Standard reversal

• At the end of the surgery, the volatile agent is turned off and high fresh gas flow is used to wash out the volatile agent

TIVA reversal

• Quoted EC50 for return of consciousness is about 1 – 1.5 mcg/ml but this may vary with patient and anaesthetic factors
  • There is persistent stimulation from surgery and endotracheal tube
• Our usual TIVA technique is with propofol and remifentanil infusion
  • Remifentanil has a shorter context-sensitive half time than propofol
  • Towards the end of surgery we begin to titrate down the propofol target first at the end of the surgery
• There is no way to speed up the reversal of anaesthesia with TIVA, unlike the way we drive out the volatile agent with high fresh gas flow, so titrating down at the end of surgery is important.

Caveat for reversal

• Some of the TCI pumps allow you to set a wake-up propofol concentration (decrement concentration)
• It can calculate how long it will take to reach that target if propofol infusion is stopped (decrement time)
• This gives you a rough estimate of when you have to think about titrating down.
• Remember to supplement analgesia with adequate longer-acting opioid
• Remember to flush the IVs when you disconnect the TIVA infusion from your patient and dispose of them appropriately