always match drug delivery to clinical signs and monitoring; avoid “set and forget” infusions.

First-time practical tips (things that prevent problems)

• Before starting: check pump settings, syringe size, drug concentration, and that the line is connected to the patient (not to a dead-end or another line).
• Use anti-siphon/anti-reflux valves if required by local policy; be aware of the risk of free-flow if a syringe is not correctly seated in the pump.
• Secure the IV and extension set; keep the cannula visible if possible so you can spot tissuing/extravasation early.
• If using remifentanil: plan postoperative pain relief early (e.g., longer-acting opioid, regional block, paracetamol/NSAID if appropriate).
• Consider PONV prophylaxis even with TIVA if the patient is high risk (multimodal approach).

Common “first shift” scenarios

• High PONV risk day-case: propofol-based TIVA + multimodal antiemetics; ensure timely wake-up and good analgesia plan.
• ENT/shared airway: confirm with surgeon how airway will be managed; ensure pumps and lines are positioned safely and not obstructing access.
• Suspected IV problem mid-case: sudden tachycardia/hypertension/movement with rising BIS (if used) may suggest inadequate anaesthesia—check IV patency and infusion delivery immediately.
• Transfer to recovery: clearly hand over what infusions were used, when stopped, and what analgesia has been given/needs giving.