Is TIVA (Total IV Anesthesia) or General Anesthesia Safer?

Richard H. Tholen, MD, FACS

Article by
Minneapolis Plastic Surgeon

First of all, TIVA is “general anesthesia” (meaning completely-asleep), as compared to IV sedation, which is “breathing for yourself and mostly unaware but arousable.”  Local anesthesia is injectable medication that keeps an operative area numb while the patient is completely awake. General anesthesia can be accomplished by IV anesthetic drugs alone (TIVA), or by a combination of IV drugs and inhalation anesthetic drugs (gas) administered via an ET tube (endotracheal tube) inserted into the trachea through the vocal cords or an LMA (laryngeal mask, which is a specialized tube that goes in the back of your throat, but not between your vocal cords). Just to be clear, TIVA patients may still require an LMA or ET tube for airway control and protection as well as oxygen (only) administration, even if inhalation anesthetics are NOT used.

Most hospitals and hospital-owned surgical centers utilize inhalation (gas) anesthesia for the vast majority of their operations because it is significantly less costly than TIVA, and because of this many hospital-based anesthesia providers have become less experienced and day-to-day comfortable with TIVA. Both are safe anesthetic methods if performed by skilled and experienced anesthesia providers, and both TIVA and inhalation anesthesia methods use the same blood pressure, ECG, oxygen, CO2, and other monitoring. But if both are safe, then which is better, and is better based only on cost?

I have been on numerous hospital staffs over the 31 years since I graduated from medical school and became a surgeon. As an operating surgeon and American Board of Plastic Surgery-certified plastic surgeon, I have witnessed many anesthetics being delivered in many hospitals, in hospital-owned and operated free-standing surgical centers, and for the last 25 years as well, in my own office-based AAAASF-accredited on-site surgical facility. So, while I will cheerfully admit to having a bias, it is one based on substantial personal experience with ALL forms of general anesthesia, delivered by anesthesiologist, anesthesiologist-supervised CRNA (certified registered nurse anesthetist), and independent CRNA working in our and other surgical facilities as independent contractors.

Our head CRNA at Minneapolis Plastic Surgery, for example, is Mayo Clinic-trained and still works at Mayo part-time in the cardiac anesthesia section. He has several equally-skilled and experienced CRNAs that help him staff our office surgical facility; I would trust any of them to put me asleep (and have!) or my family members (also have!). We have had the same anesthesia team (with three different head CRNAs) over the past 20 years, and have evolved a TIVA technique that allows multi-hour anesthetics (a 6-hour lower body lift, for example) with very rapid wake-up (short anesthetic drug half-lives), a 2% overall nausea rate, and a 0.05% (8 in over 16,000 procedures over 20 years) hospital admission rate. We utilize a continuous drip pain medication along with the anesthetic agent, so that pain receptors are continuously occupied, not just bolused when the patient responds to pain stimulus or starts to "wake up" during the surgery! We use NO inhalation anesthetics or nitrous oxide that can dilate the gut, middle ear, or sinuses, giving patients that dizzy or bloated feeling, or get absorbed into the fatty tissues, including the brain, which causes slower wake-up and more PONV than IV anesthetic drugs. Since TIVA drugs have such a short half-life, they wear off quickly, reduce post-operative nausea and vomiting (PONV), allowing shorter recovery room times, and an overall smoother and better experience (as compared to inhalation anesthetics).

Most hospitals use inhalation anesthetics because they are just as safe as TIVA, but are much less expensive. Inhalation anesthesia in a hospital is NOT better or more safe than TIVA (especially in healthy, elective, cosmetic surgery patients), and in fact, a 7-28% PONV rate with gas anesthesia that requires overnight admission in an inordinate number of otherwise-outpatient patients simply costs more, exposes the elective patient to sick hospital patients and nasty bacteria, and perhaps allows less activity than does a patient at home who has to get up to use the restroom, get pain medication, or come to the doctor's office. In the hospital, a lot of that is done FOR you (bedpans, urinals, nurse call buttons for pain shots or pills), and may just cause a tiny bit higher risk of developing a blood clot that increased activity may prevent. So if the hospitals were smart, or were to look at the total experience rather than each department's own individual budget, the "savings" in the anesthetic drug category would be wildly overbalanced by the increased expense of nausea medications, unplanned overnight stays, and the occasional infection from exposure to a sick patient, or blood clot from being kept in a hospital bed with rails up and button in the patient's hand! Perhaps TIVA is actually safer for healthy patients undergoing elective cosmetic operations, especially if it keeps more of them out of the hospital!

Again, BOTH anesthetic regimens are safe, but TIVA performed by anesthesia providers experienced in its use is truly superior for a number of reasons. After all, hospitals are in the business of filling beds, aren't they? I have a slightly different agenda with my patients--only the best and safest will do, regardless of the cost!