Skip main navigation

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.
This article is from the free online

Introduction to Using Total Intravenous Anaesthesia (TIVA)

Created by
FutureLearn - Learning For Life

Reach your personal and professional goals

Unlock access to hundreds of expert online courses and degrees from top universities and educators to gain accredited qualifications and professional CV-building certificates.

Join over 18 million learners to launch, switch or build upon your career, all at your own pace, across a wide range of topic areas.

Start Learning now