Longnecker's Anesthesiology > Part 4. Managing Anesthesia Care > Section C. Anesthesia Drugs and Drug Delivery Systems > Chapter 42. Total Intravenous Anesthesia John Sear, MA, PhD, MBBS, FFARCS, FANZCA

Key Points

"1. The appearance of new drugs with short blood–brain equilibration times (especially those with an ester linkage) enables the clinician to use anesthetics and analgesics where titratability will be easy and recovery rapid.

2. Total intravenous anesthesia (TIVA) offers some important advantages over inhalation anesthetics, including rapid recovery with minimal hangover and a low incidence of nausea and vomiting. TIVA may be the technique of choice for some operations.

3. Effective delivery of TIVA requires the clinician to have a good knowledge and understanding of pharmacokinetics, pharmacodynamics, and pharmacokinetic–pharmacodynamic (PK-PD) modeling.

4. Important drug characteristics include induction dose, rate of administration and k_e0 (rate constant for the elimination of drug from the effect compartment) (drugs with small k_e0 values take longer to equilibrate between the blood and the effect compartment or biophase). Thus for a rapid sequence induction, drugs with a large k_e0 are preferable (viz., propofol, thiopental, remifentanil, and alfentanil compared with midazolam, ketamine, and fentanyl)

5. Drug interactions are important in TIVA. Excepting ketamine, opiates and hypnotics potentiate each other and can result in synergistic cardiovascular and respiratory depression. This means the doses of each can be reduced...."