Total intravenous anesthesia

Increasing use is now being made of injectable, instead of inhalational, anesthetics during prolonged combined anesthesia (total intravenous anesthesia—TIVA). 

In the last two decades there has been increasing use of intravenous anesthetics in anesthesia, both as adjuncts to inhaled anesthetics and as part of techniques that do not include any inhaled anesthetics (eg, total intravenous anesthesia). The properties of some of the commonly used intravenous anesthetics are summarized in Table 25-1. Unlike inhaled anesthetics, intravenous agents do not require specialized vaporizer equipment for their delivery or facilities for... 

Casati A, Cappelleri G, Aldegheri G, et al. Total intravenous anesthesia, spinal anesthesia or combined sciatic-femoral nerve block for outpatient knee arthroscopy. Minerva Anestesiol. 2004 70 493-502. 

The risk of postoperative nausea and vomiting has been studied in a randomized, controlled trial of total intravenous anesthesia with propofol versus inhalational... 

Several small clinical trials have suggested that total intravenous anesthesia with propofol reduces the incidence of postoperative nausea and vomiting and results in shorter emergence times. However, a systematic review (52) and a meta-analysis (53) have shown that most studies were small, did not have follow-up for more than 6 hours postoperatively, and were sponsored by industry. The results were difficult to combine, owing to heterogeneous definitions of postoperative nausea and vomiting. 

Total intravenous anesthesia with propofol resulted in a reduced heart rate and a higher frequency of oculocardiac reflex bradycardia than thiopental/isoflurane anesthesia, with a higher sensitivity of children younger than 6 years in all groups (11). 

Hogue CW Jr, Bowdle TA, O Leary C, Duncalf D, Miguel R, Pitts M, Streisand J, Kirvassilis G, Jamerson B, McNeal S, Batenhorst R. A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient smgery. Anesth Analg 1996 83(2) 279-85. 

Total intravenous anesthesia with fentanyl has been selected for a frail 72-year-old woman about to undergo cardiac surgery. Which one of the following statements about this anesthesia protocol is accurate ... 

Homuss C, Praun S, Villinger J, et al. Real-time monitoring of Propofol in expired air in humans undeigoing total intravenous anesthesia. Anesthesiol. 2007 1006 665 74. 

Chandler JR, Myers D, Mehta D, Whyte E, Groberman MK, Montgomery CJ, et al. Emergence delirium in children a randomized trial to compare total intravenous anesthesia with propofol and remifentanil to irthalational sevoflurane anesthesia. Pediatr Anaesth April 2013 23(4) 309-15. 

Fechner J, Ihmsen H, Schuttler J, Jeleazcov C. A randomized open-label phase 1 pilot study of the safety and efficacy of total intravenous anesthesia with fospropofol for coronary artery bypass graft surgery. J Cardiothorac Vase Anesth 2013 27 908-15. 

MAC values of the inhaled anesthetics are additive. For example, nitrous oxide (60-70%) can be used as a carrier gas producing 40% of a MAC, thereby decreasing the anesthetic requirement of both volatile and intravenous anesthetics. The addition of nitrous oxide (60% tension, 40% MAC) to 70% of a volatile agent s MAC would yield a total of 110% of a MAC, a value sufficient for surgical anesthesia in most patients. 

Brief History. B.W., a 75-year-old woman, fell at home and experienced a sudden sharp pain in her left hip. She was unable to walk and was taken to a nearby hospital where x-ray examination showed an impacted fracture of the left hip. The patient was alert and oriented at the time of admission. She had a history of arteriosclerotic cardiovascular disease and diabetes mellitus, but her medical condition was stable. The patient was relatively obese, and a considerable amount of osteoarthritis was present in both hips. Two days after admission, a total hip arthroplasty was performed under general anesthesia. Meperidine (Demerol) was given intramuscularly as a preoperative sedative. General anesthesia was induced by intravenous administration of thiopental (Pentothal) and sustained by inhalation of halothane (Fluothane). The surgery was completed successfully, and physical therapy was initiated at the patient s bedside on the subsequent day. 

Inhalational agents potentiate muscle relaxants, which is of more clinical importance with regard to non-depolarizing agents. Tachyphylaxis and phase II block develop earlier and after smaller total doses of suxamethonium when volatile agents such as halothane, enflurane, or isoflurane (306,307) are used instead of balanced anesthesia. Halothane can increase the incidence of cardiac dys-rhjdhmias, especially bradycardia and nodal rhythm, after suxamethonium. Atropine and glycopyrrolate, particularly when given intravenously just before, afford some protection (SEDA-5,136) (308). 

One dosing cohort received 75 U kg rhAT, and the other cohort received a normal sahne placebo (both as single bolus intravenous injection). Heparin resistance was defined as failure to achieve an ACT of >480 seconds after receiving a total dose of 400 U kg heparin intravenously after anesthesia induction and surgical incision, but just prior to CPB. The proportion of rhAT patients who required administration... 

Propofol Propofol produces anesthesia at a rate similar to that of the intravenous barbiturates, and recovery is more rapid. Propofol has antiemetic actions, and recovery is not delayed after prolonged infusion. The drug is commonly used as a component of balanced anesthesia and as an anesthetic in outpatient surgery. Propofol may cause marked hypotension during induction of anesthesia, primarily through decreased peripheral resistance. Total body clearance of propofol is greater than hepatic blood flow, suggesting that its elimination includes other mechanisms in addition to metabolism by liver enzymes. 

Elman R (1937) Urinary output of nitrogen as influenced by i.v. injection of a mixture of amino acids. Proc Soc Exp Biol Med 37 610-613 Fischer JE (1976) Total parenteral nutrition. Little Brown, Boston Fisher MMcD (1975) Severe histamine mediated reactions to intravenous drugs used in anesthesia. Anesth Intensive Care 3 180-197... 

A 60-year-old women underwent intravenous regional anesthesia with 3 mg/kg of prilocaine 0.5% diluted with saline to a total of 40 ml for surgical treatment of carpal tunnel syndrome and 3 minutes after injection developed severe erythema and edema in the limb below the tourniquet. Intravenous hydrocortisone was started and the tourniquet was released after 20 minutes. All the skin signs disappeared within 1 hour and there were no systemic reactions after release of the tourniquet. A skin prick test later confirmed allergy to prilocaine. 

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