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Paediatric total intravenous anaesthesia

J Gaynor BM FRCA, J M Ansermino MBBCH MMed MSc (Informatics) FFA (SA) FRCPC
DOI: http://dx.doi.org/10.1093/bjaed/mkw019 369-373 First published online: 10 May 2016
  • 1A02
  • 2D02
  • 2D06
  • 3A01
  • 3D00

Key points

  • Paediatric total i.v. anaesthesia (TIVA) can facilitate surgery, reduce airway responsiveness, and minimize complications such as postoperative nausea and vomiting and emergence agitation.

  • Bolus doses of propofol are largely determined by the volume of distribution, while required infusion rates are predominantly determined by the clearance.

  • Manual infusions remain an important option in clinical practice due to variability within and between target-controlled infusion models.

  • Adjuvant agents, such as remifentanil and dexmedetomidine, play an important role in minimizing propofol requirements.

  • Avoidance of neuromuscular block, and the adjuvant use of processed EEG, is recommended to aid titration and lower the potential risk of awareness.

Total i.v. anaesthesia (TIVA) has been used in adult practice since 1982 with target-controlled infusion (TCI) regimes available since 1989. Conversely, the use of TIVA in paediatric practice is far less routine with a survey finding only 10% of paediatric anaesthetists using it weekly or more.1 It has previously been the subject of a special edition of the journal Pediatric Anaesthesia2 and the use for paediatric anaesthesia care is an increasing component at international meetings: educational sessions at the European Society for Paediatric Anaesthesia (2013), ASA (2014), and the Society for Intravenous Anaesthesia meeting in November 2015.

Despite a number of obstacles (including interindividual pharmacokinetic and pharmacodynamic variability and safety concerns regarding propofol infusion syndrome—PrIS), there are notable benefits to TIVA and particular areas where it is indicated for anaesthetic or surgical reasons, where it may surpass volatile anaesthesia.3 It is a mandatory technique when inhalation agents are contraindicated.

Indications (see Table 1)

Advantages and disadvantages

For physiological and clinical3 reasons (Table 2), TIVA has increasingly established a significant role in surgery in or around the airway (e.g. ENT) by obtunding airway reflexes (Table 2). The changes in airway reactivity facilitate extubation and result in a minimal incidence of laryngospasm and stridor …

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