Total intravenous anaesthesia in emergency surgery: a narrative review

Although the use of total intravenous anaesthesia is well established in elective surgery, its use remains limited in emergency settings, particularly for rapid sequence induction and intubation. National audit data and a recent coroner's report have highlighted implementation difficulties, while comparative outcome evidence is lacking and no emergency-specific guidelines exist.

This narrative review examines the evidence base for total intravenous anaesthesia in emergency surgery, including pharmacological considerations; rapid sequence induction techniques; safety data from national audits; and implementation challenges.

There are no randomised trials comparing total intravenous and inhalational anaesthesia techniques directly in emergency surgery. Current practice relies on extrapolation from elective surgery, where total intravenous anaesthesia reduces postoperative nausea and vomiting and emergence delirium. National audits document cases of accidental awareness under general anaesthesia and cardiac arrests during rapid sequence induction using total intravenous anaesthesia, predominantly from preventable delivery and dosing errors. Data from national surveys suggest that around one-quarter of anaesthetists use total intravenous anaesthesia for rapid sequence induction, citing concerns about the speed of induction of general anaesthesia and absence of guidelines. Multiple rapid sequence induction adaptations have emerged but lack validation. Altered patient physiology in emergency surgery also complicates total intravenous anaesthesia dosing.

The absence of emergency-specific comparative data means current total intravenous anaesthesia practice relies on extrapolation from studies with uncertain validity. National audits have documented preventable harm from implementation failures, reflecting inadequate training and absent guidelines. Institutions using total intravenous anaesthesia in emergencies require structured protocols, adequate training and clear team roles. Prospective trials are needed to determine whether theoretical advantages translate to improved patient outcomes.