Pain Therapy TIVA

TIVA can be conducted either with a single drug or with a combination of drugs. The pharmacological profile (pharmacokinetics) of the drug help clarify it’s clinical implications and thus assist in drug selection. The most commonly utilized groups of drugs include hypnotics and short-acting opioids⁵. The discovery of Propofol in the 70s revolutionized the use of TIVA. It is currently the only intravenously active hypnotic agent suitable for the induction & maintenance of anesthesia. Propofol-based TIVA techniques offer many advantages including rapid recovery of consciousness and psychomotor function, enhanced recovery speed, anti-emetic effect and a lower incidence of post-operative nausea and vomiting⁶. The Propofol can be coupled with opioids, muscle relaxants, NSAIDs etc. depending on the patient case or the type of procedure to be performed. When using TIVA via TCI, short-acting opioids such as Remifentanil are preferred. Recently, it was seen that TIVA via a TCI combining Remifentanil & Propofol effectively controlled intra-operative responses while allowing for rapid emergence from anesthesia in elective inpatient surgery⁷. Similar results have also been noted in outpatient surgeries.

As TIVA is conducted exclusively via an intravenous infusion, the choice must be made from either a peripheral or a central venous access device. This selection is often guided either by the patient condition, or by the number and types of drugs being infused. For short term procedures, where extended venous access is not considered necessary, an Intravenous Catheter could be used. For patients where it is expected that post-procedure infusions would be required (for e. g. in critically ill patients), or in patients receiving a regimen of mutually-incompatible drugs, a multi-lumen central venous catheter is recommended. For neonatal or pediatric patients, a scalp vein set could also be used as an access device.

The methodology of performing a TIVA via TCI depends highly on the choice or regimen of drugs selected which also consequently influences the drug preparation process. The selected drugs may or may not be available in ready-to-use glass/plastic vials, or glass/plastic ampoules. Ready-to-use drugs can be drawn up into syringes directly or through a filter. For drugs that need mixing, needle-free mixing devices and mixing bags could be used. In some cases, process-specific procedure kits could be made available which include all the necessary devices, drapes and dressings, based on the choice of method or drug combination. These procedure kits could support in making the entire process safer and more efficient.