The latest guidelines relating to total intravenous anaesthesia (TIVA)

Guidelines are in place to advise clinicians on improving the patient experience of anaesthesia, as well as reducing associated hospital costs and patient backlogs. These include the Enhanced Recovery after Surgery®, Getting it Right First Time and Association of Anaesthetists guidelines.

Enhanced Recovery After Surgery (ERAS®)

ERAS protocols refer to patient-centred guidelines developed by multidisciplinary teams. These protocols aim to improve perioperative mortality, morbidity, and patient recovery.¹

TIVA in relation to ERAS® guidelines

As part of the intraoperative phase of the ERAS® guidelines, prevention of PONV (Post operative nausea and vomiting) is strongly recommended. The proposed actions include minimising the usage of volatile anaesthetics, which increase the risk factor of developing PONV ².

The guidelines state:

“All patients with 1–2 risk factors should receive, as PONV prophylaxis, a combination of two antiemetics. Patients with 3–4 risk factors should receive 2–3 antiemetics and total intravenous anaesthesia (TIVA) with propofol, and opioid-sparing strategies should be encouraged.”²

Total intravenous anaesthesia has been associated with a reduction of PONV when compared to the general anaesthetic that combines intravenous and inhalation agents. ³

Furthermore, reduced impacts of PONV positively influence patient satisfaction and recovery.

Getting it Right First Time (GIRFT) guidelines

GIRFT is a national programme designed to improve the treatment and care of patients through in-depth reviews of services, benchmarking and presenting data-driven evidence.

In 2021, new GIRFT guidelines were issued for anaesthesia and perioperative medicine to encourage more procedures to become day cases, with an aim of helping services recover from COVID-19 which caused a massive growth of waiting lists. Currently, day rate cases vary between trusts, from 36-77%.⁴

Key guidelines from GIRFT that reflect the need to tackle the backlog:

• Establishing day case surgery as the default for elective procedures
• Integrating perioperative care across all surgical pathways
• Delivering enhanced recovery pathways to facilitate faster discharge⁵

TIVA in relation to GIRFT guidelines.

Adoption of total intravenous anaesthesia provides an opportunity to combat the backlog by reducing patients’ time at PACU.

A study comparing TIVA to volatile anaesthetics (VA) found that 2 patients from the VA group had to stay in PACU after the procedure. All patients who were anesthetised intravenously could be discharged the same day as their procedure.⁶

This suggests that practicing TIVA as opposed to VA can increase day-case rate.  

Association of Anaesthetists (AOA) TIVA guidelines

The mission of AOA is to improve patient care and safety in the field of anaesthesia. They have published guidelines across many different areas of anaesthesia and its allied disciplines.⁷ Association of Anaesthetists TIVA guidelines are highlighting the following recommendations:

1. All anaesthetists should be trained and competent in the delivery of TIVA. Schools of Anaesthesia and training bodies should provide teaching, training and practical experience of TIVA to all anaesthetic and intensive care medicine trainees. Consultant and staff grade, associate specialist and specialty doctor (SAS) anaesthetists have a responsibility to ensure that they have the knowledge and skills required to deliver TIVA competently and safely.
2. When general anaesthesia is to be maintained by propofol infusion, use of a target-controlled infusion (TCI) is recommended.
3. Starting target concentrations should be chosen depending on the characteristics of the patient, coadministered drugs and clinical situation. Older, frail or unwell patients may benefit from setting a low initial target propofol concentration, and making repeated small incremental increases..
4. Within an anaesthetic department, it is preferable to stock only one concentration of propofol and to dilute remifentanil to a single, standard concentration.
5. The infusion set through which TIVA is delivered should have a Luer-lock connector at each end, an antisyphon valve on the drug delivery line(s) and an anti-reflux valve on any fluid administration line. Drug and fluid lines should join as close to the patient as possible to minimise dead space. The use of administration sets specifically designed for TIVA is recommended.
6. Infusion pumps should be programmed only after the syringe containing the drug to be infused has been placed in the pump.
7. The intravenous cannula or central venous catheter through which the infusion is being delivered should, whenever practical, be visible throughout anaesthesia. When a neuromuscular blocking drug is used with TIVA, the use of a processed EEG monitor is recommended.
8. Anaesthetists should be familiar with the principles, interpretation and limitations of processed electroencephalogram (EEG) monitoring. Observation of the EEG trace and electromyography activity is likely to improve the clinical utility of the monitoring.
9. Use of a processed EEG (pEEG) monitor is recommended when a neuromuscular blocking drug is used with TIVA.
10. When TIVA is administered outside the operating room, the same standards of practice and monitoring should apply as for anaesthesia in the operating room⁷

TIVA with Mediplus

High performance, dedicated TIVA Sets from Mediplus were designed with anaesthetists to meet the highest standards of TIVA delivery. They allow hospitals to follow the ERAS^®, GIRFT and AOA guidelines, delivering additional benefits such as greater patient comfort and cost savings. You can visit our website to learn more about our dedicated TIVA sets.

References:

1. Tippireddy S, Ghatol D. Anesthetic Management For Enhanced Recovery After Major Surgery (ERAS). In: StatPearls. StatPearls Publishing; 2022. Accessed October 3, 2022. http://www.ncbi.nlm.nih.gov/books/NBK574567/
2. Feldheiser A, Aziz O, Baldini G, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiologica Scandinavica. 2016;60(3):289-334. doi:10.1111/aas.12651
3. Habib AS, White WD, Eubanks S, Pappas TN, Gan TJ. A randomized comparison of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. Anesth Analg. 2004;99(1):77-81. doi:10.1213/01.ANE.0000120161.30788.04
4. Getting it Right First Time. ‘Day Surgery as the Default’ Is Important Key to Tackling COVID-19 Surgical Backlog, Says GIRFT Report. https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2021/11/APOM-overview.pdf
5. GIRFT National Report for Anaesthesia and Perioperative Medicine.; 2022. Accessed October 6, 2022. https://www.youtube.com/watch?v=pwbr2hZuRmg
6. Smith I, Terhoeve PA, Hennart D, et al. A multicentre comparison of the costs of anaesthesia with sevoflurane or propofol. Br J Anaesth. 1999;83(4):564-570. doi:10.1093/bja/83.4.564
7. Nimmo et al. Guidelines for the safe practice of total intravenous anaesthesia (TIVA). Guidelines for the safe practice of total intravenous anaesthesia (TIVA). 2018;74(2):211-224.