H. F. Lewis1, T. Bennett2, Z. Burton3, M. Edwards2, The Paediatric Anaesthesia Trainee Research Network (PATRN), R. Lewis4

1Evelina London Children's Hospital, UK

2Southampton University Hospital, UK

3Sheffield Children's Hospital, UK

4Portsmouth Hospital University NHS Trust, UK


Total intravenous anaesthesia (TIVA) is the maintenance of general anaesthesia without the use of inhalational anaesthetic agents. Advantages of TIVA are reduced post-operative nausea and vomiting (PONV), emergence delirium and airway reactivity. Furthermore it is a requirement in certain conditions where inhalational anaesthesia is contraindicated due to the risk of rhabdomyolysis or malignant hyperthermia e.g. neuromuscular disease.

Previous surveys have shown TIVA use is increasing although routine use remains low.2 Barriers to regular use are cited as a lack of equipment (TCI pumps / models and awareness monitoring), familiarity with technique and concerns over list efficiency.3

As part of the Perioperative Childhood Obesity Study (PEACHY), data was collected on anaesthetic maintenance technique. This data is reported here.


PEACHY was a national multi-centre prospective observational cohort study. Ethical approval was granted (West Midlands REC; reference 18/WM/0394). During a site-selected consecutive seven-day study period in September and October 2019, all children (≥2 years and <16 years) undergoing general anaesthesia were included. Anonymised demographic data, surgical and anaesthetic details were collected by local Paediatric Anaesthesia Trainee Research Network (PATRN) coordinators.


102 hospitals participated (79 secondary; 23 tertiary paediatric centres) and 4,232 cases were included in analysis.

Age, sex and BMI were similar for TIVA and inhalational anaesthesia use. TIVA maintenance was used in 10% (n=423) of cases despite intravenous (IV) inductions in 62% (n=2,623). Intravenous induction combined with TIVA maintenance was used in only 7% (n=296) of all cases. The majority of TIVA use was in tertiary hospitals by consultants for non-ambulatory cases. Neurosurgery (28%) and gastroenterology (21%) had proportionally more TIVA use compared to other specialties. There was no difference in whether pain relief was required (12% versus 8.8%; p=0.09) or anti-emetic use (1.6% versus 2%; p=0.6) in recovery.

TIVA use was not higher in patients with risk factors for peri-operative respiratory adverse events; asthma, OSA and/or snoring or those having ENT surgery. There was significantly lower laryngospasm and bronchospasm in the TIVA group compared with inhalational anaesthesia for induction and maintenance (0.6% versus 2.8%; p=0.02). Children who had a gas induction were more likely to have laryngospasm on emergence than those who had intravenous induction, independent of maintenance anaesthesia (1.28% versus 2.6%; p=0.0012). There was no difference in desaturation, aspiration or obstruction between the two groups.


TIVA use remains low in paediatric anaesthesia despite reported advantages. Although this was an observational study with a possibility of confounding variables, the findings support previous evidence of a decrease in airway complication rate associated with intravenous anaesthesia when compared to inhalational techniques.  Strategies to promote increased use are education on paediatric TIVA techniques, equipment procurement to ensure enough per theatre and familiarity with technique to increase efficiency.


  1. J Gaynor, J M Ansermino, Paediatric total intravenous anaesthesia, BJA Education. 2016; 16 (11): 369–373.
  2. Goh AN, Bagshaw O, Courtman S. A follow-up survey of total intravenous anesthesia usage in children in the U.K. and Ireland. Paediatr Anaesth. 2019;29(2):180-185.
  3. Lewis H, Groome J, Arnold P, Brooks P, PATRN. How green is pediatric anesthesia? The Pediatric Anesthesia Trainee Research Network 2021 UK National Survey. Pediatr Anaesth. 2022; 32: 772–775.
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