TIVA Tips
Avoid Distressing Awareness
• Check your equipment (e.g. IV is running, infusion pumps are working and correctly programmed).
• Use EEG monitor to guide pharmacodynamic endpoint (sufficient hypnotic effect).
• Target alpha/theta spindles and delta waves on EEG trace or red train tracks in delta and alpha frequency bands on the
spectrogram (depending on which monitor is being used).
• Do not rely exclusively on processed EEG index.
• Use pharmacokinetic modeling (e.g. stanpumpR.io) to guide sufficient hypnotic dosing (effect-site concentration).
• Consider targeting brief deep anesthesia (e.g. periods of EEG suppression) for intense stimuli (e.g. intubation, incision)
• Provide adequate analgesia with a continuous infusion (e.g. remifentanil 0.05-0.2 mcg/kg/min).
• Avoid excessive NM-blockade (e.g. maintain 2 twitches on TOF).
• Reverse NM-blockade prior to discontinuing propofol at the end of the case.
• Ensure sufficient analgesia is on board at emergence.
Avoid Excessive Hypnosis
• Use EEG monitor to guide pharmacodynamic endpoint (not excessive hypnotic effect, e.g. EEG suppression).
• Target alpha/theta spindles and delta waves on EEG trace or red train tracks in delta and alpha frequency bands on the
spectrogram (depending on which monitor is being used).
• Do not rely exclusively on processed EEG index.
• Use pharmacokinetic modeling (e.g. stanpumpR.io) to avoid excessive hypnotic dosing (effect-site concentration).
• Decrease propofol infusion rate throughout the case (guided by PK modeling) to avoid excessive accumulation.
• Consider decreasing propofol concentration rate in the face of EEG suppression.
Avoid Prolonged Emergence
• Use EEG monitor to guide down-titration of propofol towards the end of the case.
• Do not rely exclusively on processed EEG index.
• Use pharmacokinetic modeling (e.g. stanpumpR.io) to guide safe down-titration of propofol towards the end of the case
(target lower effect site concentration) to avoid excessive accumulation.
• Provide adequate analgesia to allow minimization of propofol.
• Discontinue propofol early while continuing analgesic administration towards the end of the case after reversal of NM-
blockade.
Avoid Unwanted Intraoperative Movement
• Use a concomitant analgesic infusion, as opposed to intermittent boluses alone (e.g. remifentanil, dexmedetomidine)
• Provide adequate analgesia alongside propofol for TIVA anesthetics
• Monitor depth of NM-blockade when using paralytic agents
• Consider targeting brief deep anesthesia (e.g. periods of EEG suppression) for intense stimuli (e.g. intubation, incision)
