In‐theatre TIVA rapid sequence induction: what are we doing?

Discussions around the use of total intravenous anaesthesia (TIVA) when performing a rapid sequence induction (RSI) have increased recently due to the publication of a coroner's report [1], which highlighted “Lack of ‘updated’ national guidelines to support the use of TIVA for RSI” as one of the eight areas of concern within the reported case. A review of practice is pertinent, as we have seen developments within TIVA since the last large-scale survey of RSI practice within the UK [2], such as the increased use of newer models such as Eleveld and updated pumps, which change the dynamics in drug delivery. The Association of Anaesthetists' guideline on the safe practice of TIVA [3] mentions a few approaches to performing an RSI using target-controlled infusions (TCI) or manual bolus then TCI, but does not offer definitive advice as to the safest method. Other authors have suggested several viable approaches [4]. We created a survey on Google Forms and the link was distributed via email and WhatsApp to anaesthetists within our UK region. The link was sent out to the trainees via the anaesthesia co-ordinator for the region. College tutors and Staff grade and Associate Specialist (SAS) representatives for each hospital were emailed to gather responses from consultants and SAS doctors, respectively. The survey gathered data on a variety of topics, including clinician grade; hospital; preferred method of in-theatre RSI; approach to RSI when using TIVA; preferences of drugs used; preferred pump programming; use of equipment checks; and monitoring. We received 122 responses out of approximately 900 clinicians, from a variety of hospitals and physician seniority (response rate 13.5%). Some did not answer all the questions. There was a noticeable variation among anaesthetists. The majority 78/122 (64%) stated their preferred RSI method to be propofol and rocuronium, followed by inhalational anaesthesia. A ‘TIVA RSI’ methodology was preferred by 30/122 clinicians (25%). There was a significant variation in the approach to TIVA RSI (Table 1). The method of remifentanil TCI with use of 3-way tap bolus on propofol TCI and a neuromuscular blocking drug (NMBD) was preferred by 30/111 (27%) clinicians. There were 30/111 (27%) who used only the TCI pumps then a NMBD. Twenty-four out of 111 (21.6%) used a separate propofol bolus with an opioid and NMBD, then started TCI, while 10/111 (9%) started remifentanil TCI, used a separate propofol bolus and NMBD, then started TCI propofol. There were several other variances in approach (including explicit refusal to use TIVA RSI), but the significant split in the most frequent techniques is worth highlighting. Of those who responded to the question, 61/117 (52%) stated their preferred propofol TCI model as Eleveld, although this is not available in all TCI pumps yet. The most cited reservation against using TIVA RSI was ‘speed of RSI’ (75/118, 63.6%). ‘Lack of definitive guidelines on methodology’ was stated by 46/118 (39%) of respondents in their reservations about using TIVA during in-theatre RSI, and 46/118 (39%) also stated ‘unfamiliarity’ as one of their reservations. Our survey highlights that the use of RSI with TIVA is common, with a variety of different methodologies. There is, arguably, little oversight or agreement as to the optimum approach. We suggest that, following a repeat review of RSI practice within the UK, TIVA RSI specifically should be further reviewed with regard to viability and safety. If deemed acceptable, then agreed guidelines as to best practice recommendations, including acceptable patient types and cases, technique and equipment, should be specified to optimise patient safety.