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Challenges of TIVA in Emergency Surgery

Is TIVA too troublesome to use in emergency surgery? To safely deliver TIVA we must first explore the challenges of these scenarios.

Emergency Surgery

  • Rapid Sequence Induction (RSI), or a modified version of it, is frequently used to intubate the trachea in emergency situations
  • Generally, it includes
    • Denitrogenation by pulmonary pre-oxygenation
    • Administering a pre-determined dose of rapidly acting anaesthesia induction agent followed immediately by the administration of a fast-acting muscle relaxant
      • Thiopentone was traditionally the induction of agent of choice due to its reliable and rapid clinical effect
      • Propofol in recent years has gained popularity due to familiarity
      • The time to peak effect of propofol is longer than thiopentone (approximately twice as long)
    • Application of cricoid pressure (Sellick’s manoeuvre)
      • The usefulness of cricoid pressure is controversial and the evidence base is weak
  • Nature of pathology that requires emergency surgery
    • Trauma
    • Postoperative complications or unwell surgical patients
    • Critically ill medical patients with hypoxaemia
  • Challenges of emergency surgery
    • Pulmonary aspiration as a result of inadequate or unreliable fasting (full stomach)
      • Traditional teaching dictates that all emergency, trauma and obstetric patients are presumed to have a full stomach
      • Increasing use of preoperative gastric ultrasound can select those at high risk from this population
      • Rapid administration of propofol and muscle relaxant goes against the concept of slow titration to the clinical effect that has prevailed in the teachings of the previous weeks
    • Deranged physiology
    • Increased bleeding risk
      • Blood loss during surgery in particular emergency operations is common
      • Propofol has a very large volume of distribution
      • Therefore even large blood loss will have little effect on plasma concentrations
        • TCI and manual infusion do not need adjustment
      • Increased pharmacodynamic sensitivity of anaesthetic drugs is with hypovolemia
      • Reduction in organ blood flow (particularly hepatic) will reduce propofol clearance and may increase blood concentrations.
        • The same phenomenon was observed in hepatobiliary surgery with the Pringle manoeuvre (hepatic vascular clamps)
  • pEEG monitoring during major emergency/ elective surgery with any anaesthetic technique allows us to titrate
  • Ketamine is useful as a propofol sparing adjunct
Caution is required in patients with haemodynamic compromise. TCI in emergencies is not for novices and we need to develop these skills in normal, healthy patients first.
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Introduction to Using Total Intravenous Anaesthesia (TIVA)

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