Guidelines for the safe practice of total intravenous anaesthesia (TIVA)

The Association of Anaesthetists and the Society for Intravenous Anaesthesia have produced new guidelines on the use of total intravenous anaesthesia (TIVA) i.e. the maintenance of general anaesthesia by an intravenous drug infusion rather than by the more conventionally used inhaled anaesthetic drugs. These guidelines, published in the journal Anaesthesia this week (February 2019 issue), are the first nationally agreed guidelines on the use of TIVA.

Training and competency are key to delivering TIVA safely, as Dr Alastair Nimmo, consultant anaesthetist, Royal Infirmary of Edinburgh and one of the guideline authors explains: “TIVA has advantages for some patients and in certain situations is the only technique that can be used. However, recent surveys of anaesthetists working in the UK and Ireland have suggested that training in TIVA is currently inconsistent and often inadequate.

“In 2014, the 5th National Audit Project (NAP5)  on accidental awareness during general anaesthesia, found that patient self-reported cases of awareness appeared to be more common when TIVA was used. Most of the cases were considered preventable and that the most common contributory factor was inadequate operator education and training. These new guidelines support anaesthetists to deliver safe TIVA by recommending education and training“.
The guidelines include a set of 10 key recommendations that cover best practice for administration and monitoring of TIVA. In addition, the guidelines specify four key areas of knowledge required by an anaesthetist using TIVA:

  • Achieving a desired drug concentration in the patient: the principles behind achieving and maintaining an appropriate concentration of an intravenous anaesthetic or analgesic drug in the patient’s brain.
  • Choosing an appropriate target drug concentration for a patient: the factors determining the appropriate target drug concentration to aim for and how to adjust this in the light of the patient’s response.
  • Practical aspects of the safe use of TIVA: ensuring that the intended dose of drug is delivered to the patient.
  • Monitoring the patient during TIVA: This should be done in accordance with the Association of Anaesthetists’ recommendation for standards of monitoring during anaesthesia and recovery. This includes the use of a processed EEG (pEEG) monitor when a neuromuscular blocking drug (muscle relaxant) is used along with TIVA.


Professor Michael Irwin, one of the authors of the accompanying editorial, also published in Anaesthesia, Taking on TIVA. Why we need guidelines on total intravenous anaesthesia, said: “We welcome the publication of the TIVA guidelines which will enable more patients to benefit from this anaesthetic technique. TIVA has many advantages for patients such as less nausea, vomiting and pain as compared with inhalational anaesthesia”.

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