When tiva is useful

What is TIVA (and why choose it)?

• TIVA = maintaining general anaesthesia using intravenous drugs (commonly propofol + an opioid such as remifentanil), rather than inhaled volatile agents.
• Often delivered using a target-controlled infusion (TCI): a pump that aims for a chosen drug concentration (e.g., effect-site target for propofol).
• Main reasons to choose TIVA: reduce postoperative nausea/vomiting (PONV), avoid volatile-related issues, improve conditions for certain surgeries, and provide stable anaesthesia when gases are impractical.

High PONV risk (common and exam-relevant)

• TIVA with propofol reduces PONV compared with volatile anaesthesia (useful in patients with previous severe PONV or multiple risk factors).
• Particularly helpful for day-case surgery where early discharge matters.
• Still use multimodal antiemetics as indicated (TIVA reduces risk but does not eliminate it).

Airway surgery and shared-airway cases

• Useful when the surgeon needs access to the airway (e.g., microlaryngoscopy, bronchoscopy) and volatile delivery may be unreliable due to leaks or open circuits.
• Maintains anaesthesia when ventilation is intermittent or via non-standard techniques (e.g., jet ventilation) where end-tidal agent monitoring is limited.
• Plan depth monitoring carefully (clinical signs ± processed EEG if used locally) because you may not have end-tidal agent as a guide.

Neurosurgery and neuro-anaesthesia considerations

• Propofol-based TIVA can help provide a “slack brain” (reduced cerebral blood flow and intracranial pressure) compared with some volatile techniques.
• Useful when stable physiology and rapid wake-up for neurological assessment are desired.
• Common in cases needing neurophysiological monitoring (e.g., motor evoked potentials), where volatile agents can suppress signals (local protocols vary).

When inhalational anaesthesia is undesirable or impractical

• Malignant hyperthermia (MH) susceptibility: avoid triggering agents (volatile agents and suxamethonium); TIVA is a standard approach (ensure full MH precautions and machine preparation).
• Severe bronchospasm/reactive airways: propofol and opioids may be better tolerated than pungent volatiles in some patients (individualise; ensure bronchodilator plan).
• Poor access to anaesthetic machine or scavenging limitations (e.g., some remote locations): TIVA may be logistically simpler, but only if infusion equipment and monitoring are robust.

Procedures needing stillness or controlled conditions

• Some ENT, ophthalmic, and interventional radiology procedures benefit from minimal movement and stable depth (remifentanil is useful for intense, short-lived stimulation).
• Useful when you want predictable wake-up (e.g., short cases, rapid turnover), especially with remifentanil and careful propofol titration.
• Can be advantageous where low fresh gas flows/volatile wash-in and wash-out would otherwise slow control of depth.

Practical tips for new starters (safe first-time use)

• Always run a continuous opioid alongside propofol for surgical anaesthesia (propofol alone is not enough for most operations).
• Use a dedicated IV cannula for infusions where possible; check patency before induction and re-check after positioning/draping.
• Secure lines well and keep the cannula visible if feasible; extravasation or disconnection can cause awareness.
• Have a clear plan for: induction, maintenance targets, analgesia, antiemetics, and emergence (including postoperative pain plan if using remifentanil).
• If using neuromuscular blockade, ensure appropriate monitoring and reversal plan; paralysis can mask inadequate depth.
• Document drug concentrations, pump settings/targets, and any changes with time stamps.