Update on total intravenous anesthesia in children

To summarize recent evidence in pediatric total intravenous anesthesia (TIVA), highlighting advances in pharmacokinetics-pharmacodynamics, target-controlled infusion (TCI), electroencephalography (EEG)-guided titration, emerging agents, safety, and sustainability, and to provide clinicians with an updated, practical framework for pediatric TIVA practice.

Recent evidence highlights major advances in pediatric TIVA, including clearer developmental pharmacokinetic-pharmacodynamic patterns, refined propofol-remifentanil dosing, and growing use of dexmedetomidine. Remimazolam shows promise but currently has limited pediatric evidence. Universal TCI models improve dosing accuracy across ages, while EEG-guided and combined pharmacokinetics-EEG strategies enhance safety in infants. TIVA reduces emergence delirium, postoperative nausea and vomiting, and perioperative respiratory adverse events; supports neurophysiologic monitoring; and yields substantially lower environmental greenhouse gas emissions than inhalation anesthesia.

Pediatric TIVA is moving toward greater precision, safety, and sustainability. Moderate effect-site targets, opioid titration, and early down-titration remain central, particularly in neonates. Propofol infusion syndrome is exceedingly rare, and organ-protective effects of TIVA are reported in major surgery. Despite clinical and environmental advantages, adoption varies globally due to limited training, variable pump availability, and regulatory barriers. Expanding structured education and pediatric-specific TCI tools is essential for broader implementation.