Barriers and facilitators to the use of total intravenous anaesthesia amongst anaesthesiologists: a systematic review using the Theoretical Domains Framework

Background Anaesthetic gases contribute up to 63% of perioperative greenhouse gas emissions. To reduce these emissions and improve patient outcomes, many anaesthesia organisations recommend total intravenous anaesthesia (TIVA). Despite this recommendation, anaesthesiologists do not consistently use TIVA where possible. We systematically reviewed the literature to identify barriers and facilitators for using TIVA. Methods This review was registered on Prospero. Embase, Medline, Web of Science and Scopus databases were searched for journal articles published between January 2000 and May 2024, using terms in three key areas: ‘anaesthesiologists’, ‘TIVA’ and ‘behaviours and attitudes’. Studies were included if they were original research identifying any barriers or facilitators to using TIVA amongst anaesthesiologists. After abstract screening, data extraction and quality evaluation, determinants for TIVA use were coded into themes and categorised using the Theoretical Domains Framework (TDF). Results 14 studies were included in the final analysis, most of which were survey studies. A total of 3579 anaesthesia providers were included as participants. 24 themes were identified, covering 10 of the 14 TDF domains. Commonly cited domains included perceived barriers to: ‘environmental context and resources’ ( n = 13 studies, e.g. lack of availability of TIVA equipment), ‘memory, attention and decision processes’ ( n = 12, e.g. gases are easier to use than TIVA), and ‘beliefs about consequences’ ( n = 11, e.g. concerns around using TIVA such as patient awareness). Facilitators to using TIVA included ‘intentions’ (n = 4; to learn about or use more TIVA). A lack of representativeness and non-response bias were present across most studies. Conclusions Reported barriers to TIVA use were found across many TDF domains. However, most evidence came from surveys with concerns about representativeness and non-response bias. Possible interventions include: ensuring there is time and support to implement changes to both individual routines and hospital culture, ensuring training covers the concerns of practitioners, and increasing resources such as access to equipment where possible. Future researchers should take these barriers and related interventions into account, while remaining cognisant of the local context. Systematic review registration This review was registered on Prospero in May 2024, ID number CRD42024542316.