Expert Multinational Consensus Statement for Total Intravenous Anaesthesia (TIVA) Using the Delphi Method

Abstract

Introduction: The use of total intravenous anaesthesia (TIVA) has been well established as an anaesthetic technique over the last few decades. Significant variation in practice exists however, and volatile agents are still commonly used. This study aims to determine the motivations and barriers for using TIVA over the use of volatile agents by analysing the opinion of several international anaesthetists with specific expertise or interests. Methods and participants: The Delphi method was used to gain the opinions of expert panellists with a range of anaesthetic subspecialty expertise. Twenty-nine panellists were invited to complete three survey rounds containing statements regarding the use of TIVA. Anonymised data were captured through the software REDCap and analysed for consensus and prioritisation across statements. Starting with 12 statements, strong consensus was defined as ≥75% agreement. Stability was assessed between rounds. Results: Strong consensus was achieved for four statements regarding considerations for the use of TIVA. These statements addressed whether TIVA is useful in paediatric anaesthesia, the importance of TIVA in reducing the incidence of postoperative nausea and vomiting, its positive impact on the environment and effect on patient physiology, such as airway and haemodynamic control. Conclusions: Using the Delphi method, this international consensus showed that cost, lack of familiarity or training and the risk of delayed emergence are not considered obstacles to TIVA use. It appears, instead, that the primary motivations for its adoption are the impact of TIVA on patient experience, especially in paediatrics, and the benefit to the overall procedure outcome. The effect of TIVA on postoperative nausea and vomiting and patient physiology, as well as improving its availability in paediatrics were considered as priorities. We also identified areas where the debate remains open, generating new research questions on geographical variation and the potential impact of local availability of monitoring equipment.

Availability of total intravenous anaesthesia for obstetric surgery

“…A recent international consensus statement from 29 panellists found that they would prioritise TIVA over inhalational anaesthesia in paediatric patients to reduce PONV, to improve the effects on physiology, and to increase its availability. Cost and lack of familiarity or training were not considered obstacles to the use of TIVA 6 . In contrast, 144 respondents in our survey chose unfamiliarity as a reason not to use TIVA in obstetric patients.…”

“…Cost and lack of familiarity or training were not considered obstacles to the use of TIVA. 6 In contrast, 144 respondents in our survey chose unfamiliarity as a reason not to use TIVA in obstetric patients. Forty-five percent (134/298) of obstetric anaesthetists surveyed did have some experience in using TIVA in the obstetric population, albeit rarely.…”

Anaesthetic subspecialties and sustainable healthcare: a narrative review

“…Paediatric TIVA has gained popularity in the last decade, but there remain barriers, perceived and actual, to its wider adoption. These include: lack of training and experience; unreliable pharmacokinetic models, leading to concerns around awareness or prolonged sedation; lack of availability of essential equipment; concerns about propofol-related infusion syndrome; and the ubiquity of inhalational inductions [44,45]. The environmental benefits of TIVA in the paediatric population have been shown using mathematical modelling and lifecycle analysis to answer several questions around the relative carbon footprints of TIVA and volatile anaesthesia in children of differing weights undergoing procedures of varying durations [46].…”

Real Evidence and Misconceptions about Malignant Hyperthermia in Children: A Narrative Review

“…Another unusual situation at risk of MH is sedation with inhaled anesthetics in the pediatric intensive care unit (PICU) [ 66 , 67 , 68 ]. If these types of sedation devices are used, children susceptible to MH in the PICU may be at risk for such exposure, highlighting the significance of MH differential diagnosis in intensive care patients admitted for other conditions [ 69 ].…”

“…Moreover, pediatric regional anesthesia is usually performed in combination with general anesthesia or some degree of sedation. There is no evidence to support elective intensive care unit management of MH-susceptible patients after uneventful trigger-free anesthesia [ 67 ].…”