In the last few years, Total Intravenous Anaesthesia (TIVA) has become very popular with anaesthetists in many parts of the world.Total Intravenous Anaesthesia + TCI (Target Controlled Infusions) is set to become the most popular, safe and kind method of administering anaesthesia.

TIVA-TCI involves the giving of a lipid based anaesthetic (propofol) and, usually, an analgesic with a remarkably short half-life-Remifantanil. For the majority of cases the anaesthetist will add an IV drip infusion and this virtually removes the likelihood of PONV (post operative nausea & vomiting). Many anaesthetists will only use TIVA-TCI on their patients as the technique is well proven to be safer than ‘gas’ inhalational anaesthesia.

A good example is with gastric surgery where retching and vomiting are likely to cause damage after the operation. With obese patients who are more likely to require gastric-band/bypass surgery they are at a much higher risk of developing cardiac abnormalities than those undergoing TIVA-TCI.

Inhalational anaesthesia is being increasingly rejected by anaesthetists worldwide in several surgical areas. It does rather beg the question, why cannot every patient have TIVA-TCI?

Worldwide many anaesthetists are becoming extremely vigilant about IV safety and TIVA-TCI is no exception.

There are many concerns over safety in administering TIVA-TCI, i.e.

what sort of infusion lines to use? Are non-return valves needed? What has been put into the infusion set to prevent a drug

bolus? How do we stop the cannula dislodging? What happens if someone tampers with the distal section of

the set? How can we ensure that the right drug label matches that of

the syringe in the TCI pump? What do I do if the patient bleeds out and I cannot find

another access as I want to give high-flow fluids (apart from say, a percutaneous cut-down)?

The SALG Report-2009 (Safety Anaesthesia Liaison Group) and Project Orcadian-2004 (Department of Health) highlighted several of the above concerns.

Several companies have gone some of the way in making their 3-Way TIVA Multiple Infusion Sets safer but, unfortunately, this only went a part of the way to solve the IV safety problems which, sad to say, occur more than we would all like.

There are several postings on the internet which refer to these safety concerns and how they have been solved. A couple of useful search terms would be ‘Safety in TIVA-TCI’ and ‘3-Way Multiple Infusion Sets’

By using, typically, a 3-Way Multiple Infusion Set i.e. Two lines and a distal limb (with valve) one has multiple drug delivery options and a standard flow of IV fluids.

THIS IS NOT ENOUGH!

An ultra safe TIVA Multiple Infusion Set would have as standard:

Drug Identification Tags to ensure that syringe contents matched that of the line used.

Adjustable Line Fixation Device to make sure the line was fixed in the right place to avoid any ‘cannula tug’ or possible disconnection. This particularly important when selecting a TIVA-TCI set as disconnection could amount to patient awareness!

Distal Line Guard to prevent not just kinking of line but to provide a ‘tamperproof’ distal connection

High-Flow Valve which will ensure that high-flow fluids are available whatever the type of surgery

Non Traumatic Eye Protection is advocated as standard ‘cut to size’ dressing material or non-sterile surgical tape are not to be recommended as there can create tissue trauma when removed and therefore a possible portal of infection, particularly important with immuno-compromised patients.

TIVA-TCI pump technology is roaring ahead but, sadly, until now there was no real focus on FULL safety in 3-Way TIVA Multiple Infusion Sets.