Tiva

[Dryacku]

first year anesthesia resident here

wanted to learn different ways to do TIVA

I have been primarly doing them with .008 mcg/kg/min of sufent and 100 mcg/kg/min propofol and then titrating as needed depending on the patients needs and what the neurophysiolgist tells me

any other suggestions or things to consider during these cases

also what is a good source to look up more info on TIVA cases

thanks

---

Members don't see this ad.

 

[rsgillmd]

first year anesthesia resident here

wanted to learn different ways to do TIVA

I have been primarly doing them with .008 mcg/kg/min of sufent and 100 mcg/kg/min propofol and then titrating as needed depending on the patients needs and what the neurophysiolgist tells me

any other suggestions or things to consider during these cases

also what is a good source to look up more info on TIVA cases

thanks

I assume you are using the above regimen for spine cases because you are referring to checking with the neurophysiologist. I've used remifentanil and Propofol also. I've used fentanyl and propofol. I'm sure there are people out there that have used Precedex for these cases.

Unfortunately I don't know of any good source that will give you regimens you can start with. Posting on forum like this and discussing the case with experienced colleagues or attendings can help.

When creating a TIVA technique think of the elements involved in anesthesia (unconsciousness, amensia, analgesia, muscle relaxation) to guide you in picking the drugs for your technique.

Remember, also, TIVA doesn't just have to be for neuro cases. Use your imagination. Once I had an attending say to me, "Pretend this kid (for a lap appy) has a h/o MH. Pick a technique and do it." So I induced with propofol, fentanyl, and rocuronium. After the intubation, I started Propofol at 300 mcg/kg/min, and turned on 66% N2O (I know technically not TIVA since I used N20 -- but you get the point). I then titrated the propofol during the case, shutting it off when the laparoscope was out. I shut the N2O off when I was ready to wake the patient up (who was already breathing spontaneously by this time).

 

[Mista Suprane]

also a CA-1. we have an attending who uses exclusively TIVA for every case. one of his recipes:

50cc propofol (500mg) + 1cc ketamine (100mg) + 1cc (1mg) remifentanil -- mix in one syringe

start at a rate of 100mcg/kg/min of propofol, which workes out to 20mcg/kg/min ketamine, and 0.2mcg/kg/min remifentanil. titrate up and down as needed; about 45 min before they are done with case, switch to just propofol, 15 min before finish, turn off propofol. titrate in longer acting narcotic to respiratory rate if desired. obviously the timing at the end is the tricky part (the times above naturally are different with everyone, and are really just a generic guideline), just like with any other anesthetic plan, and we are years away from even being good at it, much less perfecting it, but i after two weeks with him i felt like i wasn't too bad. i also kept propofol inline at the end so i could hand bolus if needed.

wake up is beautiful.

 

[jennyboo]

Agree that TIVA has a lot of applications in addition to neuromonitoring cases. There's also the opportunity to "practice" it for patients at high risk for PONV (see Apfel et al, A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting), typically hysteroscopies etc.

For spines, I've done propofol (120-150 mcg/kg/min) and remifentanil (0.05-0.2 mcg/kg/min, start at 0.1 mcg/kg/min), plus or minus a constant infusion of ketamine at 10 mcg/kg (I think it's mcg/kg/min but can't remember if it's by hour or by minute).

Propofol/ketamine is another reasonable combination. I'm not as comfortable with this as I've been with prop/remi (probably institutional practice) but I've started doing this lately to get more familiar with it during endoscopies, breast biopsies etc. The downside is that ketamine can be nausea inducing so I'm not sure it's as "protective" against PONV as propofol alone has been demonstrated to be.

 

[bogatyr]

When creating a TIVA technique think of the elements involved in anesthesia (unconsciousness, amensia, analgesia, muscle relaxation) to guide you in picking the drugs for your technique.

Remember, also, TIVA doesn't just have to be for neuro cases. Use your imagination. Once I had an attending say to me, "Pretend this kid (for a lap appy) has a h/o MH. Pick a technique and do it." So I induced with propofol, fentanyl, and rocuronium. After the intubation, I started Propofol at 300 mcg/kg/min, and turned on 66% N2O (I know technically not TIVA since I used N20 -- but you get the point). I then titrated the propofol during the case, shutting it off when the laparoscope was out. I shut the N2O off when I was ready to wake the patient up (who was already breathing spontaneously by this time).

What was the point of the nitrous? To add post-op nausea?

 

[bubalus]

For spines, I've done propofol (120-150 mcg/kg/min) and remifentanil (0.05-0.2 mcg/kg/min, start at 0.1 mcg/kg/min), plus or minus a constant infusion of ketamine at 10 mcg/kg (I think it's mcg/kg/min but can't remember if it's by hour or by minute).

Not a big fan of remi for spines unless I'm going to do a wake up test. Spines can really hurt (depending on the procedure and number of levels). Why would I want to use an opioid that will disappear in 5 minutes? Sure I can titrate in longer lasting narcs, but why not start off with that and use sufenta. That's just me.

 

[SleepIsGood]

Propofol 100 mcg/kg/min
remi 0.05-2 mcg/kg/min

slap a BIS monitor on

towards the titrate, fentanyl

 

[NeuroPhysGuy]

also a CA-1. we have an attending who uses exclusively TIVA for every case. one of his recipes:

50cc propofol (500mg) + 1cc ketamine (100mg) + 1cc (1mg) remifentanil -- mix in one syringe

start at a rate of 100mcg/kg/min of propofol, which workes out to 20mcg/kg/min ketamine, and 0.2mcg/kg/min remifentanil. titrate up and down as needed; about 45 min before they are done with case, switch to just propofol, 15 min before finish, turn off propofol. titrate in longer acting narcotic to respiratory rate if desired. obviously the timing at the end is the tricky part (the times above naturally are different with everyone, and are really just a generic guideline), just like with any other anesthetic plan, and we are years away from even being good at it, much less perfecting it, but i after two weeks with him i felt like i wasn't too bad. i also kept propofol inline at the end so i could hand bolus if needed.

wake up is beautiful.

Great regimen for neuromonitoring 👍

 

[loveumms]

We use precedex here a lot. I like fentanyl with propofol and precedex. Turn off the fentanyl when starting to close, titrate down the propofol at that point and keep the precedex on until the very end. It is an art and demands practice.

 

[Mofeen]

Bump

 

[seinfeld]

I see many are titrating the propofol up and down. I consider changes in hemodynamics to be more related to pain than amnesia so i generally tirate the opioid.

 

[MTGas2B]

We tend to use propofol, remi +/- dex.

If I am using a BIS (depends on my attending that day) and its trending up or I have hemodynamic changes plus signs of being light I may titrate up the propofol. Our cases with neuromonitoring tend to be long, big spine cases, complex intracranial vascular or complex tumor. I tend to try and get off of propofol as soon as I can. Once SSEP/MEP folks tell me they are done shooting motors, usually about 10 or 20 minutes after closing dura, I turn off the propofol and switch to volatile (des preferably) around a half mac then bring the remi down to about about 0.08 to 0.1 I find it just gives me much better control of the wake up. Waking up after 8 hours of anesthetic level of propofol can be be painful.

 

[Idiopathic]

ive been using IV lidocaine 2mg/min on my spine cases, after being converted by an attending we have here. add it to prop/su or prop/remi, sometimes throw precedex in...ive seen postop backs require little to no opioid in PACU.

 

[Pilot Doc]

One of my gray-haired attendings said that as a resident he did a lidocaine only TIVA as a learning exercise.