Use of Total Intravenous Anesthesia (TIVA) versus Inhaled
Volatile Anesthesia (INVA) in Elective Non-cardiac Surgery
Bethany Pennington, PharmD, BCPS
October 21, 2022
Co-PI: Allison Janda, MD
Disclosures
Grant / Research (current):
• Patient-Centered Outcomes Research Institute (PCORI) Project Program
Award (PLACER-2020C3-21106)– Co-investigator, “Trajectories of
Recovery after Intravenous Propofol vs. Inhaled Volatile Anesthesia
(THRIVE)”
Background
• Practice patterns and variations of agents used with TIVA and INVA-
based techniques are not well described.
• A further understanding of general anesthetic practices in the US will
be informative for a large multi-center pragmatic randomized
controlled trial comparing patient recovery experiences with TIVA
and INVA
– Trajectories of Recovery after Intravenous propofol versus
inhaled VolatilE anesthesia (THRIVE) Trial.
Aims and Hypothesis
• We proposed to analyze the patterns of TIVA use in patients
undergoing elective non-cardiac surgery across MPOG centers and
to understand potential sources of variation in practice patterns.
• We hypothesize that institution, clinician, and patient/case level
variables are associated with TIVA use.
Aims
• Aim 1: Identify variables associated with TIVA use.
– Determine the associations observed
– Explore the relative contribution of each level to variation in TIVA use
accounting for the nested structure of the data
• Aim 2: Describe the frequency, variation and duration of
administration of agents used during TIVA and inhaled-volatile based
anesthetic (INVA) techniques.
• Aim 3: Describe the frequency, variation and duration of
administration of agents used during TIVA and INVA techniques in
homogenous surgical subgroups.
Aim 1: Identify variables associated with TIVA use.
Explore the relative contribution of each level to variation in TIVA use
TIVA: administration of only IV anesthetic agents with < 5 minutes
administration of volatile anesthetic agents or nitrous oxide gas between
anesthesia start and anesthesia end, as documented in the anesthesia record.
INVA: administration of an inhaled anesthetic
for ≥ 5 minutes (either a volatile
anesthetic agent or nitrous oxide gas) at any time between anesthesia start
and anesthesia end, as documented in the anesthesia record.
Using a multi-level statistical model, we will estimate the variation contribution
of TIVA use which emerges from institution-, clinician- and patient/case-levels.
Candidate Variables of Interest
• Patient/Case-level
– Age, Sex, Race, BMI
– ASA status
– Surgical procedure type by body region
– Extent defined by Anesthesia Base Units
– Anesthesia duration
– Year of procedure
– Elixhauser comorbidities
– History of alcohol or drug use
– CRNA case (Yes/No)
– Anesthesiology resident case (Yes/No)
– Attending only case (Yes/No)
– Average attending staffing ratio (for all
cases)
– Out of hours cases (evenings and
weekends)
● Clinician-level
- Attending anesthesiologist annual case volume for
all cases during the study period defined by
anesthesiologist attending at start of case
- Proportion of outpatients cases over study period
- Proportion of GA cases over study period
- Average number of days/working/week signed into
a case over study period
● Institutional-level
- Institution annual case volume
- Academic vs. Non-Academic Institutions
- Bed size
- Institutional proportion of cases with CRNAs
- Institutional proportion of cases with residents
- Institutional proportion of cases with attending only
Methods: Inclusion & Exclusion Criteria
Inclusion criteria Exclusion criteria
1. Adult patients (≥18 years) undergoing elective
noncardiac surgical procedures from January 1,
2016 - December 31, 2021 with a case duration
lasting ≥ 60 minutes.
2. General anesthesia with a tracheal tube or
laryngeal mask airway [Technique Code 1,2 or 3
from Anesthesia Technique: General Phenotype]
1. No documentation of TIVA, halogenated gas, or nitrous throughout case
2. Emergency surgery (ASA E Modifier)
3. Obstetrics cases
4. Lung, Liver or heart transplantation
5. Cardiac surgeries
6. Cardiopulmonary bypass used
7. Location Tags: Facility Type - Office-based anesthesia, OB-GYN - Labor and
Delivery, OB-GYN - Obstetric OR, OB-GYN-IVF-only room, Other-Pediatric,
Radiology-MRI, Service Specific Room-Cardiac OR
8. Body Region: Other Procedures, Obstetrics, or Radiologic Procedures
9. Non-operative procedures and MRIs
10. ASA Class 5 or 6
11. Organ harvest (Anesthesia CPT 01990)
12. Absence of an actual or predicted anesthesia CPT
13. Active propofol infusion prior to patient in room
14. Patient arrived to the OR already intubated (phenotype)
15. Patient not extubated prior to departure from the OR (phenotype)
Methods- Statistical Analysis
Assessment of variance between: patients, clinicians, institutions
• Multilevel multivariable mixed-effects models were performed with
patients nested within clinicians nested with institutions to assess the
association between TIVA administration and relevant patient-,
clinician-, and institutional-level factors
• Using intraclass correlation coefficients, variance partition
coefficients, and median odds ratios
Results
Results
● 2,506,473 patients across 50 MPOG institutions with 5,826 providers
were included
○ 169,175 (6.8%) received TIVA
○ 2,337,298 (93.3%) received INVA
● Patient characteristics were similar between groups
Results
● Preliminary unadjusted generalized linear mixed models showed:
- 47.8% of the variation was explained by patient factors
- 17.8% by the primary attending
- 34.4% by the institution
● Over 50% of the variation was explained by clinician and institution
● Adjusted MORs for receiving TIVA:
- 2.2 between randomly selected primary attending
- 2.8 between randomly selected institutions
● Following multivariable
modelling, these are the
factors strongly associated
(adjusted odds ratio, <0.8,
or >1.2) with a statistically
significant increased or
decreased likelihood of
receiving a TIVA.
Factor Descriptor OR 95% CI
Gender Female
Male
Reference
0.55 (0.544,0.558)
Race White
Black
Reference
0.74 (0.724, 0.756)
Case Hours Out of Hours 0.75 (0.736,0.77)
Body Region Urologic
Male Reproductive
Burn
Head
Neck
Thorax-Extrathoracic
Thoracic
Spine and Spinal Cord
0.71
0.69
0.35
3.11
1.99
2.02
6.53
5.36
(0.684,0.735)
(0.625, 0.756)
(0.275, 0.436)
(3.033, 3.194)
(1.936, 2.05)
(1.964, 2.08)
(6.318, 6.746)
(5.206, 5.523)
Comorbidity Cerebrovascular 1.34 (1.284, 1.394)
Year of
procedure
2016
2017
2018
2019
2020
2021
Reference
1.29
1.38
1.59
1.61
1.63
(1.254, 1.324)
(1.34, 1.415)
(1.543, 1.629)
(1.566, 1.657)
(1.586, 1.679)
Affiliation Academic 4.54 (1.338, 15.427)
*all P values < 0.001
Results
Summary
● Institution and clinician accounted for over half of the variation of TIVA
administration
● These data may serve as a model for understanding general anesthesia practice
variation and provide context for planned randomized trials like THRIVE.
● More evidence is needed to inform whether this practice variation is irrelevant, or a
target for practice improvement
Limitations
- MPOG does not include ALL institutions across the US
- Most institutions were university-affiliated
Future Directions
○ Aim 2 and Aim 3 statistical analyses
○ Qualitative interviews with clinicians
Thank you
Allison Janda MD
Douglas Colquhoun, MB ChB, MSc, MPH
Graciela Mentz, PhD
Nan Lin, PhD
Michael L Burns, MD PhD
Sachin Kheterpal, MD, MBA
Michael Avidan, MBBCh, FCA SA
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