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TIVA, TCI, and pediatrics: where are we and where are we going?
1Department of Anesthesiology, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA. jerrold.lerman@gmail.com
Insights
Total intravenous anesthesia (TIVA) use in children is growing but faces challenges. Overcoming hardware, drug, and monitoring issues is key to widespread pediatric TIVA adoption.
Area of Science:
- Pediatric Anesthesiology
- Pharmacology
- Medical Device Technology
Background:
- Total intravenous anesthesia (TIVA) use in pediatric patients is increasing due to evolving medical and surgical needs.
- Current limitations in hardware, drug availability, and monitoring hinder widespread TIVA adoption in children.
- Pediatric TIVA often involves off-label drug use and poorly understood pharmacokinetics, posing safety concerns.
Purpose of the Study:
- To review the current status and challenges of TIVA in pediatric anesthesia.
- To identify obstacles to the broader implementation of TIVA in children.
- To outline future directions for improving TIVA techniques in pediatric patients.
Main Methods:
- Literature review of TIVA in pediatric anesthesia.
- Analysis of hardware, pharmacokinetic, and monitoring limitations.
- Discussion of drug-related issues, including off-label use.
- Examination of logistical barriers such as infusion pump availability.
Main Results:
- Pediatric TIVA is currently limited by hardware constraints and insufficient pharmacokinetic data.
- A significant number of drugs used for TIVA in children are off-label.
- Limited availability of infusion pumps and challenges with intravenous access are major bottlenecks.
- Current practice often results in a 'partial' TIVA technique rather than a true TIVA approach.
Conclusions:
- Widespread pediatric TIVA requires addressing hardware limitations, standardizing drug use, and improving monitoring.
- Resolving off-label drug designations and ensuring adequate infusion pump availability are critical.
- Implementing painless intravenous access methods is essential for true TIVA.
- Future advancements aim to enable ubiquitous and safe TIVA practice in children.
Abstract:
The current role of TIVA in children is limited because of hardware limitations, and pharmacokinetic and monitoring issues. Nonetheless, the role of TIVA in children has been increasing in the past decade, in part because of surgical and medical indications. If TIVA is to become more widely used, it must be easy and simple to set up, without serious drawbacks and without added risks. Currently, many drugs destined for use with TIVA in children are off-label, and their pharmacology is poorly understood. Such off-label designations must be resolved if TIVA is to become more widely used. At the same time, many institutions have a limited number of infusion pumps, which creates a serious bottleneck and restriction on the use of TIVA.. If a true TIVA technique is used, i.v. access must be established before induction of anesthesia, which will require a means to establish i.v. access painlessly, e.g., using a topical local anesthetic. This is not a common practice in a number of jurisdictions but must be introduced if TIVA is to expand in its scope in children. Currently, I believe that we deliver a 'partial' TIVA technique in which TIVA occasionally follows an inhalational induction but in the future when the current obstacles have been resolved, I believe that we will be able practice a true TIVA technique ubiquitously in children.
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