The introduction of TCI pumps into clinical practice invoked a sense of interest, and a sense of reservation stemming from the concern of getting the dose wrong and causing awareness. I experienced the frustration of not grasping all of the intricacies of the complicated pharmacokinetics. I experienced the annoyance of delayed emergence from getting the dose wrong from both TCI and manual infusions. There was only the rare TIVA enthusiast who could explain aspects of this dark art. Therefore like a lot of my colleagues I did not bother too much with using TIVA except for neurosurgery or for those with a history of severe PONV. It just felt like too much of a nuisance for not much gain.

The recent NAP 5 report in the UK showed that many of the cases of awareness associated with TIVA were due to poor technique and inadequate dosing.[1] In short, we don’t teach TIVA as well as we do inhalational anaesthesia. Yes, we have those occasional lectures and workshops built into our curriculum for trainees, covering pharmacokinetics/pharmacodynamics (PK/PD) and TIVA. However, trainees learn from watching their seniors from day to day in the operating room (OR). The vast majority of this training is gas based; it’s easy to use, everything is set up, the vaporiser is full and you’re ready to go as soon as you reach the OR. Why bother going to all the work of setting up for TIVA: surely that’s just for specialised cases? Thus our trainees are rarely exposed to TIVA and, in turn, become the gaseous trainers of the future. No wonder that when called upon to use TIVA in those circumstances where there is no alternative, even experienced anaesthetists can have difficulty. It’s often our trainees who are called upon to provide sedation for patients transferring between locations, or provide anaesthesia and sedation in remote sites without the infrastructure to support inhalational anaesthesia. These same trainees have often not learned TIVA in a practical way and are then struggling to remember, was it mg.kg−1.h−1, or µg.kg−1.min−1? How can we transfer the knowledge and skills that we have learned, over many years of passing the gas, to the art of TIVA?

At some time during one’s practice in anaesthesiology, one cannot help but notice certain obsessive–compulsive tendencies in our colleagues. Such traits are quickly revealed when you put them under pressure by asking them to do an unplanned emergency case and disrupt the cocoon that is their elective list. In contrast to having known and prepared for all of the patient’s problems, they are now compelled to deal with a relatively unknown and often sub-optimal situation. More likely than not, they will have to induce anaesthesia with rapid sequence induction (RSI). Whereas some may be thrilled, others are less impressed with the disorder introduced into their world. What is it about emergency cases that should be such a bother? In particular, can TIVA enthusiasts thrive in this environment? At the time of writing, the use of TIVA in emergency is indeed somewhat uncharted territory as very few studies have examined this area.

In keeping with the spirit of producing a practical book, we took editorial privileges and removed some of the more detailed text from various chapters and yet felt it would be a waste if some of it weren’t shared with our readers. At the same time, there are aspects of TIVA that are not necessarily recommended for novices but may entice those who have had a bit of experience and want to extend their TIVA repertoire. Therefore we thought we would create a final chapter that would incorporate some such material, hopefully in a semi-logical fashion.

The arrival of versatile, easy-to-use, commercially available, target-controlled drug delivery systems have simplified TIVA making it as simple as using a vaporiser. Most have a choice of PK algorithms. The Marsh and Schnider models are the most commonly used for propofol and have various pros and cons. However, the important point about these models is that they can both make proportional changes in blood concentration allowing easy titration. New data is becoming available for more precise keo and PK that will improve accuracy – and therefore new models are likely to be developed. Remifentanil can also be administered with TCI using the Minto model but, as the pharmacokinetics are relatively simple, can also be delivered as an ordinary infusion (µg.kg−1.min−1). The use of these techniques is discussed elsewhere in the book so here we will concentrate on how to physically set up your TIVA system.

Like many of you, we’re sure, we were trained to use IV anaesthetic agents for induction of anaesthesia but volatiles for maintenance – a sensible and seemingly safe combination that has been used for decades. So why change? The initial attraction of TIVA was the extremely rapid, smooth and clear-headed recovery of patients when using propofol as the hypnotic component of an anaesthetic. This is particularly apparent when the drug is used for cases of short to intermittent duration, for example in day-case surgery with earlier discharge from the post-anaesthetic care unit.[1] Clearly in modern practice, which is moving towards shorter in-patient stays, this represents a major advantage. In addition, improved levels of patient satisfaction occur with TIVA, presumably due to the favourable recovery profile.[2] Certainly, desflurane and sevoflurane allow rapid recovery but it is not as smooth, there may be more emergence delirium and quality indicators are not as good.[3]

Anaesthesia is possibly the most pharmacology oriented of all clinical medical specialties. What we do every day is, effectively, applied pharmacology. Yet with all this practical experience, some aspects, particularly pharmacokinetics, can appear dauntingly complex. Indeed, mathematical modelling and developing target-controlled infusions is difficult as is the design of modern vaporisers for inhalational drugs but, as an analogy, we don’t need to be able to design a car in order to know how to drive it. However, there are certain basic PK features that will enhance your understanding and improve your ability to use these drugs appropriately.