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Minimising the adverse effects and maximising the benefits of TIVA

In this article we will discuss the steps we can take to ensure the best outcomes in our elderly patients when using TIVA

Minimising adverse effects

  • Caution is required to avoid adverse side effects
  • pEEG can be used to help avoid excessively deep levels of anaesthesia
    • Allows drug titration based on PD response, particularly if paralysed
    • May improve safety
    • ↓ Postoperative neurobehavioral disease (PND)
  • Which site to target?
    • Plasma or effect-site targeting can be used
    • Effect-site targeting will lead to higher initial plasma concentrations
      • ↑ Risk of hypotension post-induction
    • Plasma site targeting results in longer induction times
      • ↑ Haemodynamic stability
  • Start LOW and go SLOW
    • Drug distribution from the plasma to the site of action is also delayed in elderly patients, hence the onset of action is slower
  • Define V1 through the lean body
    • Actual weight is likely to be useful to define the other distribution volumes
    • Age-related drug elimination and age-adjusted Keo to reflect the delayed onset

Effect of ageing and suggested drug adjustments

  • Metabolism and distribution of certain drugs (e.g. propofol) will be affected more than others (e.g. remifentanil)
  • Polypharmacy (regular use of 5 or more medications) is seen in over 40% of elderly patients with implications for drug interactions
  • Propofol
    • Pharmacokinetics
      • ↓ Vd
      • ↓ Protein Binding
      • ↓ Clearance
    • Pharmacodynamics
      • ↑ Hypotension (dose-dependent)
      • ↑ Brain sensitivity
    • Recommended dose adjustment
      • ↓ 20-50% (Bolus and Infusion)
  • Remifentanil
    • Pharmacokinetics
      • ↓ Vd
      • ↓ Clearance ~30% (↓plasma esterase)
    • Pharmacodynamics
      • ↑ Respiratory and vasomotor centre depressant effect
      • ↑ Brain sensitivity (50% decrease in EC50)
    • Recommended dose adjustment
      • ↓ 50% (Bolus and Infusion) context insensitive
A delay in the emergence of elderly patients from anaesthesia may be partially due to their increased proportion of fat or inadvertent overdosing

Advantages of TIVA in the elderly

  • Anaesthesia and analgesia components can be administered independently
  • Titration of anaesthesia is easier than with inhalation anaesthesia (which is very difficult to titrate and usually guessed, based on MAC)
  • Haemodynamic stability
  • Smooth recovery profile
  • ↓ Postoperative neurocognitive disorders
    • ↓Cognitive impairment, delirium and pain
    • Possible benefits in cancer surgery
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Introduction to Using Total Intravenous Anaesthesia (TIVA)

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