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Update on total intravenous anesthesia in children.
Vinícius Caldeira Quintão1,2,3, Ricardo Vieira Carlos2,3, Britta S von Ungern-Sternberg4,5,6,7
1Department of Pediatrics, Faculdade de Medicina, Universidade de São Paulo.
Current Opinion in Anaesthesiology
|March 12, 2026
Summary
Pediatric total intravenous anesthesia (TIVA) is advancing with improved precision and safety. Recent evidence shows benefits in reduced side effects and environmental impact, with a call for better training and tools for wider adoption.
Area of Science:
- Anesthesiology
- Pediatric Pharmacology
- Pharmacokinetics and Pharmacodynamics
Background:
- Pediatric total intravenous anesthesia (TIVA) practice requires updated frameworks.
- Advances in pharmacokinetics-pharmacodynamics (PK-PD) are crucial for pediatric anesthesia.
Purpose of the Study:
- To summarize recent evidence in pediatric TIVA.
- To highlight advances in PK-PD, target-controlled infusion (TCI), electroencephalography (EEG)-guided titration, emerging agents, safety, and sustainability.
- To provide an updated, practical framework for pediatric TIVA.
Main Methods:
- Review of recent evidence in pediatric TIVA.
- Analysis of pharmacokinetic-pharmacodynamic patterns.
- Evaluation of target-controlled infusion models and EEG-guided strategies.
Main Results:
- Clearer developmental PK-PD patterns and refined propofol-remifentanil dosing.
- Growing use of dexmedetomidine; remimazolam shows promise but lacks pediatric data.
- EEG-guided and combined PK-EEG strategies enhance infant safety; TIVA reduces adverse events and environmental impact.
Conclusions:
- Pediatric TIVA is advancing towards precision, safety, and sustainability.
- Moderate effect-site targets and opioid titration are key, especially in neonates.
- Wider adoption requires improved training, TCI tools, and addressing regulatory barriers.
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