I Love TIVA

[seamonkey]

As a new CA-1 finishing up my 1-1 month, my two attendings so far have been big big TIVA fans. This stuff is amazing and seems really simple to use. The induction is smooth, maintenance easy, and emergence is like velvet, with almost no post-op probs. People wake up within 5 minutes of shutting off the Alaris pump. And they feel great.

Propofol + remifentanil + phenylepherine = success


so, since I'm new, I must be missing something. Why isn't this used more often? This method seems much more simple and elegant, and much easier on the patient (especially in emergence) than using volatile agents.

Someone please clue me in, 'cause at this point I'm already a convert.

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[Licoricestick]

seems really simple to use. The induction is smooth, maintenance easy, and emergence is like velvet, with almost no post-op probs.

Yeah...wait til you're on your own. Any anaesthetic technique can be really smooth with experience!

About 6-8 weeks in (other side of the world - our year starts in Feb) I did my first case where my boss wasn't in theatre for any of it - it wasn't the smoothest anaesthetic I've ever given! Couldn't get the opioid titration right and she woke up sorer than she should have. Straightforward case...but experience goes a long way.

 

[ssmallz]

b/c its expensive and requires time to set up. Both propopfol and remi are much more expensive than using VA for a patient, especially when the case is long. Setting up the mixutre and pump takes some time before hand and can be a pain in the butt if your room is turning over quick. I do love using narcotic drips but prefer using the them as an adjunct to VA instead of as part of a TIVA b/c the VA is much more easily titratable if something isn't goin smoothly.

 

[dfk]

seamonkey,
tiva's are smooth and expensive. is your current facility affected by the national remi shortage?

 

[seamonkey]

As for setting up the pumps, I'm pretty quick at it now, so its not too big a deal.

It is pretty easy to just push a big slug of propofol and/or remi with rapid onset of effect if needed. And so far the patients respond within a minute or two when we turn down the drip rates. Maybe I've just been lucky so far, but they seem relatively easy to titrate.

Yes, we are hit by the remi shortage. Did a couple of cases this week using propofol + sufentanil, and will do about 4 more with that combo on monday. That mix (prop + suf) was amazing. Vitals looked like railroad tracks across the page, it was so stable. Only problem was induction hypotension, but it was easily fixed, and smooth sailing from then on out.

 

[drccw]

Did you use BIS for moitoring depth of anesthesia? I'm not a big BIS fan (don't even have it at my hospital) but I think for TIVA it's almost necessary. ET agent is nice, not for depth of anesthetic but to assure proper anesthetic drug delivery. I have seen many many TIVA anesthestic failures (I once had a resident give a Total intravenous remifentanil anesthetic). As for remi- I think it's a crappy drug. It's only good for two things:
1) Surgeries with almost zero post operative pain
2) Attendings who do not trust their residents and worry about overdosing them...

I've seen big 10 hour back wacks where remi is used.. and that's just ******ed... A fentanyl infusion is so much cheaper and provides beter post operative pain control... though it requries a little more experience with the drug because I know many a patient that has required a little post operative ventilation...

I havent used remi in 2 years.. I cant seem to find a use for it... well I take that back... when I want to intubate patients without relaxant (ie myasthetnics) I will use a slug...

Learn TIVA, put it in your reperotoire.... but in aneshtesia there is many many ways to skin a cat...

 

[Planktonmd]

Giving Remifentanyl intra-operatively to achieve deep analgesia could cause post-operative hyperalgesia and creates acute tolerance to narcotics.
This actually applies to any technique that relies on high dose narcotics intra-op.

 

[dhb]

Totally agree with you drccw

 

[DrRobert]

Remifentanil definitely has utility in short cases that have very intense stimulation periods with very mild post-op pain.

Examples would include things like laryngoscopy, esophagoscopy, dilatation, tear duct probing, etc.

You can run fairly high dose infusions, keep them deep, then titrate the drip to off. Of course you always need to give a little something longer acting at the end of the case before wake up.

I agree that Remi is not a great choice for long cases, especially those that will have a significant amount of post-op pain like spines. I think fentanyl and sufentanil infusions are much better for these cases.

 

[Planktonmd]

Remifentanil definitely has utility in short cases that have very intense stimulation periods with very mild post-op pain.

Examples would include things like laryngoscopy, esophagoscopy, dilatation, tear duct probing, etc.

You can run fairly high dose infusions, keep them deep, then titrate the drip to off. Of course you always need to give a little something longer acting at the end of the case before wake up.

I agree that Remi is not a great choice for long cases, especially those that will have a significant amount of post-op pain like spines. I think fentanyl and sufentanil infusions are much better for these cases.

The need to give huge doses of narcotics intra-operatively is something taught in residency, so when you are a resident you always overdose your patients intra-op and for that reason you need Remi because you can overdose them but they still wakeup and you still give the illusion of knowing what you are doing.
Then with experience (hopefully) you learn that you can achieve good anesthetics with a fraction of the doses you were taught to use and this is when you realize that you almost never need an agent like Remi because you just don't ever need to overdose patients.

 

[anesthesiadoc]

Giving Remifentanyl intra-operatively to achieve deep analgesia could cause post-operative hyperalgesia and creates acute tolerance to narcotics.
This actually applies to any technique that relies on high dose narcotics intra-op.

There is some evidence that using Nitrous Oxide intraop can decrease the Remifentanil-induced hyperalgesia, presumably via it's effect on NMDA receptors. I personally like remi, but I make sure I titrate in some longer acting opioid toward the end of the case. Sufentanil has a nicer tail, but I feel like it's a little more challenging to titrate and time a wakeup for longer cases.

 

[yes2drugs]

As a new CA-1 finishing up my 1-1 month, ..... People wake up within 5 minutes of shutting off the Alaris pump. And they feel great.

Propofol + remifentanil + phenylepherine = success


someone please clue me in, 'cause at this point I'm already a convert.

I love seeing people excited about anesthesia.
Enjoy this time in your career. It is great to be in anesthesia and even more so if you are a doc. You will make a difference. Anesthesia is Kooool.
Don't kill the buzz by visiting the midlevel thread. There will be time for that later.
TIVA is nice. Not the best choice for most procedures in a hospital. A few years from now when you are out on your own and working in a swank plastic surgery center TIVA will be your friend.
Propofol + Fentanyl +Ketamine = success as well. Best thing since WD40 for outpatient stuff.

 

[thegasman]

I havent used remi in 2 years.. I cant seem to find a use for it... well I take that back... when I want to intubate patients without relaxant (ie myasthetnics) I will use a slug...

Learn TIVA, put it in your reperotoire.... but in aneshtesia there is many many ways to skin a cat...

I find remi very useful on cases that are somewhat stimulating where muscle relaxant must be avoided eg thyroidectomy with nims tube - it is a good drug for certain cases, but tends to be overused.

 

[proman]

The need to give huge doses of narcotics intra-operatively is something taught in residency, so when you are a resident you always overdose your patients intra-op and for that reason you need Remi because you can overdose them but they still wakeup and you still give the illusion of knowing what you are doing.
Then with experience (hopefully) you learn that you can achieve good anesthetics with a fraction of the doses you were taught to use and this is when you realize that you almost never need an agent like Remi because you just don't ever need to overdose patients.

Don't assume that just because you were taught in residency everyone is taught it. I have several attendings who have taught me opioid-sparing anesthetics, and that's typically what I do even when working with others.

 

[narcusprince]

At my institution we are doing TIVA techniques with propofol/alfentanyl. From my experiance the patients wake up very well, pain free. I have not seen any respiratory depression, as we generally wake the patients up and send them to the PACU w/o supplemental oxygen. Also, these are ambulatory surgery cases and the patient population are mostly ASA1-3's. The issue is the infusion rates and boluses are based on some fuzzy math, but it works.

 

[DrRobert]

The need to give huge doses of narcotics intra-operatively is something taught in residency, so when you are a resident you always overdose your patients intra-op and for that reason you need Remi because you can overdose them but they still wakeup and you still give the illusion of knowing what you are doing.
Then with experience (hopefully) you learn that you can achieve good anesthetics with a fraction of the doses you were taught to use and this is when you realize that you almost never need an agent like Remi because you just don't ever need to overdose patients.

I guess you haven't done any laryngoscopies or esophagoscopies with dilatations... these are extremely short and stimulating procedures. Even with high doses of Remi like 0.5 mcg/kg/min the patients can still get tachycardic with stimulation. With Remi you are able to block this intense sympathetic response and still wake the patient up quickly at the end.

I think narcotics have a significant role intraoperatively. People who dismiss their utility usually don't know how to use the drug properly. I believe patients do much better with balanced anesthesia using the least amount of inhalational as possible. Narcotic + non-opioid adjunct like ketoralac + minimal gas = comfortable patient.

 

[Planktonmd]

I guess you haven't done any laryngoscopies or esophagoscopies with dilatations... these are extremely short and stimulating procedures. Even with high doses of Remi like 0.5 mcg/kg/min the patients can still get tachycardic with stimulation. With Remi you are able to block this intense sympathetic response and still wake the patient up quickly at the end.

I think narcotics have a significant role intraoperatively. People who dismiss their utility usually don't know how to use the drug properly. I believe patients do much better with balanced anesthesia using the least amount of inhalational as possible. Narcotic + non-opioid adjunct like ketoralac + minimal gas = comfortable patient.

Why do you feel that you need a narcotic to do the job of a beta blocker?
And if you use high dose Remi without muscle relaxant to do these procedures you will most likely get chest wall rigidity.
If you are using muscle relaxants (which I am pretty sure you are) then I don't see why you need to treat tachycardia with a narcotic?
I am not saying you should not use any narcotics but I am saying you really don't need the huge doses that you now think you need.

 

[Jeff05]

i did most of my ENT sinus endoscopies with remi/nitrous/prop.
glyco 0.2 3 min before induction.
prop 2mg/kg
remi bomb - about 5mcg/kg
lidocaine 1.5mg/kg
tube.
infraorbital and sphenopalatine blocks.

run remi pretty high 0.2-0.5 with 70% nitrous and a touch of prop - 30mcg/kg/min.

able to achieve moderate hypotension, stable hemodynamics, fast/buck free/compliant emergence. tube out within 3-5 min of the last noxious stimulus.

no PONV, as they all got dex 10 and zofran. high risk would get drop 0.625.

 

[proman]

i did most of my ENT sinus endoscopies with remi/nitrous/prop.
glyco 0.2 3 min before induction.
prop 2mg/kg
remi bomb - about 5mcg/kg
lidocaine 1.5mg/kg
tube.
infraorbital and sphenopalatine blocks.

run remi pretty high 0.2-0.5 with 70% nitrous and a touch of prop - 30mcg/kg/min.

able to achieve moderate hypotension, stable hemodynamics, fast/buck free/compliant emergence. tube out within 3-5 min of the last noxious stimulus.

no PONV, as they all got dex 10 and zofran. high risk would get drop 0.625.

I need to get more experience with those (though SP should be chip shots). Why so much dex? I like succ drips for the esophageal dilations.

 

[Precedex]

I think narcotics have a significant role intraoperatively. People who dismiss their utility usually don't know how to use the drug properly. I believe patients do much better with balanced anesthesia using the least amount of inhalational as possible. Narcotic + non-opioid adjunct like ketoralac + minimal gas = comfortable patient.

Couldn't agree more.

 

[Planktonmd]

I find it really disturbing that so many people seem to believe that a narcotic based anesthetic is actually a good anesthetic!
This used to be acceptable 20 years ago but I thought we know better now.
Oh well...

 

[Licoricestick]

I find it really disturbing that so many people seem to believe that a narcotic based anesthetic is actually a good anesthetic!
This used to be acceptable 20 years ago but I thought we know better now.
Oh well...

OK then - what do you do with the tachycardic, tachypnoeic patient who is already running at a MAC of about 1.5-1.6? Drive the volatile up further and give them an isoelectric EEG? Cause we know that's really good for people.

And laryngoscopies - where they see-saw between hypertensive and hypotensive depending on the stimulation?

 

[dfk]

Why do you feel that you need a narcotic to do the job of a beta blocker?
And if you use high dose Remi without muscle relaxant to do these procedures you will most likely get chest wall rigidity.
If you are using muscle relaxants (which I am pretty sure you are) then I don't see why you need to treat tachycardia with a narcotic?
I am not saying you should not use any narcotics but I am saying you really don't need the huge doses that you now think you need.

i worked with an attending who's thought processes were to treat sympathetic stimulation (albeit surgery cuts and manipulations, etc...) with beta blockers, and treat pain in the post-op care unit. i didn't and don't care for his techniques. where's the pre-emptive analgesia here?

i'd be curious to see studies (they may occur already) that compare opioid use to beta blocker use status-post/intra-intraopertive sympathetically stimulated periods.

 

[yes2drugs]

i worked with an attending who's thought processes were to treat sympathetic stimulation (albeit surgery cuts and manipulations, etc...) with beta blockers, and treat pain in the post-op care unit. i didn't and don't care for his techniques. where's the pre-emptive analgesia here?

i'd be curious to see studies (they may occur already) that compare opioid use to beta blocker use status-post/intra-intraopertive sympathetically stimulated periods.

It's in the same place as multi-modal analgesia.
Scott Reuben, MD Baystate Medical Center.

 

[Precedex]

I find it really disturbing that so many people seem to believe that a narcotic based anesthetic is actually a good anesthetic!
This used to be acceptable 20 years ago but I thought we know better now.
Oh well...

In my experience they work great. Please elaborate, if you will, on your criticism of the technique.

 

[Planktonmd]

In my experience they work great. Please elaborate, if you will, on your criticism of the technique.

I have already elaborated.
But here we go:
Giving LARGE doses of narcotics intra-op is not the best way to give GA because you are trying to suppress the sympathetic response to surgical stimulation by saturating the opioid receptors while leaving other substances and inflammatory responses untouched.
In addition to that, the more narcotics you give intra-op the more tolerance you create and hyperalgesia post-op.
The concept of preemptive analgesia lacks evidence and many people think that it does not exist.
If you are trying to suppress the sympathetic response then why don't you give a sympathetic blocker?
If you truly want to block the response to surgical stimulation then use regional anesthesia.
If you don't want the patient to move then use a muscle relaxant.
In other words: give a balanced anesthetic.

 

[DrRobert]

In other words: give a balanced anesthetic.

If you re-read my post, I referred to my argument as balanced anesthesia.

 

[Planktonmd]

If you re-read my post, I referred to my argument as balanced anesthesia.

I am not sure what is "balanced" in giving a huge dose of narcotics as your main anesthetic.

 

[OB1🤙]

More and more, I find myself giving nitro or esmolol in the middle of a case when HR/BP increases and I'm convinced my anesthetic depth is deep enough, whereas before I would have reached for fentanyl.

This whole hyperalgesia thing may or may not clinically relevant outside of the use of remi, but if the patients wake up as comfortable (or even more so) than with the intraop narcs, then I say who needs 'em.

I've had the whole "you cannot experience pain under GA" argument a few times with non-anesthesia residents recently, and it amazes me how resistant to the idea people are.

 

[seamonkey]

Regarding use of remi and poor post-op pain control.

I just sat through 45 min of a whole other attending telling me why he only uses TIVA (has not touched volatile agent in 6 years), and that he feels his post-op pain control is better that way. The feeling is that with remi, you know it will be off immediately, so you can dose your post-op opiods without worrying about residual intra-op opiod affecting anything. Any post-op probs will be only due to non-remi drugs.

With fentanyl (for example) used for intra-op analgesia, the context specific half-life is significant enough that once you are in the post-op realm, you have to try to balance effects of intra-op meds and post-op meds. They think it simplifies things, providing better pain control with less chance of respiratory depression.

Anywho...admittedly I'm just kind of parrotting my attendings at present. I have nowhere near the necessary experience to speak with any authority on this. I will say, in the past 3 weeks I have done easily 20 TIVA cases and had no issues with post-op pain. However, most have been short cases, i.e. ENT stuff.

Y'all have offered a lot of other perspectives on this, which I really appreciate. This is why I lurked for so long...to get into useful conversations once I finally was a CA-something.

 

[dfk]

More and more, I find myself giving nitro or esmolol in the middle of a case when HR/BP increases and I'm convinced my anesthetic depth is deep enough, whereas before I would have reached for fentanyl.

This whole hyperalgesia thing may or may not clinically relevant outside of the use of remi, but if the patients wake up as comfortable (or even more so) than with the intraop narcs, then I say who needs 'em.

I've had the whole "you cannot experience pain under GA" argument a few times with non-anesthesia residents recently, and it amazes me how resistant to the idea people are.

in your case, i would consider nitro and esmolol as bandaids. they are short acting. why would you choose these?

 

[Planktonmd]

in your case, i would consider nitro and esmolol as bandaids. they are short acting. why would you choose these?

Because the sympathetic changes intra-op are "short acting"?
By the way I have seen many CRNA's (new ones) giving every patient Metoprolol intra-op, is there some hidden wisdom behind that new approach to anesthesia?

 

[OB1🤙]

in your case, i would consider nitro and esmolol as bandaids. they are short acting. why would you choose these?

Because I'm treating short-lived changes of heart rate and vascular tone, not treating pain.