TIVA outside the OR

Souvik Maitra MD, DNBAssistant Professor,

Department of Anaesthesia& Intensive Care,PGIMER, Chandigarh

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More than 25% procedure necessitate anesthesiologists' presence are done outside

operating room

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Hypoxia occurred in 40.2 cases per 1000 in adult patients

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Acad Emerg Med. 2016;23(2):119-34.

Hypoxia occurred in 157 times in 10000 cases in children

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Pediatrics. 2006;118(3):1087-96.

Areas need anaesthesiologits’ presence

• Radiology (CT, MRI, interventional radiology)• Cardiac catheterization lab• Endoscopy suite• Ovum pick up for IVF• Modified- ECT

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TIVA out side OR

• TIVA can be used for any procedures/ surgeries if not contraindicated

• Particularly suitable for MRI, image guided neuro-interventional procedures, ERCP, cardiac catheterization etc.

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TIVA: Is it really beneficial?

• Less PONV- both in patients who are at high or low risk of PONV

• Reduction in extubation time & PACU stay when compared to Desflurane based anaesthesia

• Hemodynamic stability during emergence• More costly than inhalation technique

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• A small RCT compared TCI, manual TIVA and sevoflurane based anaesthesia for brain biopsy- no difference in emergence and hemodynamics

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At the cost of….

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But…..

• All these evidences are obtained when TIVA was used in OR

• No randomized trial has compared TIVA with other anaesthetic technique outside OR

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TIVA: Manual vs TCI

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TCI required higher propofol dose, less interventionQuality of sedation was similarAdverse effects were similar

TIVA: Continuous infusion vs repeated boluses?

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Pediatr Crit Care Med. 2011;12(6):e262-5.

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A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min.

Significantly shorter recover time with single bolus regimen

Drugs used for TIVA outside OR/ procedural sedation

• Propofol• Midazolam• Fentanyl/ alfentanil/ remifentanil• Dexmedetomidine• Thiopentone/ Methohexital/ pentobarbital• Ketamine

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“patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine Sedation”

Propofol for GI endoscopy: Red alerts?• Use of propofol- more life threatening events

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Dexmedetomidine: As a sole agent

• Used in pediatric MRI as sole agent• Relatively high dose was used (2-3 mcg/kg

boluses followed by 1-2 mcg/kg/hr)• Around 20% patients required additional

boluses of rescue drug• Hypotension & bradycardia are common

concern• Respiratory compromise uncommon

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Int J Pediatr 2015;2015:397372.

Paediatr Anaesth. 2008;18(5):403-11

Paediatric sedation: Propofol or Dexmedetomidine?

6/11/16 Int J Clin Exp Med. 2015 Aug 15;8(8):11881-9.

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Similar results from RCTs

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Less patients’ satisfactionMore hemodynamic changes

Dexmedetomidine- opioid combination

• Dexmed-Remifentanil combination was equivalent to propofol- remifentanil combination for GI endoscopy

• Side effect profile was similar• Endoscopists were more satisfied with

dexmed probably less GI motility

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World J Gastroenterol. 2015;21(12):3671-8.

Ketamine: Dose it have a role in modern anaesthesia practice?

• Evidences are available from mostly cardiac catheterization laboratory

• Low dose ketamine does not affect recovery profile when used along with propofol

• No advantages when used along with dexmedetomidine

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Pediatr Cardiol. 200526(5):553-7.

Clin Ther. 2010;32(4):701-9.

Ketofol (Propofol- ketamine combination)

• Propofol- Ketamine combination has been used both for induction of anaesthesia and sedation

• Primary aim is hemodynamic stability• Reduction in adverse effects of either drug is

the aim of this technique

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A significant reduction in respiratory complications

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A similar incidence of psychomimetic events

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Less hemodynamic changes

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Hypotension

Bradycardia

A similar incidence of nausea-vomiting

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Optimum propofol: Ketamine ratio?

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10:1 propofol-ketamine ratio provided greatest hemodynamic stability and least recovery time

Ketamine or Opioid?

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A significant reduction in recovery time with remifentanil (median 10.3 minutes versus 22.5 minutes)

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More propofol required in fentanyl group, quality of recovery was similar

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Similar incidence of adverse effects and quality of sedation

Propofol: Safety concerns

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Propofol versus Pentobarbital

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• Dexmedetomidine may be an alternative for image guided procedure

• Less airway maneuver required• Discharge time similar

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J Res Med Sci. 2014;19(6):549-54.

• Etomidate is also a reasonable alternative• Better quality sedation• Less airway intervention required

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Pediatr Emerg Care. 2007;23(10):690-5

Midazolam premedication?

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• Increased incidence of desaturation (1.6% versus 7.3%)

• Similar emergence reaction (7.1% versus 6.2%)• Less vomiting with midazolam

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Oocyte retrieval: Does anaesthetic technique matters?

• All anaesthetic techniques are equally effective

• Propofol- whether it affects pregnancy outcome or not is controversial

• GA may be associated with worse outcome when compared to SAB-

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Cochrane Database Syst Rev. 2013 Jan 31;(1):CD004829.

Anesth Pain Med. 2013;3(2):239-42.

• Remifentanil may be a better choice than fentanyl

• Propofol accumulates in follicular fluid- dose & duration related, effects unknown

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Int J Fertil Steril. 2011;5(2):86-9.

Most of these remote locations do not have a scavenging system, so…..

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What these studies did not say….

• N2O is potential green house gas and responsible for 6% of heating and causes ozone depletion

• All halogenated inhalation anaesthetics are also green house gases

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Science. 2009;326:123–125.

Nature. 1989;341:635–637

Arctic ices are melting fast…..

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Thank you!

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