Guidelines for Total Intravenous Anesthesia (TIVA) with Target-Controlled Infusion (TCI)

Drug Selection and Dosing

For general anesthesia, use propofol TCI at an effect-site target of 0.5-1 mcg/ml combined with remifentanil TCI at 1-3 ng/ml, avoiding bolus dosing to prevent over-sedation and respiratory depression, particularly when used together 1, 2, 3
Target effect-site concentration of 0.5-1 mcg/ml for propofol TCI maintenance 1, 2, 3
Doses exceeding 1.5 mcg/ml of propofol carry significant risk of over-sedation and hypoventilation, especially with concomitant opioid use 1, 2, 3
Avoid bolus dosing of propofol during TIVA to prevent hemodynamic instability 1, 2, 3
Effect-site target of 1-3 ng/ml for remifentanil TCI maintenance 1, 2, 3
Avoid bolus dosing of remifentanil during maintenance to prevent respiratory depression 1, 2, 3
Fentanyl can be used as an alternative opioid option at 0.5-1 mcg/kg boluses as needed 1, 2, 3
Alfentanil can be used as an alternative opioid option at 5 mcg/kg initial bolus, then 1-3 mcg/kg as required 1, 2, 3

Use processed EEG monitoring (BIS or Entropy) targeting BIS 40-60 to prevent awareness and avoid excessive anesthetic depth 4
Quantitative neuromuscular monitoring is mandatory when using muscle relaxants 4
Document train-of-four ratio ≥0.90 before extubation to ensure complete reversal 4
Establish invasive arterial blood pressure monitoring before induction when feasible, with transducer at tragus level 5
Have vasopressors immediately available (ephedrine or metaraminol) to treat hypotension 5

Consider propofol dosing based on lean body weight in obese patients 4
Assume all obese patients have some degree of sleep-disordered breathing and modify technique accordingly 4

Ensure return of airway reflexes and adequate tidal volumes before extubation 4
Extubate awake in sitting position 4
For obese patients with confirmed OSA, insert nasopharyngeal airway before emergence 4
Reinstate home CPAP immediately upon return to ward if patient uses it 4

The World Journal of Emergency Surgery recommends rocuronium 0.9-1.2 mg/kg for rapid sequence induction 6
The World Journal of Emergency Surgery suggests succinylcholine 1-2 mg/kg as an alternative for rapid sequence induction 6
The American College of Surgeons may recommend targeting lighter anesthesia depth (BIS 50 vs 35) to reduce postoperative delirium in elderly patients (>60 years) 6
Avoid extremely low BIS values and burst suppression in elderly patients (>60 years) to reduce postoperative delirium risk 6
Monitor closely for hypotension as elderly are more sensitive to propofol's cardiovascular effects 6
Propofol increases vasopressor requirements in hemodynamically challenged patients, including obese patients 6

Total Intravenous Anesthesia (TIVA) significantly reduces postoperative nausea and vomiting (PONV) compared to volatile anesthetics 6, 7
TIVA has possible beneficial effects on cancer outcomes, based on laboratory and retrospective data 6
Avoid nitrous oxide as it increases PONV and delays bowel function, as suggested by the American Journal of Obstetrics and Gynecology 8

In patients over 60 years, avoid BIS values below 35 to reduce postoperative delirium risk, as recommended by the World Journal of Emergency Surgery 6
Avoid burst suppression patterns on EEG in patients over 60 years to reduce postoperative delirium risk 6