Total intravenous anesthesia (TIVA) is undergoing a major transformation in pediatric medicine. Once limited by insufficient pharmacokinetic data and concerns about dosing accuracy in infants and young children, TIVA is now emerging as a highly precise, safer, and environmentally responsible anesthetic technique.

A comprehensive 2026 review by Quintão et al. highlights significant advances in pediatric TIVA, including improved pharmacokinetic-pharmacodynamic (PK/PD) models, target-controlled infusion (TCI) technology, electroencephalography (EEG)-guided dosing, and new medications such as remimazolam.

The review also emphasizes that TIVA can reduce emergence delirium, postoperative nausea and vomiting (PONV), respiratory complications, and greenhouse gas emissions compared with inhalational anesthesia.

Why pediatric TIVA is gaining momentum

TIVA relies on intravenous administration of anesthetic medications instead of inhaled anesthetic gases. While widely adopted in adult practice for decades, pediatric implementation has progressed more slowly because children exhibit significant age-dependent differences in:

• Drug clearance
• Drug distribution
• Brain sensitivity
• Cardiovascular responses
• Recovery characteristics

Recent advances now allow clinicians to better predict how anesthetic drugs behave across different pediatric age groups, from neonates to adolescents.

Key drivers behind the growing popularity of pediatric TIVA include:

• Improved PK/PD modeling
• Better infusion technology
• Enhanced EEG monitoring
• Reduced postoperative complications
• Improved conditions for neurophysiologic monitoring
• Lower environmental impact

Major advances in propofol pharmacology

Propofol remains the cornerstone of pediatric TIVA.

The review highlights several important developmental differences:

Neonates

Neonates have:

• Lower propofol clearance
• Increased sensitivity to hypotension
• Slower recovery
• Greater risk of prolonged emergence

Because of these characteristics, dosing must be conservative and carefully titrated.

Infants and children

In contrast, infants demonstrate:

• Rapid clearance
• Shorter context-sensitive half-times
• Faster recovery
• Higher weight-adjusted infusion requirements

This means younger children often require proportionally higher maintenance doses than adults.

Recommended effect-site targets

The authors recommend moderate propofol effect-site concentrations:

• Approximately 3.5–4 μg/mL during maintenance
• Up to 4–5 μg/mL during intense surgical stimulation
• Around 2 μg/mL during emergence

Avoiding unnecessarily high concentrations helps reduce delayed recovery.

Dexmedetomidine continues to expand its role

Dexmedetomidine has become an increasingly important component of balanced pediatric anesthesia.

Benefits include:

• Sedation
• Sympatholysis
• Opioid-sparing effects
• Reduced emergence delirium
• Improved hemodynamic stability

The review notes that dexmedetomidine works particularly well when combined with:

• Propofol
• Remifentanil

This combination allows clinicians to reduce opioid exposure while maintaining effective anesthesia.

Important safety consideration

Rapid loading doses may cause:

• Bradycardia
• Hypertension

For this reason, slow administration over 10–20 minutes is preferred.

Remifentanil remains the preferred opioid partner

Remifentanil continues to be the opioid of choice for pediatric TIVA because it provides:

• Rapid onset
• High potency
• Predictable recovery
• Very short context-sensitive half-time

Studies show that remifentanil can reduce propofol requirements by approximately 30–50%.

Importantly, opioid dosing should be guided primarily by clinical signs rather than EEG indices because remifentanil has minimal effect on bispectral index (BIS) values.

Remimazolam: a promising new anesthetic option 

Remimazolam is one of the most exciting developments in pediatric anesthesia.

Introduced in 2020, this ultra-short-acting benzodiazepine undergoes rapid metabolism by carboxylesterase enzymes and offers:

• Fast onset
• Rapid recovery
• Hemodynamic stability
• Potentially improved safety profile

Although pediatric evidence remains limited, early studies show encouraging results.

Findings from recent pediatric trials

A multicenter randomized trial demonstrated:

• Successful induction and maintenance of anesthesia
• Less pain on injection compared with propofol
• Lower incidence of bradycardia
• Favorable overall safety profile

Additional studies suggest remimazolam may reduce emergence delirium when used during sevoflurane anesthesia.

Potential future applications include:

• High-risk infants
• Congenital heart disease
• Pulmonary disease
• Outpatient procedures
• Pediatric intensive care sedation

Better postoperative outcomes with TIVA

Reduced emergence delirium

Emergence delirium remains one of the most challenging pediatric postoperative complications.

Children may experience:

• Agitation
• Crying
• Confusion
• Self-injury
• Accidental removal of intravenous lines

According to the review, propofol-based TIVA is the most effective preventive strategy available.

Meta-analysis data show approximately:

• 75% reduction in emergence delirium risk

Dexmedetomidine also contributes significantly to prevention.

Lower postoperative nausea and vomiting

PONV is especially common after:

• Tonsillectomy
• Strabismus surgery
• Procedures in children older than three years

Compared with volatile anesthetics, TIVA substantially reduces:

• Early PONV
• Late PONV
• Need for rescue antiemetics

Current guidelines recognize propofol-based TIVA as an important preventive measure.

Improved respiratory safety

One of the most important findings concerns respiratory outcomes.

TIVA appears to decrease:

• Bronchial hyperreactivity
• Airway complications
• Perioperative respiratory adverse events

Benefits are especially notable in children with:

• Recent upper respiratory infections
• Reactive airway disease
• Obstructive sleep apnea

Large randomized studies found the lowest respiratory complication rates in children maintained with propofol-based TIVA.

Is propofol infusion syndrome still a concern?

Propofol infusion syndrome (PRIS) has historically been a major concern.

However, modern evidence is reassuring.

A nationwide study involving nearly 50,000 pediatric patients reported:

• PRIS-like findings in only about 0.13%
• No deaths
• No cases meeting full diagnostic criteria

The review concludes that PRIS is exceedingly rare in contemporary pediatric anesthesia practice.

EEG-guided anesthesia improves precision

One of the most important innovations in pediatric anesthesia is the use of EEG-guided drug titration.

Why traditional BIS monitoring has limitations

In infants younger than one year:

• BIS values may be falsely elevated
• Up to 70% of adequately anesthetized infants may appear under-anesthetized
• Clinicians may unnecessarily increase propofol doses

This increases overdose risk.

New EEG-based approaches

Experts increasingly recommend:

1. Raw EEG monitoring
2. Density spectral array analysis
3. Age-specific EEG interpretation
4. PK-EEG hybrid dosing strategies

These approaches help clinicians:

• Avoid excessive anesthetic exposure
• Detect burst suppression earlier
• Individualize dosing
• Improve safety in neonates and infants

TIVA remains the preferred choice for neurophysiologic monitoring

Children undergoing:

• Spinal surgery
• Neurosurgery
• Procedures requiring motor-evoked potentials (MEPs)

often benefit from TIVA.

The review reports that volatile anesthetics can significantly suppress:

• MEPs
• Somatosensory-evoked potentials

Propofol-remifentanil TIVA preserves signal quality and improves monitoring success.

Environmental sustainability: an unexpected advantage

Healthcare sustainability has become a major priority worldwide.

The review highlights dramatic differences in greenhouse gas emissions between anesthetic techniques.

Carbon footprint comparison

For a 60-minute anesthetic:

• Propofol-remifentanil TIVA: approximately 1.26 kg CO₂e
• Intravenous induction plus sevoflurane: approximately 2.58 kg CO₂e
• Inhalational induction and maintenance: approximately 2.98 kg CO₂e

Nitrous oxide dramatically increases emissions and remains one of the least sustainable anesthetic options.

As hospitals seek to reduce their environmental footprint, TIVA may play an increasingly important role.

Challenges preventing wider adoption

Despite its advantages, pediatric TIVA is not universally available.

Current barriers include:

• Limited access to infusion pumps
• Lack of pediatric TCI systems
• Variable clinician training
• Regulatory restrictions
• Workforce shortages
• Resource limitations in low-income settings

The review emphasizes that structured education programs significantly improve confidence and patient safety.

Conclusion

The latest evidence demonstrates that pediatric TIVA is entering a new era of precision medicine. Advances in PK/PD modeling, target-controlled infusion systems, EEG-guided titration, dexmedetomidine integration, and emerging drugs such as remimazolam are transforming the safety and effectiveness of intravenous anesthesia in children.

Beyond improving clinical outcomes, TIVA offers substantial environmental benefits and supports sophisticated neurophysiologic monitoring. While challenges involving training, technology access, and regulatory approval remain, the future direction is clear: pediatric anesthesia is becoming more individualized, safer, and more sustainable than ever before.

Reference: Quintão VC et al. Update on total intravenous anesthesia in children. Curr Opin Anesthesiol. 2026;39:304–316. 

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