Claire Nestor

Claire Nestor

Consultant Anaesthesiologist Tallaght University Hospital
Associate Editor Anaesthesia

Location Ireland


  • Dexmedetomidine has a faster onset and offset than clonidine and may be more beneficial in the periop setting

  • Dexmedetomidine has a faster onset and offset than clonidine and may be more beneficial in the periop setting

  • Dexmedetomidine has a faster onset and offset than clonidine and may be more beneficial in the periop setting

  • I've added some details of the PBT index to the article

  • Everyone's style of TIVA will vary slightly and that's ok! You are correct the method described above takes a little longer but I rarely need to support the blood pressure after induction. I believe I save this additional time when it comes to the recovery from anaesthesia.

  • Hi @MylesMonaghan research supports a propofol concentration of between 2.51 and 2.81 in combination with a remifentanil concentration at 4.70 to 8.27 as an optimal hypnotic-opioid balance. Is this in keeping with your clinical experience?

  • @PaolaBotello @JoannaKrawczyk Week 6 Special Patient Cohorts covers delivering TIVA for Emergency Surgery!!

  • Unfortunately, this is not possible with the format!

  • We have the same checklist in both Hong Kong and Ireland. I don't find it delays the process too much. I do tend to get the checklist out of the way as soon as possible and start whilst reviewing the plan with the anaesthetic nurse and trainee. I find any time lost at the start is made up at the end as you have a better understanding of the concentrations that...

  • I have rarely encountered problems with ketamine at the doses used (25mg-30mg at induction) I don't tend to re-dose if not particularly painful. I also find it incredibly helpful for TIVA-based sedation at very low doses (10-20mg). I tend to avoid midazolam.

  • The cost of Dexmedetomidine has been greatly reduced recently. Hopefully, this will reduce some of the barriers to use.

  • Different recipes exist for the various available opioids. Titration down based on CSHT is key to avoid delays in wakening. Making the most of adjuncts available including regional would be wise.
    Below are some recipes @mgirwin discussed previously

    Potency ~20% of fentanyl
    Context sensitive half-life (CST) is reasonably predictable but rises...

  • The TIVA simulation used for the mentioned scenarios used Eleveld effect-site target. Whilst the mixture is licensed it is not licensed for use as part of a TCI infusion. I would suggest the PK characteristics of remifentanil are more favourable, specifically, for longer procedures if available. The elimination half-life of alfentanil is 60 – 120 min vs 8-12...

  • The improved recovery profiles of a patients could possibly be a driver for this

  • Let's hope this course can change that!

  • Thank you for sharing your practice. We acknowledge there is a wide scope of practice out there but this is a technique we strongly discourage. We are aware that mixing is popular in some paediatric centres the following article and reply...

  • @AliceHumphreys Getting surgical teams on board and involved in charting the peri-operative analgesics I believe is the way forward for it to run efficiently. Proformas have worked nicely in previous institutions I've worked in.

  • Optimal flow rates depend on the source of the electricity in that country. Energy consumption is required for the production of both oxygen and air. Energy consumption for air is 0.00017 kWh/L. In countries that do not use renewable energy the increased energy consumed in the production of medical gases has to be balanced against the reduction in CO2 absorbers.

  • In my current institution, the logistics of ensuring analgesics as a premed is given is difficult. Oral premeds work very well as part of multimodal analgesia if the system allows and have a lower economic and environmental cost (more on this later). Getting surgical buy-in is hugely important and the development of a peri-operative pain pathway.

  • The effect of ketamine on the electroencephalogram (EEG) is altered in the presence of propofol: by itself, it increases θ and decreases α waves, whereas ketamine induces a significant shift to beta band frequencies in the presence of propofol. I find at the low doses we use the effect is relatively short on the EEG and am guided by clinical signs. I favour...

  • I personally do not use TCI for dexmedetomidine

  • I believe the cost of dexmedetomidine has been greatly reduced recently. It may be worthwhile looking into this in your institution. I agree cost initially was prohibitive for its use routinely.

  • For short cases, I may give the loading dose depending on the patient but would usually not run an infusion. If the infusion is not turned off 30-60 minutes before the end delays in emergence will be seen. I would use infusions for longer cases with higher analgesics requirements routinely.

  • Getting familiar with the EEG waves and not solely relying on the absolute number is hugely important.

  • I find EEG useful in all cases where I expect the patient's PK and PD responses to differ. Elderly patients would definitely fall into this patient group in addition to obese, septic and drug-dependent patients. I use a short-acting muscle relaxant when intubation is required and often find with high-dose remifentanil further doses are not required to...

  • This starting point is anxiolytic only and not an induction dose! We start low and go slow. I find it very useful to have it running at this low level whilst making the final preparations. I find by doing this once we start titrating up for induction of anaesthesia the patient is calm, less nervous and loss of response to verbal stimulus is at around effect...

  • Changed! Thanks Alice

  • Changed! Thanks Bob

  • Hi Hosam. thank you for taking the time to sign up for this course. Hopefully, this course will provide the knowledge required to increase TIVA usage.

  • Thanks Taif, we run workshops at conferences for this reason. So if you enjoy the course please sign up for one in the future.

  • Hi Faisal, compared to the newer volatile agents TIVA is not really more expensive we have included some cost analysis later in the course. Stable electricity and pump availability/purchase are all barriers to TIVA use in low-resource companies. Hopefully the course will address some of the other concerns you mention!

  • Hi Bob, thanks for your comment. These are all concerns but hopefully, by the end of the course, some of these will be less. Low and high-pressure alarms are available on some TCI pumps which alerts the anaesthetist to drug delivery failure. Stay tuned to find out more :)

  • Hi Lucy, hopefully, this course will give some of the infrequent users more confidence to #TakeOnTIVA this was a driving force behind the creation of this course.