Total intravenous anesthesia (TIVA) has gained a significant foothold in the outpatient arena. Some providers use TIVA general anesthesia or, depending on the case, monitored anesthesia care (MAC) - local anesthesia with IV sedation - almost exclusively. Other providers combine IV induction with inhalational agents as their preferred general anesthesia regimen. To help you gain perspective of how and why your anesthesia providers strategize their cases, Outpatient Surgery conducted a virtual roundtable with six anesthesia providers via e-mail and telephone.

What factors guide your approach to each case?
Dr. Marco: I consider the personality of the patient and the wishes of the patient or the surgeon, because some prefer "asleep" surgery. Next, I look at the skill of the surgeon with local anesthesia, since sedation should supplement local, not cover for poorly administered local anesthesia. I look at the procedure itself. Lastly, I consider the patient's concurrent medical conditions.

Dr. Dorin: In many cases, it's simply based on surgeon preference. Many procedures we can do under IV sedation and local turn into general cases because the surgeon doesn't want to bother giving local and just wants the patient "asleep." This results in greater costs, greater risk for the patient and leaves them with less post-op pain control. But it's just the way the system often works.

Dr. Friedberg: I'm horribly biased on this subject. I've found that IV with propofol plus another agent produces the best anesthesia outcomes and, combined with consciousness monitoring, we can duplicate the outcomes. It's also what patients themselves want.

Mr. Beechly: The determination depends on the type of case, surgeon preference, the patient and the agents available. The same basic standards also apply to other techniques, such as peripheral nerve blocks, spinal and epidural anesthesia. All things being equal with an otherwise healthy surgical outpatient, many providers' choices of the particular anesthetic agent for a case can vary as much as how much cream they put in their coffees that morning.

Dr. Barinholtz: There's never a singular approach to anesthesia, but whether it's for MAC or general, I almost always stick with a TIVA regimen. It's a question of choosing clinical quality over personal convenience.

Dr. Joshi: It's really a question of which method is safest and most effective in the provider's hands. TIVA works very well for some providers but at our hospital, we discovered superior results with inhaled anesthesia.

Mr. Randolph: The fastest way to decide whether to administer a general anesthetic or plan IV sedation is to ask, "What if it were I?"

Look at the patient's health, anxiety level, medications (licit or illicit), and compliance with pre- and post-operative instructions. Many health disorders - such as allergies, hepatic or renal impairment, and sleep apnea - preclude the use of one or the other type of anesthesia. Anxiety sometimes makes IV sedation trickier to gauge. Patients who disregard pre-operative NPO orders are especially tough.

Consider the procedure. Some borderline-decision cases are pediatric procedures such as strabismus surgery or diagnostic imaging, cosmetic procedures requiring high levels of lidocaine containing tumescent solution, procedures in which the patient won't be positioned for top-quality breathing or long procedures such as abdominoplasty with a fair amount of bodily manipulation. Here, I prefer using general anesthetic but don't always get my way. General is preferable from a safety standpoint for cases that allow limited or no immediate access to the patient's airway, such as rhinoplasty and oral surgery.

Under what circumstances would you change your technique?
Dr. Marco: I know surgeons who routinely perform breast biopsies under MAC. Another refuses to do so and insists that the patient go to sleep. At first, it baffled me as to what to offer his patients, but I came to the conclusion that this surgeon could not, for whatever reason, do the case with sedation, so I feel that it's truthful telling his patients that I recommend general anesthesia. Another example is inguinal hernia repair. I know many surgeons who routinely perform this under sedation/local (or regional), but others insist on general, saying patients don't have enough muscle relaxation otherwise.

Dr. Goldman: We may go from IV to gas if deep IV sedation could obstruct the airway to the point where the patient needs an LMA or ETT. More providers use LMAs to fill the gap with these difficult borderline cases. A good example is a forearm shunt revision case with a renal dialyses patient. These patients are usually sick, on multiple meds ... [with] increased gastric volume. In the past, we did these cases with local or regional anesthesia. Now, more surgeons ask for deep IV or LMA plus local.

Dr. Barinholtz: The only time I routinely opt to use gas rather than TIVA is for some short pediatric cases, such as myringotomy tube insertion. Some patients require mask induction, but I switch to TIVA as soon as I start the IV. When I must intubate, I typically avoid muscle relaxants altogether.

Mr. Randolph: Office-based surgery often is not conducive to general anesthesia because the necessary equipment, medications, personnel and space might be lacking. Outpatient surgery in a hospital or ASC usually provides for a wider choice of anesthetics. Consider anesthetist-patient communication barriers? such as language or uncooperativeness.

What are TIVA's pros and cons?
Dr. Barinholtz: TIVA is more labor-intensive. Inhalational agents are total anesthetics, whereas most IV push drugs have one function only. On the flip side, TIVA lets you precisely control each component of the case - hypnosis, amnesia, analgesia and muscle relaxation - individually, with a higher level of normal physiologic functioning and a superior recovery profile.

Dr. Joshi: Most patients prefer IV induction with propofol but ? with consciousness monitoring, we can titrate inhalational agents such as desflurane and sevoflurane with control equal to TIVA. Studies have also shown more rapid early recovery with some of the newer inhalationals compared with propofol-based TIVA. That holds true even when you titrate propofol to BIS levels. One definite benefit to TIVA is lower PONV rates.

Discuss PONV and fast-tracking.
Dr. Joshi: It seems logical to assume TIVA equates to better fast-tracking due to lower PONV, but we found no differences in PONV-related late recovery that requires phase one PACU stay and delays home readiness.1 Anti-emetic prophylaxis and reduced use of opioids help to greatly reduce PONV rates. Current data also suggest that nitrous oxide does not contribute to PONV.

Dr. Barinholtz: You might get the patients out and get them home just as soon with inhalationals, but if you ask two groups of patients, one given propofol-based TIVA, the other gas, how they feel, the TIVA group will almost always report feeling better after surgery. Why work hard to circumvent PONV when you don't have to? Propofol has no cumulative emetic effects but inhalationals do.

Dr. Joshi: Inhalational anesthesia has an economic advantage over TIVA, primarily due to propofol costs. But many factors influence cost. In my mind, the cost differences are too small to warrant changing your approach one way or the other.

Dr. Barinholtz: Titrating drugs to BIS levels has decreased drug costs. Since we implemented BIS monitoring in my practice, we've seen propofol use decrease by about 20 percent.

Can you apply consciousness monitoring to titrating inhalational anesthesia?
Dr. Joshi: Titrating volatile anesthetics to BIS levels reduces the drug requirements and hastens emergence. For instance, when I use a desflurane and nitrous oxide combination, I know from BIS studies that the patient will have adequate hypnosis 3 to 3.5 percent end-tidal concentration.

Dr. Friedberg: But is it just as good to run sevoflurane at, say, a BIS 50 to 60 reading for cosmetic surgery? It depends on whether you consider a 1-in-50,000 risk of malignant hyperthermia an acceptable risk for these patients. I don't. Perhaps before propofol, but definitely not now.

1. Anesthesiol Clin North America. 20003 Jun; 21 (2): 263-72.