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Barriers to the widespread adoption of TIVA

What stands in the way of widespread use of TIVA? In this article, we discuss the barriers to using TIVA.

Establishing the Baseline

  • The HKU department of anaesthesia carried out an international survey to gauge the factors that have hampered widespread uptake
  • Respondents were divided into groups depending on their frequency of TIVA use
    • Infrequent users <5%
    • Intermediate users 5-50%
    • Frequent users >50%
  • 763 completed surveys returned
    • 41.4% infrequent users
    • 42.3% intermediate users
    • 16.3% frequent users

Setup/ Efficiency

  • Over half (52%) of infrequent users considered additional effort as a deterrent whilst this did not factor into account for the vast majority of frequent users (86%)
  • Increased turnover did not impact frequent TIVA users decisions (2%) compared to infrequent users (31%)
  • Longer induction was less likely to impact the decision not to use TIVA for frequent users (6%) than for infrequent users (14%)
  • Some infrequent users (15%) were discouraged by the crowded conditions created around the patient but this was not a consideration for the vast majority of frequent users (98%)

Drug Delivery/Awareness

  • Frequent users (22%) were more likely to cite difficult IV access as a reason to avoid TIVA compared with infrequent users (13%)
  • Approximately one-third of infrequent users (34%) cited missing drug delivery failure as a reason for not choosing TIVA compared with only 2% of frequent users.
  • The intravenous infusion line not being visible or accessible elicited a similar response to the above for the infrequent (33%) and frequent (3%) groups
  • The lack of real-time concentration monitors for propofol concentration acted as a significant barrier for the infrequent users (40%) with a 10 fold increase in the numbers reporting it as a reason not to choose TIVA compared with frequent users (4%)
  • Unavailability of equipment such as TCI pumps and one-way valve were more likely to impact infrequent users (22%, 12%) choice than frequent users (3%, 9%)
  • The lack of availability of depth of monitoring bothered the frequent users (7%) more than the infrequent user (29%)
  • Increased in the incidence of awareness is more likely to discourage infrequent users (22%) but not frequent users (2%)


  • No outcome benefit was considered a stronger factor for not choosing TIVA for the infrequent user (24%) in comparison to the frequent user (11%)
  • Frequent users (22%) were more likely to not choose TIVA due to a greater likelihood of cardiovascular instability compared with infrequent users (17%)
  • Infrequent users (30%) were 5 times more likely to consider volatile was better for a case than frequent users (6%)

Patient Variability and Titration

  • Large inter-patient variability, difficulties in titrating dose to clinical needs and analgesia on emergence were more concerning for the infrequent user (30%, 25% and 17%) than the frequent user (7%, 6% and 10%)

Technology and Training

  • Complicated pharmacokinetic models and concerns about their accuracy affected infrequent users (15%, 17%) more than frequent users (13%, 6%)
  • More frequent users (24%) felt that insufficient training was a reason for not choosing TIVA compared with infrequent users (11%)

Preferences and Expenses

  • Anaesthetists who frequently used TIVA (11%) were less likely to be swayed by institutional preference when choosing their anaesthetic technique in comparison to the infrequent users (34%)
  • 28% of infrequent users claimed additional expense was a reason for not choosing TIVA this is in contrast to only 2% of frequent users

As you can see the relative importance of factors for not choosing TIVA varies greatly with experience. We believe that non-technical factors play a significant role in our choices and decisions are not only based on evidence. Some of the factors cited may not accurately reflect modern TIVA practice. We will explore this further in the next section as we attempt to break down these barriers!

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Introduction to Using Total Intravenous Anaesthesia (TIVA)

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