Guidelines surrounding 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:


  1. Use of a target-controlled infusion (TCI) is recommended when general anaesthesia is to be maintained by propofol infusion.
  2. Initial target concentrations should be chosen based on the patient, co-administered drugs and clinical situation.
  3. It is preferable to only carry one concentration of propofol and to dilute remifentanil to a single, standard concentration.
  4. The TIVA infusion set should be specifically designed for TIVA and have a Luer-lock connector at each end, an anti-syphon valve on the drug delivery line(s), and an anti-reflux valve on any fluid administration line. Additionally, drug and fluid lines should join as close to the patient as possible to minimise dead space.
  5. Infusion pumps should only be programmed after the syringe containing the drug to be infused has been placed into the pump.
  6. The cannula or catheter through which the infusion is delivered should be visible throughout the procedure, when practical.
  7. Clinical utility monitoring is likely improved through observation of electroencephalogram (EEG) trace and electromyography activity, so anaesthetists should be familiar with the principles, interpretations, and limitations of processed EEG monitoring.
  8. When a neuromuscular blocking drug is used with TIVA, the use of a processed EEG monitor is recommended.
  9. Outside of the operating room, the same standards for administering TIVA apply as inside the operating room.8


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. Long-term strategy   Association of Anaesthetists. Accessed October 4, 2022. https://anaesthetists.org/Home/About-us/Long-term-strategy
  8. 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.
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