Vol 29S1
June 2015
EDITORIAL U p d a t e o n T o t a l I n t r a v e n o u s An e s t h e s i a Wi t h S p e c i a l E m p h a s i s o n C ardi o v a s c u la r An e s t h e s ia
T
OTAL INTRAVENOUS ANESTHESIA (TIVA) techniques are broadly applied around the world in a wide variety of surgical settings, although the TIVA approach is perhaps less popular in the United States compared with some regions. To examine the current state-of-the-art of TIVA practice, the author and colleagues convened for a roundtable discussion in Short Hills, New Jersey, in December 2013 (Drs. Talmage D. Egan of Utah, Thomas W. Schnider of Switzerland, T.J. Gan of New York, Martin S. Angst of California, Michael G. Irwin of Hong Kong, and Stefan Schraag of the United Kingdom). The roundtable outlined the fundamental scientific principles underpinning TIVA practice, considered why TIVA may be somewhat less popular among US practitioners, and addressed some unique aspects of TIVA as they relate to cardiovascular anesthesia. This supplement of the Journal of Cardiothoracic and Vascular Anesthesia is a brief overview of the roundtable findings. Each chapter represents a summary of the roundtable discussion content according to the contributing authors’ views. The supplement is intended to be a concise review of important aspects of TIVA practice, including certain topics especially relevant to cardiovascular anesthesia. The supplement begins with my article contrasting TIVA with inhalation anesthesia techniques from a drug delivery perspective. I highlight the significant disadvantages associated with TIVA in its early days. These disadvantages stemmed largely from gaining access to the circulation directly; exploiting the equilibration process that occurs when delivering a drug through the lung is a fundamental advantage of inhalation anesthesia. I argue that theoretical and practical scientific advances related to intravenous anesthetics have now addressed most of the early shortcomings associated with TIVA. Chief among these advances are more suitable drugs, target-controlled infusion technology (TCI), and sophisticated clinical pharmacology concepts. TIVA is now a popular technique internationally (especially where TCI is available) and compares favorably with traditional inhalation anesthesia approaches.
Next, the supplement turns to a review of important clinical pharmacology concepts in TIVA practice, contrasting them with certain inhalation anesthesia principles such as minimum alveolar concentration (MAC). Among the key ideas outlined by Dr. Thomas Schnider are the effect site concept, the contextsensitive half-time and decrement time, and pharmacodynamic drug interactions. Dr. Schnider also highlights the importance of TCI in the application of advanced pharmacokinetic concepts in TIVA. The supplement then addresses the question of how outcomes differ between TIVA and inhalation anesthesia techniques. Using a theoretical “ideal anesthetic” as a conceptual framework, Dr. T.J. Gan, with colleague Dr. Timothy Miller, considers some potential advantages of TIVA including a reduced incidence of postoperative nausea and vomiting (PONV) and less concern about atmospheric pollution. Drs. Gan and Miller also address some more controversial elements of TIVA practice including intraoperative awareness, myocardial protective effects, and the management of postoperative pain. Dr. Martin Angst next sharpens the focus on the issue of postoperative pain management after TIVA. In particular, Dr. Angst reviews the complex topics of acute opioid tolerance and opioid-induced hyperalgesia with special attention on remifentanil as it relates to these phenomena. He concludes with practical suggestions about how to manage pain after TIVA. The final 2 articles of the supplement address issues specifically related to cardiovascular anesthesia. Dr. Michael Irwin and colleague Dr. Gordon Wong outline the current thinking regarding opioid-induced cardioprotection (and other organs) with special reference to remifentanil, the most common mu-agonist drug used in TIVA. After reviewing the relevant biology and mechanisms,
© 2015 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2015.01.025
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No S1 (June), 2015: pp S1–S2
S1
S2
they synthesize the still-emerging literature, point out gaps in our current knowledge, and suggest future directions for this line of research. The supplement wraps up with a summary of the role of TIVA in modern cardiac anesthesia practice. Dr. Stefan Schraag and his colleague Dr. Christopher Hawthorne begin by reviewing the history of TIVA in cardiac anesthesia, focusing largely on the European experience. Next they briefly summarize the understanding of the cardiovascular effects of common TIVA drugs. They finish with an appraisal of current knowledge concerning cardiopulmonary bypass and myocardial protection as they relate to TIVA.
EGAN
The roundtable was a useful exercise addressing both theoretical and practical aspects of TIVA. The roundtable participants hope the supplement will be a useful compendium of up-to-date information guiding practitioners in the application of TIVA techniques in their practices.
Talmage D. Egan, MD Departments of Anesthesiology, Pharmaceutics and Bioengineering University of Utah School of Medicine Salt Lake City, Utah
June 2015
EDITORIAL U p d a t e o n T o t a l I n t r a v e n o u s An e s t h e s i a Wi t h S p e c i a l E m p h a s i s o n C ardi o v a s c u la r An e s t h e s ia
T
OTAL INTRAVENOUS ANESTHESIA (TIVA) techniques are broadly applied around the world in a wide variety of surgical settings, although the TIVA approach is perhaps less popular in the United States compared with some regions. To examine the current state-of-the-art of TIVA practice, the author and colleagues convened for a roundtable discussion in Short Hills, New Jersey, in December 2013 (Drs. Talmage D. Egan of Utah, Thomas W. Schnider of Switzerland, T.J. Gan of New York, Martin S. Angst of California, Michael G. Irwin of Hong Kong, and Stefan Schraag of the United Kingdom). The roundtable outlined the fundamental scientific principles underpinning TIVA practice, considered why TIVA may be somewhat less popular among US practitioners, and addressed some unique aspects of TIVA as they relate to cardiovascular anesthesia. This supplement of the Journal of Cardiothoracic and Vascular Anesthesia is a brief overview of the roundtable findings. Each chapter represents a summary of the roundtable discussion content according to the contributing authors’ views. The supplement is intended to be a concise review of important aspects of TIVA practice, including certain topics especially relevant to cardiovascular anesthesia. The supplement begins with my article contrasting TIVA with inhalation anesthesia techniques from a drug delivery perspective. I highlight the significant disadvantages associated with TIVA in its early days. These disadvantages stemmed largely from gaining access to the circulation directly; exploiting the equilibration process that occurs when delivering a drug through the lung is a fundamental advantage of inhalation anesthesia. I argue that theoretical and practical scientific advances related to intravenous anesthetics have now addressed most of the early shortcomings associated with TIVA. Chief among these advances are more suitable drugs, target-controlled infusion technology (TCI), and sophisticated clinical pharmacology concepts. TIVA is now a popular technique internationally (especially where TCI is available) and compares favorably with traditional inhalation anesthesia approaches.
Next, the supplement turns to a review of important clinical pharmacology concepts in TIVA practice, contrasting them with certain inhalation anesthesia principles such as minimum alveolar concentration (MAC). Among the key ideas outlined by Dr. Thomas Schnider are the effect site concept, the contextsensitive half-time and decrement time, and pharmacodynamic drug interactions. Dr. Schnider also highlights the importance of TCI in the application of advanced pharmacokinetic concepts in TIVA. The supplement then addresses the question of how outcomes differ between TIVA and inhalation anesthesia techniques. Using a theoretical “ideal anesthetic” as a conceptual framework, Dr. T.J. Gan, with colleague Dr. Timothy Miller, considers some potential advantages of TIVA including a reduced incidence of postoperative nausea and vomiting (PONV) and less concern about atmospheric pollution. Drs. Gan and Miller also address some more controversial elements of TIVA practice including intraoperative awareness, myocardial protective effects, and the management of postoperative pain. Dr. Martin Angst next sharpens the focus on the issue of postoperative pain management after TIVA. In particular, Dr. Angst reviews the complex topics of acute opioid tolerance and opioid-induced hyperalgesia with special attention on remifentanil as it relates to these phenomena. He concludes with practical suggestions about how to manage pain after TIVA. The final 2 articles of the supplement address issues specifically related to cardiovascular anesthesia. Dr. Michael Irwin and colleague Dr. Gordon Wong outline the current thinking regarding opioid-induced cardioprotection (and other organs) with special reference to remifentanil, the most common mu-agonist drug used in TIVA. After reviewing the relevant biology and mechanisms,
© 2015 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2015.01.025
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No S1 (June), 2015: pp S1–S2
S1
S2
they synthesize the still-emerging literature, point out gaps in our current knowledge, and suggest future directions for this line of research. The supplement wraps up with a summary of the role of TIVA in modern cardiac anesthesia practice. Dr. Stefan Schraag and his colleague Dr. Christopher Hawthorne begin by reviewing the history of TIVA in cardiac anesthesia, focusing largely on the European experience. Next they briefly summarize the understanding of the cardiovascular effects of common TIVA drugs. They finish with an appraisal of current knowledge concerning cardiopulmonary bypass and myocardial protection as they relate to TIVA.
EGAN
The roundtable was a useful exercise addressing both theoretical and practical aspects of TIVA. The roundtable participants hope the supplement will be a useful compendium of up-to-date information guiding practitioners in the application of TIVA techniques in their practices.
Talmage D. Egan, MD Departments of Anesthesiology, Pharmaceutics and Bioengineering University of Utah School of Medicine Salt Lake City, Utah
