Systemic fragility in European total intravenous anesthesia delivery and opportunities for resilient real-time decision support

Total intravenous anesthesia (TIVA) is a well-established technique for general anesthesia and is increasingly relevant to Europe’s transition toward more digital, sustainable, and patient-centred healthcare. However, its use remains uneven across centres and still depends heavily on population-based drug models, variable monitoring practices, and repeated clinician adjustment. Differences in training, data access, device compatibility, patient response, and institutional resources can limit safe and consistent personalization. In this Review, we examine the main sources of fragility in current TIVA practice and discuss how interoperable perioperative data, digital patient simulators, patient-adaptive models, multimodal monitoring, and closed-loop decision support could improve safety and resilience. We emphasize that these technologies should support, not replace, the anesthesiologist, and should remain transparent, clinically supervised, and easy to override. We conclude by outlining priorities for European collaboration in data infrastructure, training, validation, regulation, and evaluation of AI-enabled tools. Ionescu et al. outline a European roadmap for strengthening Total Intravenous Anesthesia Delivery through resilient, human-in-the-loop real-time decision support. Current practice remains uneven and fragile, while interoperable data, validated simulators, adaptive models, robust control, and clear regulation enable safer personalization.