INTRAVENOUS

ANESTHESIA
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totalaanesthesia
nesthesia
DEFINITION
TIVA means the use of IV agents
exclusively to provide a complete
anesthetic.
s
3 A's of Anesthesia(with or
without muscle relaxation):Amnesia
(anxiolysis, ataraxia), Autonomic
areflexia (CV, resp, GI), Analgesia,
Muscle relaxation
(Gordon, 2003)
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totalaanesthesia
nesthesia
ADVANTAGES
Combination of drugs, separately
infused, allows titration of each to the
specific dose required to meet the
s
specific needs of the case.
The anesthetic is completely

independent of the patient's airway

and breathing.
Very portable. No anesthesia machine

(vaporizers) needed.
(Gordon, 2003)
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ADVENTAGES (CONTD)
totalaanesthesia
nesthesia
Discharge time from PACU may be shortened
when propofol used as induction and
maintanance of anesthesia
Decrease morbidity due to malignant
s
hypertermia associated with succinylcholine
and other volatile anesthetics in susceptible
patient
No environmental contamination

Reduction of ponv following propofol

anesthesia enhanced patient (and family)
satisfaction
(Hammer & Krane, 2000)
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DISADVANTAGES
totalaanesthesia
nesthesia
Wider variety of response
No reliable technique for monitoring
plasma concentration of drugs (equivalent
to ET inhalation agent monitoring)
s
Unknown anesthetic depth, increased
awareness
Increased drug cost

Limited clinical experience

Need of infusion pumps

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totalaanesthesia
nesthesia
IDEAL IV ANESTHETICS
High therapeutic index
No toxic metabolites

Non-cummulative

Potent
s
Resistance to microbial contamination

Compatible with other drugs

Quick and smooth induction and recovery

Reversible with spesific antagonist

Non-allergenic

No cardiopulmonary depression

Independent of liver and kidney metabolism and excretion

No effect on CBF

No endocrinologic effect

No pain on injection

inexpensive
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totalaanesthesia
nesthesia
No single agent can provide 3A anesthesia
Need combined drugs with different mechanism
Less toxicity
s
Faster recovery

Reduced cost
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totalaanesthesia
nesthesia
ROUTE OF TIVA
Simple intravenous bolus
Variable rate continuous infusion
(simple syringe pump, target
s
controlled infusion pump)
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ADVANTAGES OF CONTINUOUS
totalaanesthesia
nesthesia
INFUSION
Hemodinamic stability
More stable depth of anesthesia
More predictable and rapid recovery
s
Lower total dose of drugs used
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totalaanesthesia
nesthesia
Amnesia/sedation : propofol,
ketamin, benzodiazepin, barbiturate,
etomidate
s
Analgesia : fentanyl, remifentanyl,
sufentanyl, alfentanyl, morphime
Muscle relaxant : atracurium,
vecuronium
 DRUGS COMMONLY USED IN TIVA
intravenou
totalaanesthesia
nesthesia
(TITRATE TO EFFECT)
Propofol
Induction: 2-2.5 mg/kg
Maintenance: 50-200 mcg/kg/min
s
Ketamine
Induction 0.5-2mg/kg
Maintenance 20-90mcg/kg/min
Can combine w/propofol 4:1
e.g.200mgpropfol+50mg ketamine

Dexmedetomidine (alpha-2 agonist)

Maintenance:
Loading infusion: 1mcg/kg over 10 minutes
Maintenance infusion: 0.2-0.7 mcg/kg/hr
 DRUGS COMMONLY USED IN TIVA
intravenou
totalaanesthesia
nesthesia
(TITRATE TO EFFECT)
Fentanyl
Induction 5-75mcg/kg
Maintenance 0.01-0.05mcg/kg/min
Sufentanyl
s
Induction 1-10mcg/kg
Maintenance 0.005-0.15mcg/kg/min
Remifentanil (Ultiva)
Induction: 0.5-1 mcg/kg (over 30-60 sec)
Maintenance:
0.1-2 mcg/kg/min with 50% N2O
0.05-2 mcg/kg/min with Propofol at 100-200
mcg/kg/min
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totalaanesthesia
s
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nesthesia
totalaanesthesia
s
(Contd )
 intravenou
totalaanesthesia
nesthesia
morfin petidin fentanyl alfentanyl sufentanyl remifentany
l

Dosis 0,05-0,2 mg/kg 0,5-1 mg/kg im

premeedikasi im

Dosis 0,1-1 mg/kg iv 2,5-5 mg/kg iv 2-150 mcg/kg 8-100 mcg/kg 0,25-30 mcg/kg 1 mcg/kg iv
intraoperatif iv iv iv 0,5-20
0,5-3 mcg/kg/mnt iv
mcg/kg/mnt iv

Puncak (mnt) 30-60 mnt 5-7 mnt 3-5 mnt 1,5-2 mnt 3-5 mnt 1,5-2 mnt
s
Durasi (jam) 3-4 2-3 0,5-1 0,2-0,3 0,5-1 0,1-0,2

Cardiac min min min min Min

contractility

RR D D D D D D

HR D no D D D D

Muscle rigidity + + + ++ ++ +

Waktu D D D D D D
Pengosongan
lambung

Retensi urin + + + + + +

alergi + + jarang jarang jarang jarang

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nesthesia
totalaanesthesia
s terimakasih
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INDIKASI
sedasi tindakan regional anestesi

pembedahan yang memerlukan masa pulih

yang cepat dan penuh
teknik anestesi konvensional sulit untuk
dilaksanakan
s
keadaan sadar selama cardiopulmonary bypass

memperbaiki proteksi cerebral selama potensial

terjadinya iskemia serebral
alternative inhalasi anestesi pada penderita
hiperpireksia maligna
 intravenou KECEPATAN TRANSFER DAN EFEK
totalaanesthesia
nesthesia
ANESTESI TERGANTUNG DARI :

Morgan, 2006
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CARA PEMBERIAN
totalaanesthesia
nesthesia
1. Intermitten
rentang kedalaman anestesi sangat luas antara
batas atas bawah dari target
konsentrasi obat yang tinggi pada setiap pemberian
bolus diikuti oleh penurunan yang cepat pula,
diakibatkan distribusi dan redistribusi yang cepat
s
menyebabkan fluktuasi kadar obat dalam darah
dan otak, tergantung dosis bolus dan frekuensi
pemberian
bisa menyebabkan ketidakstabilan hemodinamik
dan respiratorik
umumnya dilakukan untuk prosedur operasi yang
durasi pendek
 2. Infus kontinyu
intravenou
totalaanesthesia
nesthesia
memungkinkan untuk mempertahankan
konsentrasi obat dalam darah (dan otak)
pengaturan peningkatan dosis obat
kecepatan infuse disesuaikan kebutuhan
bila obat diberikan melalui infuse dengan
peningkatan dosis dengan interval tertentu,
jumlah yang diberikan akan ditambahkan dengan
s
yang telah ada di dalam tubuh
kadar total obat dalam tubuh meningkat bertahap
sampai kecepatan pemberiannya menyamai
kecepatan eliminasi
bila waktu penambahan obat kurang dari dua kali
kecepatan eliminasi, maka akan terjadi akumulasi
obat
 Pemberian dengan kecepatan tetap
intravenou
totalaanesthesia
nesthesia untuk periode yang panjang akan
menyebabkan kenaikan progresif
konsentrasi plasma sampai keadaan
steady state
Pada keadaan steady state ini
s
kecepatan pemberian (rate of
administration) seimbang dengan
kecepatan pembuangan (rate of
elimination)
Waktu untuk mencapai steady state
bervariasi pada setiap obat, dan
tergantung pada waktu paruh
terminal dan volume distribusi
 Untuk mencapai keadaan steady state ada
intravenou
totalaanesthesia
nesthesia
beberapa cara (Kay, 1991):
1. Infus kecepatan tetap
konsentrasi obat dalam plasma meningkat secara
eksponensial
mempercepat kecepatan infuse dapat
mempercepat terjadinya stadium anestesi
s
mudah menyebabkan overdosis dan depresi
berbagai system tubuh

2. Kombinasi dari loading dose ditambah dengan

infuse kecepatan tetap dan disesuaikan dengan
keadaan klinis
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totalaanesthesia
nesthesia
BENZODIAZEPIN
Mekanisme :
Fasilitasi GABA
s
Dosis :

Miller, 2005
 Efek samping dan kontraindikasi
intravenou
totalaanesthesia
nesthesia Problem signifikan midazolam adalah depresi
respirasi
Diazepam dan lorazepam menimbulkan iritasi
vena dan tromboflebitis
Amnesia post operatif dan sedasi setelah
s
induksi dan maintenance dengan midazolam
dapat memanjang
Efek residual ini dapat diatasi dengan
flumazenil
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totalaanesthesia
nesthesia
BARBITURAT
Mekanisme :
Fasilitasi GABA
s
Dosis :

Miller, 2005
 Efek Samping dan Kontraindikasi
intravenou
totalaanesthesia
nesthesia
Reaksi alergi

Nekrosis dan thrombosis pada Injeksi intra

artikuler
Kontraindikasi barbiturat :
Pasien dengan obstruksi respiratorik atau airway
inadekuat
s
Instabilitas kardivaskular berat atau shock
Status asthmatikus
Porfiria
Tidak tersedianya peralatan airway yang memadai
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totalaanesthesia
nesthesia
PROPOFOL
Mekanisme :
Mengurangi disosiasi GABA
s
Dosis :

Miller, 200
 intravenou
totalaanesthesia
nesthesia
Most commonly used hypnotic for tiva
No active metabolites

Rapid onset
s
Antiemetic

Not MH trigger

CBF : autoregulation and CO2 responsiveness

not affected
Proportional reduction in CMRO2 and CBF,

decrease in ICP
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totalaanesthesia
nesthesia
DISADVANTAGES
Seizure, opisthotonus, Myoclonus phenomenon
Pain and phlebitis on injection

Alleergic reaction
s
Bacterial growth

Propofol infusion syndrome : infus propofol dosis

tinggi >75 mcg/kg/menit selama > 24 jam
ditandai dengan asidosis laktat
(stoelting, 2006)
 KETAMINE
intravenou
totalaanesthesia
nesthesia
Mekanisme :
Blokade reseptor NMDA

Dosis :
s

Miller, 2005
 Efek Samping dan Kontraindikasi
intravenou
totalaanesthesia
nesthesia
peningkatan tekanan intrakranial

peningkatan tekanan intraokuler

hipertensi dan takikardi yang akan

meningkatkan konsumsi oksigen miokard.
penggunaan ketamine pada pasien dengan
s
riwayat gangguan psikiatrik sebaiknya juga
dihindari

17
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totalaanesthesia
nesthesia
DEXMEDETOMIDINE
Highly selective 2 adrenoreceptor agonist
Ssedative and analgesic effect, without

respiratory depression (in clinical dose range).

Another method for patient with difficult airway
s
Aginistic effect on 2 adrenoreceptor in
simpathetic ganglion resulting simpatholitic,
bradicardia and hipotension
In increased dose, causing vasoconstriction and
increased of blood pressure
 OPIOID
intravenou
totalaanesthesia
nesthesia
Mekanisme :
Bekerja pada reseptor Mu1, Mu2, delta,
kappa, sigma dan epsilon

Dosis :
Fentanyl: 1,5 g/kg, dosis lanjutan 0,8 g/kg
s
Sufentanyl: 0,15 g/kg, dosis lanjutan 0,08
g/kg
Alfentanyl: 4 g/kg, dosis lanjutan 2 g/kg

Morfin: 0,1 mg/kg dosis lanjutan 0,05 mg/kg

Miller, 2005
 Efek Samping dan Kontraindikasi
intravenou
totalaanesthesia
nesthesia
Penurunan tekanan darah biasanya akibat

bradikardi, venodilatasi atau penurunan dari

reflek simpatik
Efek histamine release

Kombinasi opioid dengan obat anestesi lain

(misalnya N2O, benzodiasepin, barbiturate, agen

s
volatile) akan mengakibatkan depresi miokard
depresi pernafasan, terutama laju nafas

menurunkan konsumsi oksigen, aliran darah

otak dan tekanan intracranial

Menurunkan pengosongan lambung, dengan

memperlambat peristaltik

17
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totalaanesthesia
s
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totalaanesthesia
s

Morgan, 2006
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nesthesia
totalaanesthesia
s

Morgan, 2006
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totalaanesthesia
nesthesia
AWARENESS DURING ANESTHESIA
Estimates of awareness during anesthesia in
nonobstetric and noncardiac surgeries are
approximately 0.1-0.2%.
s
Recognized risk factors for awareness include the following:
Light levels of anesthesia, which are common in hypovolemic, trauma, and
obstetric patients.
Patients undergoing cardiac surgery with cardiopulmonary bypass also
have a higher incidence of postoperative recall (about 1%) because of the
reliance on narcotic-based anesthesia, which minimizes myocardial
depression but produces unreliable amnesia.
The use of muscle relaxants is an independent risk factor for awareness.
Machine malfunction, such as empty vaporizers, intravenous anesthetic
pump malfunction or disconnection, etc.
Occasionally in patients with unrecognized increased anesthetic
requirements, such as the very young, chronic substance-abusing patients,
and hypernatremia.
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SIGNS AND SYMPTOMS OF LIGHT
totalaanesthesia
nesthesia
ANESTHESIA
Motor signs in response to light anesthesia frequently precede
hemodynamic changes or sympathetic activation. Specific motor
signs include eyelid or eye motion, swallowing, coughing,
grimacing, and movement of the extremities or head. Increased
respiratory effort is due to activity of intercostal and abdominal
s
muscles, which are suppressed at deeper levels of anesthesia.
With the use of neuromuscular blockade, motor signs do not
provide information about anesthetic depth.
Consequently, sympathetic activation represents an additional
method for assessing light anesthesia. Sympathetic effects
associated with light anesthesia include hypertension,
tachycardia, mydriasis, tearing, sweating, and salivation. Such
findings are nonspecific and are modified by anesthetic agents;
thus their presence or absence is an unreliable indicator of
awareness.
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totalaanesthesia
nesthesia
BISPECTRAL INDEX (BIS)
The purpose of any of these forms of EEG analysis is to
estimate the degree of hypnosis that the patient is
experiencing. Raw data, collected by electrodes placed on
the forehead and temporal area, are processed by the
s
computer module to create a numerical representation of
the degree of sedation. Lower numbers correspond to a
greater depth, while higher numbers are found in awake or
lightly sedated patients.
The incidence of awareness in high-risk cases was reduced
by approximately 82% (0.91-0.17%) when BIS-guided
anesthesia was provided with a BIS goal of 40-60% during
anesthesia. Using BIS during general anesthesia with
concurrent muscle relaxation resulted in a similar
reduction of 77% (0.18-0.04%) in the incidence of
awareness.
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AUDITORY EVOKED POTENTIALS
totalaanesthesia
nesthesia
(AEP)
AEP use auditory stimuli to evaluate the level of cerebral
activity.
To evaluate the depth of anesthesia, midlatency AEP
(MLAEP) recorded 10-100 min after auditory stimulation.
s
The AEP-A monitor generates an index derived from
analysis of MLAEP waveforms. Once this monitor has
acquired the baseline signal, the signal changes during
anesthesia, the A-line ARX index (scale to 0-100) reflects
the hypnotic state of the individual.
AEP cab be use to control the propofol plasma
consentration sufficient to provoked narcosis status for each
individual patient, avoiding risk of awareness and reducing
side effect.
(ferraro, et all., 2006)
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TARGET CONTROLLED INFUSION
totalaanesthesia
nesthesia
(TCI)
Consentration in the effect site is a direct
determinant of drug effect rather than plasma
consentration.
TCI : Computerised infusion systems capable of
s
delivering variable infusion regimes based on
mathematical solution to complex
pharmacokinetic models.
Allow the anesthetist to achieve and maintain
desired target drug consentration appropriate to
an individual patient and level of surgery
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totalaanesthesia
nesthesia
PROPOFOL-REMIFENTANYL
Induction bolus : propofol 1,5 mg/kg, remifentany
1-1,5 mcg/kg 60s before DL
Maintanance infusion :
s
Propofol 150 mcg/kg/min for 15 min
Propofol 125 mcg/kg/min for 2nd 15 min
Propofol 100 mcg/kg/min untul terminated

Remifentanyl 0,25 mcg/kg/min titrasi

Bolus 0,25-1 mcg/kg prn