When is TIVA considered TIVA?

[RxBoy]

I never understood this concept. I don't understand when the surgeons ask for IV sedation but they don't want the patient to move throughout the procedure. Isn't this essentially TIVA? How is a high does propofol infusion any different then say a LMA with a pt SV a MAC of 1?

I always choose LMA over "unconscious iv sedation". Aside from the risk of laryngospasm I don't see any advantage to IV sedation. I'm sure volatiles at low flows through closed circuit are much more economic then burning through propofol. I pull almost all my LMAs deep so my turn around is just as quick . Any aspiration/difficult ventilation risk factors such as obesity, severe GERD, full stomachs, ect should be tubed anyways.

The only scenario I can think of that would truly require "TIVA" is a case such as a laproscopic GI case with a known hx of malignant hyperthermia. I would guess it would involve IV induction, tube with O2/Air, and IV infusion. You could supplement with a little nitrous but I guess that wouldn't be considered TIVA either.

So am I missing something here?

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[Idiopathic]

Conceptually, I guess everyone could have a different idea of what TIVA is, but to me, TIVA is a general anesthetic without volatile. Remember, often times our surgical colleagues often think that "LMA anesthesia" is fundamentally different from "general anesthesia", so its good to clarify.

and they can want what they want, but if they request IV sedation because a patient is too sick, or they want to minimize the recovery time, they may have to tolerate some patient movement, especially with more invasive parts of procedures (i.e. tunneling a central line). this is also a good time to remind them of everyones friend, local anesthesia.

Times when you should consider a true TIVA
1) ICP issues
2) Severe PONV history
3) MH susceptibility
4) evoked potential monitoring (MEP>SSEP, not absolutely indicated, but we do it for all MEP cases)
5) others, certainly

its your job to do whats best for the patient, which typically means if you can avoid intubation, you should. Local "MAC" cases on propofol drips or with versed/fentanyl boluses need to be expeditious, but most typically I use them on
1) vascular angiography/angioplasty
2) port insertions/removal
3) endoscopic procedures
4) small hernia repairs
5) removal of small skin lesions

 

[jwk]

Idiopathic is exactly correct - a TIVA is a general anesthetic. It is not MAC, it is not heavy sedation.

We have GI docs complain that patients move during their colonoscopy. My response is along the lines of "...and your point is? " I tell them it's not a general anesthetic, that the patient will in fact probably move, but if they REALLY want the patient to be totally still, I'll be happy to wake them up, get an anesthesia machine, and put them all the way to sleep. Of course that will take about 45 minutes to get it all ready, and they could probably get the procedure done before the patient wakes up from their MAC and then wait to get a machine over here, but hey, that's their choice. Nobody has taken me up on my offer yet.

 

[Impromptu]

We have an ENT fellow who absolutely insists that we use TIVA for his endoscopic sinus surgeries. I am just now reading about his reasons why, since he didn't bother to tell us. He wants controlled hypotension which will result in less bleeding in the surgical field and therefore less risk of complications.

My quick look just now yielded the following Italian article. http://www.actaitalica.it/issues/2004/3-04/tirelli.pdf. In this study both TIVA and volatile agents prodcued hypotension, but TIVA had a little less bleeding.

None of the other anesthesia residents or attendings really wanted to do controlled hypotension if it meant going below 20% of the pt's baseline BP, especially if it meant using a big bottle of propofol and having the pharmacy mix up bag of remifentanyl for a likely short case (though with fellows and residents these do sometimes go long).

Do any of you use TIVA for endoscopic sinus surgery?

 

[2ndyear]

We have an ENT fellow who absolutely insists that we use TIVA for his endoscopic sinus surgeries. I am just now reading about his reasons why, since he didn't bother to tell us. He wants controlled hypotension which will result in less bleeding in the surgical field and therefore less risk of complications.

My quick look just now yielded the following Italian article. http://www.actaitalica.it/issues/2004/3-04/tirelli.pdf. In this study both TIVA and volatile agents prodcued hypotension, but TIVA had a little less bleeding.

None of the other anesthesia residents or attendings really wanted to do controlled hypotension if it meant going below 20% of the pt's baseline BP, especially if it meant using a big bottle of propofol and having the pharmacy mix up bag of remifentanyl for a likely short case (though with fellows and residents these do sometimes go long).

Do any of you use TIVA for endoscopic sinus surgery?

No, but they usually ask for relatively low BP. Volatiles seem to work pretty well for this in my book...

 

[Arch Guillotti]

Do any of you use TIVA for endoscopic sinus surgery?

No. This sounds silly. For lower BP use volatile or whatever.

 

[Jeff05]

TIVA classically is prop + opioid per Barash.

gas produces hypotension mostly by decreasing SVR. remi produces hypotension by decreasing CO. so at equal BPs, there is more bleeding with VA - as the vasculature is more dilated.

i run my endo patients at a mean of 55 (no cardiac/carotid/cerebrovascular dz) and everyone does great. dry surgical field.

also do infraorbital block and greater palatine blocks (local and epi) to produce great analgesia and additional hemostasis.

the 20% BP figure doesn't make any sense, just cookbook anesthesia that should be reserved for nurses.

 

[fakin' the funk]

the 20% BP figure doesn't make any sense, just cookbook anesthesia that should be reserved for nurses.

While I'm not opposed to using a % decrement from "baseline BP" as a general guide (and applying clinical judgment to following that guide or not), I would agree that 20% seems a little conservative whereas 40-50% decrement is maybe a bit much.

But the biggest problem is, choosing which available preop BP to use as "baseline" is a crapshoot and therefore applying 20%, 30%, 40% decrement to that is just as arbitrary.

Most patients just rolled into the OR are either anxious, in pain, or just have jacked up BP's from not taking their CCB/ACEi/ARB/BB/hydralazine etc that morning. And what if they really do live at a MAP of 120 -- is a MAP of 60-70 for cuppla hours going to make a difference in cerebral, renal, or coronary perfusion?

 

[NotAMD]

if theres an ETT or LMA its TIVA
if theres no invasive airway other than a guedel or nasal trumpet its mac

 

[Idiopathic]

if theres an ETT or LMA its TIVA
if theres no invasive airway other than a guedel or nasal trumpet its mac

i mean sure this is how its supposed to be, but weve all seen room-air general anesthetics done both in the OR and in the ED, for example, so while there should be a clear dividing line, it isnt always apparent.

 

[jwk]

TIVA classically is prop + opioid per Barash.

gas produces hypotension mostly by decreasing SVR. remi produces hypotension by decreasing CO. so at equal BPs, there is more bleeding with VA - as the vasculature is more dilated.

i run my endo patients at a mean of 55 (no cardiac/carotid/cerebrovascular dz) and everyone does great. dry surgical field.

also do infraorbital block and greater palatine blocks (local and epi) to produce great analgesia and additional hemostasis.

the 20% BP figure doesn't make any sense, just cookbook anesthesia that should be reserved for nurses.

We have a couple of ENT docs that don't want volatile because they equate vasodilation with more surgical bleeding.

Regardless - we don't do deliberate hypotension for anyone for anything anymore.

 

[Bertelman]

if theres an ETT or LMA its TIVA
if theres no invasive airway other than a guedel or nasal trumpet its mac

You may want to propose the ASA change it's definition of general anesthesia.

GENERAL: Unarousable even with painful stimulus, airway intervention often required

DEEP SEDATION: Purposeful response after repeated or painful simuli, airway intervention may be required

CONSCIOUS SEDATION: Purposeful response to verbal or tactile stimuli, no airway intervention required

 

[fakin' the funk]

Regardless - we don't do deliberate hypotension for anyone for anything anymore.

Hip?

 

[jwk]

Hip?

Nope.

 

[pgg]

Hip?

Nope.

Also nope.

 

[jwk]

Hip?

Here's the deal in a nutshell - hemostasis is a surgical issue. Anesthesia doesn't stop hemorrhage - bovies and clips and magic powder and suture ties and cocaine pledgets and all the other things that surgeons have available to them are what controls hemorrhage.

 

[goosegas]

if theres an ETT or LMA its TIVA
if theres no invasive airway other than a guedel or nasal trumpet its mac

Ahhhh, No.
An anesthetic is not defined by the type of airway that is or isnt present.

 

[NotAMD]

well then you are saying that you are doing general anesthetics without airways.. which I think would open you up to liability.. while in reality that happens all the time, I dont think I would officially call it a GA and not document an airway, is what I meant. They can be out and meet the criteria for a general anesthetic but without an airway im not sure i would document it as a GA.

 

[jwk]

well then you are saying that you are doing general anesthetics without airways.. which I think would open you up to liability.. while in reality that happens all the time, I dont think I would officially call it a GA and not document an airway, is what I meant. They can be out and meet the criteria for a general anesthetic but without an airway im not sure i would document it as a GA.

Then you don't know what you're talking about.

An airway device is NOT required for general anesthesia.

 

[pgg]

well then you are saying that you are doing general anesthetics without airways.. which I think would open you up to liability.. while in reality that happens all the time, I dont think I would officially call it a GA and not document an airway, is what I meant. They can be out and meet the criteria for a general anesthetic but without an airway im not sure i would document it as a GA.

NotAMD, what's your status? Obviously "not a MD" but does that mean you're a pre-med, med student, resident who's a DO, attending who's a DO, nurse, CRNA, RT, what?

I'm just trying to wrap my brain around why you're (still) arguing about these definitions with a forum full of anesthesiologists, particularly after Bertelman's post left essentially no room for ambiguity or confusion.

 

[goosegas]

well then you are saying that you are doing general anesthetics without airways.. which I think would open you up to liability.. while in reality that happens all the time, I dont think I would officially call it a GA and not document an airway, is what I meant. They can be out and meet the criteria for a general anesthetic but without an airway im not sure i would document it as a GA.

You should stop before you dig your hole any deeper.
You can administer 2% Sevo via mask and that is a general. They did it in the "old'n" days all the time. And I do breast augs under TIVA with nothing more than a nasal cannula. They are unconscious and do not move. That is a general anesthetic.

 

[Idiopathic]

Ive masked plenty of kids through surgery, definitely general anesthesia, nothing in the mouth or nose.

 

[scudrunner]

NotAMD, what's your status? Obviously "not a MD" but does that mean you're a pre-med, med student, resident who's a DO, attending who's a DO, nurse, CRNA, RT, what?

I'm just trying to wrap my brain around why you're (still) arguing about these definitions with a forum full of anesthesiologists, particularly after Bertelman's post left essentially no room for ambiguity or confusion.

Not so fast, looks like they are a resident MD now...

http://forums.studentdoctor.net/showthread.php?p=2074521#post2074521

 

[Bertelman]

Ive masked plenty of kids through surgery, definitely general anesthesia, nothing in the mouth or nose.

Srsly.

I'm wondering how NotAMD does his BMTs...MAC?

 

[NotAMD]

so you list all your colonoscopies as general?

 

[goosegas]

so you list all your colonoscopies as general?

If I give them propofol and they become unconscious, then of course we call it a general anesthetic because that is what it is. If I give only versed and some fent and they remain conscious then that is sedation.

 

[Idiopathic]

so you list all your colonoscopies as general?

you should, if they get propofol.

people are way too liberal with requesting or charting "MAC". In my opinion, MAC is pretty much putting the monitors on and talking to the patient, but I understand the way things are

 

[NotAMD]

this has been interesting to me because i chart them all as MAC and they are definitely unconscious and almost always meet the criteria for being generally anesthestized and we are trained to code them as MAC.. no induction, no airway, etc... interesting to hear the different opinions.. and fyi I now am an MD its an old profile..

 

[Idiopathic]

again, thats the way things are

 

[goosegas]

Bertelman provided all the answers.
http://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx
MAC is a service, that can be billed for, not a type of anesthetic. Read the definition of MAC on this page. All shall be made clear. Its not opinion when it is fact.