Learning objectives

• Describe the indications for total intravenous anesthesia
• Describe the techniques and models used for total intravenous anesthesia
• Describe the advantages, disadvantages, and safety measures for total intravenous anesthesia

Background

• Total intravenous anesthesia (TIVA) is a technique where intravenous agents are used to induce and maintain general anesthesia, avoiding the use of inhalational anesthetics
• Continuous intravenous infusion is commonly done by a target-controlled infusion (TCI) pump, but can also be achieved using intermittent boluses or manual infusion techniques
• TCI allows precise and individualized administration of intravenous anesthetics
• Both hypnosis and analgesia can be achieved using an intravenous technique
• Goals for TIVA: Smooth induction, reliable and titratable maintenance, and rapid emergence

Indications

• Malignant hyperthermia susceptibility
• Long QT syndrome
• History of severe PONV
• Surgery requiring neurophysiological monitoring
• Anesthesia in non-theatre environments
• Transfer of anesthetized patients between different locations
• Sedation in intensive care
• Tubeless ENT procedures and rigid bronchoscopy
• Thoracic surgery
• Intracranial surgery
• Procedures requiring sedation (e.g., endoscopy, cardioversion)

Anesthetic agents

• Propofol is the hypnotic agent of choice for TIVA
• Analgesia can be achieved using short-acting opioids (alfentanil, remifentanil)

Target-controlled infusion (TCI)

• Sophisticated TCI syringe drivers incorporate real-time pharmacokinetic models that deliver the appropriate dose to achieve and maintain the requested target concentration
• The microprocessor within the syringe driver continuously calculates the appropriate infusion rates 
• A bolus/elimination/transfer principle is used to maintain an appropriate plasma level of anesthetic agents
• Induction is achieved by a rapid propofol infusion, giving a bolus calculated to achieve the required plasma concentration
• This is followed by a progressively decreasing infusion rate calculated to match the transfer between compartments and elimination of the drug, maintaining the required plasma level 
• Once the compartments reach a steady-state concentration, the infusion rate slows to match elimination only
• To increase the target plasma level, the syringe driver delivers an additional bolus to achieve the desired concentration and then maintains a higher infusion rate
• To decrease the target plasma level, the syringe driver stops infusing until the microprocessor calculates that the new target has been achieved, and the new level is maintained
• Modern TCI pumps also have software that allows titrating to effect-site concentration (the concentration in the brain)
• Depth of anesthesia monitoring (e.g., bispectral index) is required, as there is considerable variation in the uptake and effect of anesthetic agents in individual patients

Propofol TCI models

• Propofol TCI allows easy control and rapid change of the target propofol concentration
• Unpremedicated adult patients >55 years: Target propofol concentration 4-8 µg/mL for induction (usually takes 60-120 seconds)
• When co-administering an analgesic, maintenance at 3-6 µg/mL
• Lower target concentrations are used in the elderly population due to the risk of side-effects
• Propofol TCI is not routinely used in children
• Propofol TCI models:
  • Marsh
    • Calculations based on the assumption that the central compartment volume is proportional to the patient’s weight, ignoring age
    • Assumes that the central compartment volume is 19.4 L for an 85 kg patient
    • Designed primarily to target plasma concentrations
    • Only used for patients >16 years of age
  • Schnider
    • Requires age, height, and body weight
    • Calculates a sex-specific lean body mass and determines the dosages accordingly
    • Assumes that the fixed central compartment volume is 4.27 L for an 85 kg patient (4-fold difference with the Marsh model)
    • Allows for effect site concentration to be targeted
    • More commonly used in the elderly population
  • Paedfusor
    • Variant of the Marsh model for patients 1-16 years of age
    • Uses weight to calculate target plasma concentration and features a nonlinear scaling of central compartment volume as age exceeds 12 years
  • Kataria
    • Can be used for patients 3-16 years of age with a minimum weight of 15 kg
    • Uses weight to calculate target plasma concentration

Other TCI models

• Minto: For remifentanil
• Bergmann: For fentanyl
• Maitre: For alfentanil
• Gepts: For sufentanil
• Eleveld: For propofol & remifentanil
• Domino: For ketamine
• Dick & Hannivoort: For dexmedetomidine
• Greenblatt: For midazolam

Analgesia

• Since propofol has no analgesic properties, TIVA is commonly achieved by combining propofol infusion with a regional block or supplemental opioids
• Supplemental short-acting opioids:
  • Remifentanil
    • Elimination half-time: 3-10 min
    • Does not accumulate in hepatic or renal failure
    • Context insensitive: the time required for the drug concentration to fall by 50% is always the same (~3 min), regardless of age, weight, sex, or hepatic or renal function
    • Opioid of choice for TIVA for many anesthesiologists
    • Can be given using the Minto model (allows easy titration based on patient age, gender weight and height
    • Target plasma concentration: 3-8 ng/mL for induction, up to 15 ng/ml in stimulating procedures 
    • Ensure adequate analgesia after remifentanil has worn off
  • Alfentanil
    • Short onset time (90 s)
    • Given using Maitre model (calculations based on age, gender and weight)
  • Sufentanil
    • Much more potent than remifentanil
    • Longer duration of action
    • Tends to accumulate during prolonged infusion
    • Two TCI models: Gepts (fixed compartment volume) and Bovill (assumes that the central compartment volume is proportional to body weight)

Advantages & disadvantages

Safety

• Ensure the cannula is visible and accessible at all times and checked regularly to prevent disconnection or tissuing
• Check the pump setup regularly to prevent tubing disconnection, ensure clamps are open/closed accordingly, pump alarms are rectified and no backtracking of drug occurs
• Ensure the drug concentration matches the programmed concentration
• Ensure the correct syringe is placed in the correct syringe driver
• Use anti-reflux and anti-syphon valves with clamps in multilumen tubing for safe delivery
• Use a processed EEG monitor when a neuromuscular blocker is used 

Suggested reading

• Nimmo AF, Absalom AR, Bagshaw O, Biswas A, Cook TM, Costello A, et al. Guidelines for the safe practice of total intravenous anaesthesia (TIVA). Anaesthesia. 2019;74(2):211-24.
• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
• Al-Rifai Z, Mulvey D. (2016). Principles of total intravenous anaesthesia: Basic pharmacokinetics and model descriptions. BJA Educ 16(3): 92–7.

Clinical updates

Deng et al. (BJA, 2024) report in a large multicentre randomised trial of 3083 adults undergoing elective cardiac surgery that propofol-based TIVA was not associated with differences in major in-hospital complications or 30-day mortality compared with volatile anesthesia (33.2% vs 33.8%), with no separation in 6-month or 1-year mortality, ICU/hospital length of stay, or costs. These findings suggest that, despite theoretical cardioprotective advantages of volatiles, contemporary propofol TIVA delivers equivalent short- and long-term clinical outcomes in predominantly low-risk cardiac surgery patients, supporting technique selection based on patient-specific indications rather than expectation of improved hard outcomes.

Bernat et al. (BJA, 2025) report a large multicentre observational study of 35 242 adult general anaesthetics showing that propofol-based TIVA had a substantially lower carbon footprint than even optimised inhalational strategies. However, TIVA was associated with higher plastic waste generation (≈72 g per case) and potential concerns around propofol pollution, highlighting that while TIVA is the lowest-emission GA technique, sustainable practice must balance greenhouse gas reduction against material use and waste management.

• Read more about this study HERE.
• Listen to NYSORA’s podcast discussing this HERE.

Quintão et al (Current Opinion in Anaesthesiology, 2026) report that pediatric TIVA is becoming more precise through universal TCI models and EEG-guided dosing, with moderate propofol effect-site concentrations and remifentanil titration improving recovery profiles while reducing dosing errors, particularly in neonates and infants. The review also highlights emerging evidence for remimazolam as a hemodynamically stable alternative to propofol, and shows that propofol-based TIVA reduces emergence delirium, postoperative nausea/vomiting, and perioperative respiratory adverse events while supporting intraoperative neurophysiologic monitoring.

• Read more about this study HERE.