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Introduction: Automatic drug dispensers are now widely used in critical care.1-2 They can provide information about dispensed drugs. Good practice in sedation restricts the use of sedatives and titrates doses to defined responses.3-4 Objectives: To extract drug dispenser issuing records for sedatives and link these to patient records to evaluate sedative use. Method(s): in October 2019, we introduced two Omnicell XT automated dispensing cabinets (Omnicell inc. CA, USA) into a 42 bedded general/neurological unit. ICNARC (Intensive care national audit and research centre) and CCMDS (Critical care minimum data set) data was collected using the Ward Watcher program. Dispenser issuing records for alfentanil, propofol and midazolam were obtained as Excel files for 13 months from January 2020. Output time stamps were converted to dates and times. Outputs were linked to outputs of the ICNARC and CCMDS records for the patients that the drugs were issued to. All the outputs had patients identified by their unique hospital numbers. These were used in Excel "power queries" to produce a spread sheet with a single row per patient. Multiple admissions used the first diagnosis, the final outcome and the total length of stay. The total dose of sedatives was calculated from ampoule dose and number. The duration of treatment was calculated from the first and last issues of the drug. ICNARC codes were used to identify the primary system in the admission diagnostic code and those patients admitted for COVID-19. Variables were compared using Chi Squared, Mann-Whitney U and Kruskal Wallis Tests. The significance of associations was established using Spearman's Rho. Linear regression was used to define relationships more clearly. Result(s): Table one summarises the patient characteristics with respect to all admissions during the study period and for patients who had had the studied drugs issued to them. Midazolam was used in fewer patients, they were more likely to be male, heavier (p>0001) and to die than patients receiving Propofol or Alfentanil (p>0.001). With respect to diagnostic groups, all the sedatives, particularly Midazolam (p<0.001), were more likely to be used in patients with COVID-19. The relationship between the dose of sedative drugs and patient age and weight was explored using the dose per advanced respiratory day. All three drugs had a significant but weak negative relationship with age, lower doses being given to older people (Propofol r2 = 0.02, p=0.01. Alfentanil r2 = 0.04, p=0.00. Midazolam r2 = 0.07, p=0.00.). There was also a weak but significant relationship between increasing dose of Propofol with patient weight (r2 = 0.02, p=0.01), but there was no relation between weight and doses of the other drugs. Conclusion(s): Information from automatic drug dispensers can be interpreted and combined with other datasets to produce clinically relevant information. The limited weak relationships between drug dose and age and weight suggests that sedative drugs could have been better titrated to response.
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Objectives: Analgosedation of patients with severe respiratory failure due to coronavirus disease 2019 (COVID-19) proved to be challenging. Patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO) seemed to require analgosedative drugs in high doses. This study reviews analgosedation practices in patients with COVID-19 associated severe respiratory failure supported with VV ECMO. Method(s): This is a retrospective, single-center registry study including all patients with COVID-19 associated severe respiratory failure that were supported with VV ECMO at our center. All sedative and analgetic drugs administered intravenously or via inhalation to patients for at least two hours were recorded and analyzed. Result(s): Between March 2020 and January 2022, 88 patients with COVID-19 associated severe respiratory failure were supported with VV ECMO at our center. Propofol and sufentanil were used most frequently for analgosedation in this cohort. Both drugs were co-administered following treatment standards established prior to the emergence of COVID-19 at our center. Sedative and analgetic drugs were switched to alternative regimens after a median time of 3 and 12.5 days. Alternative regimens included Isofluran, alpha-2- agonists (clonidine or dextomidine) or esketamine. Alpha-2- agonists were initiated at a median time of 2 days after starting VV ECMO support. Benzodiazepines were used primarily as last resort treatment option for sedation at our center. During the four waves of the pandemic experienced at our center, we experienced an increased average number of drugs needed for analgosedation. Conclusion(s): Analgosedation in critically ill COVID-19 patients supported with ECMO is challenging. It remains unclear, whether the standard analgosedation regimen with sufentanil and propofol established at our center prior to the COVID-19 pandemic is optimal for this patient cohort. Further studies are needed to determine optimal and long term safe analgosedation regimens in critically ill patients supported by VV ECMO. Furthermore, changes experienced during the course of the pandemic need to be scrutinized in comparison to other cohorts. (Table Presented).
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COVID-19-associated ARDS (C-ARDS) is mentioned to express higher analgosedation needs, in comparison to ARDS of other etiologies. The objective of this monocentric retrospective cohort study was to compare the analgosedation needs between C-ARDS and non-COVID-19 ARDS (non-C-ARDS) on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Data were collected from the electronic medical records of all adult patients treated with C-ARDS in our Department of Intensive Care Medicine between March 2020 and April 2022. The control group included patients treated with non-C-ARDS between the years 2009 and 2020. A sedation sum score was created in order to describe the overall analgosedation needs. A total of 115 (31.5%) patients with C-ARDS and 250 (68.5%) with non-C-ARDS requiring VV-ECMO therapy were included in the study. The sedation sum score was significantly higher in the C-ARDS group (p < 0.001). COVID-19 was significantly associated with analgosedation in the univariable analysis. By contrast, the multivariable model did not show a significant association between COVID-19 and the sum score. The year of VV-ECMO support, BMI, SAPS II and prone positioning were significantly associated with sedation needs. The potential impact of COVID-19 remains unclear, and further studies are warranted in order to evaluate specific disease characteristics linked with analgesia and sedation.
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Background: Many EP procedures are moving from the hospital to the ambulatory surgery center (ASC) outpatient setting. The COVID-19 pandemic and the CMS Hospitals Without Walls (HWW) program has been an impetus in accelerating this transition. Anesthesia provider perioperative management is critical in facilitating safe procedures with rapid, same-day discharge. Our EP-dedicated 2-OR ASC completed more than 3,000 procedures and more than 500 left-sided ablations utilizing general anesthesia with endotracheal intubation with same-day discharge. To our knowledge, this experience is unique within an ASC setting in both volume and complexity. Objective(s): We present our comprehensive anesthesia strategy and lessons learned to facilitate safe, efficient procedures and discharge in an EP ASC. Method(s): A nurse anesthesiologist with more than a decade of EP-dedicated experience developed and taught a perioperative anesthesia strategy to facilitate high volume, safe and quick discharge care. Fundamental to this is the avoidance of opioids and benzodiazepines whenever possible. Propofol or general anesthesia with sevoflurane and complete reversal with sugammadex allow for quick recovery. Mandatory video laryngoscope utilization minimizes airway trauma, while liberal antiemetic use eliminates most nausea. All femoral access is device closed. Positive inotropes are used liberally during anesthetic to avoid heart failure. The goal is to deliver all patients to PACU on room air with stable hemodynamics. Anesthesia providers manage the preop and recovery area. Result(s): More than 90% of all patients undergoing general anesthesia and heparinization for left-atrial ablation were discharged home in under 3 hours. Nearly all procedures not requiring femoral access were discharged within 30-60 minutes. High procedure volumes with efficiencies far exceeding our in-hospital experience were thus facilitated with improved patient safety. Since HWW began, five patients have required transfer to the hospital without any deaths. All others were discharged same day. Conclusion(s): We suggest that a dedicated anesthesia team with a tailored perioperative anesthesia plan facilitates performing nearly all EP-related surgical procedures in an ASC. This success is facilitated by appropriate patient selection, preoperative evaluation, intraoperative care prioritizing quick return to baseline, and end-to-end anesthesia perioperative management. We believe this type of anesthesia management is critical to the transition of EP procedures to ASCs.Copyright © 2023
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Background: Atrial fibrillation (AF) is a cardiac complication commonly associated with COVID-19 infection, especially in severe cases. The sedative agent dexmedetomidine is known to cause bradycardia. In this study, we are testing whether dexmedetomidine could reduce the occurrence of AF in mechanically ventilated COVID-19 patients. Method(s): This prospective trial included 144 patients who were randomly allocated to one of two groups: Group C patients were sedated with propofol and fentanyl. Group D patients were sedated with the same medications in addition to dexmedetomidine infusion. Result(s): Demographic, clinical, and cardiac characteristics of all patients did not significantly differ between the two groups. The duration of intensive care unit (ICU) stay was comparable between the two groups. However, both propofol and fentanyl consumption significantly declined in Group D. The number of AF attacks showed a significant decline in association with dexmedetomidine administration (mean = 12.5% in Group D vs. 29.2% in Group C). Dexmedetomidine also reduced the amount of required electrical cardioversion episodes. Additionally, antiarrhythmic medication needed reduced significantly in Group D. Mortality rates did not differ between the two study groups (58.3% and 63.8% in Groups D and C, respectively). Conclusion(s): Dexmedetomidine is associated with a significant reduction in the burden of AF in patients with severe COVID-19 infection, manifested by fewer AF attacks, the need for electrical cardioversion shocks, and the consumption of antiarrhythmic medication without impact on mortality.Copyright © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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Introduction: Delirium in intensive care unit (ICU) patients is a common disorder which is characterized by non-specific brain dysfuncion and is associated with increased mortality [1]. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-COV-2 is associated with increased delirium rates through various mechanisms including hypoxaemia, circulation of inflammatory mediators and direct central nervous system damage [2]. Due to life-threatening respiratory manifestations in COVID-19 patients delirium is often underestimated. Aim of the study was to record the pharmacologic treatment of delirium in ICU patients treated with non-invasive ventilation and the differences in delirium treatment between COVID-19 and non-COVID-19 patients. Method(s): Consecutive patients with respiratory failure were retrospectively included. All patients were hospitalized in the ICU and noninvasive ventilation was applied. Patient characteristics, length of ICU stay and medication were recorded. Result(s): Totally 64 patients were included (33 patients with COVID- 19). Pharmacologic management of delirium included administration of remifentanyl, dexmedetomidine, propofol and combinations of the above. COVID-19 patients were younger (61 vs 70.4 years, p = 0.02), had longer ICU hospitalization (p < 0.001) and needed longer intravenous medication administration (p = 0.001). Additionally, the proportion of patients with COVID-19 treated with intravenous medication due to delirium was higher than non-COVID-19 patients (81.8% vs 48.4%, p = 0.008). COVID-19 seemed to have worse outcomes than non-COVID-19 patients and this difference tended to be statistically significant (p = 0.09). Conclusion(s): Delirium is quite common and requires aggressive treatment among COVID-19 patients, despite being younger than non- COVID-19 patients. Physicians should be vigilant to assess and manage delirium to improve the long-term outcomes of COVID-19 patients.
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Aim: In this study, we aimed to evaluate factors affecting the anxiety and pain of patients undergoing colonoscopy during the COVID-19 period. Material(s) and Method(s): Before the colonoscopy, patients aged 18-80 years were asked to fill out the Spielberger State-Trait Anxiety Inventory Scale (STAI), along with a personal data form in which demographic data and medical history were questioned, and their pain was questioned with the Visual Analogue Scale (VAS). The pain was questioned in patients who underwent colonoscopy under sedoanalgesia according to VAS after full recovery (Modified Aldrete Score >=8). Result(s): Three hundred and thirty patients (M/F=53/47) with a mean age of 53.41+/-14.75 years participated in the study. 22.7% of the patients had COVID-19 infection. COVID-19 vaccine was administered to 47.6% of the patients. 85.5% were concerned about COVID-19 transmission during colonoscopy. The mean STAI-S (STAI-State) was 47.49+/-8.86, and STAI-T (STAI-Trait) was 39.84+/-8.94 in the patients. The mean VAS score was 2 (0-10) before colonoscopy and 4 (0-10) after colonoscopy. There was no difference in STAI-S, STAI-T, pre and post-colonoscopy VAS scores between those who had COVID-19 and those who did not (p=0.134, p=0.155, p=0.891, p=0.953). There was no difference in STAI-S, STAI-T, and VAS scores between those vaccinated with the COVID-19 vaccine and those not vaccinated (p=0.127, p=0.527, p=0.932, p=0.983). Gender, educational status, STAI-S, STAI-T scores, and colonoscopy waiting time affected VAS scores. Discussion(s): Being infected with COVID-19 and being vaccinated with COVID-19 vaccine are not among the factors affecting patients' anxiety and pain.Copyright © 2023, Derman Medical Publishing. All rights reserved.
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A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.
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Background: Postoperative Delirium (POD) is the most frequent neurocognitive complication after general anesthesia in older patients. The development of POD is associated with prolonged periods of burst suppression activity in the intraoperative electroencephalogram (EEG). The risk to present burst suppression activity depends not only on the age of the patient but is also more frequent during propofol anesthesia as compared to inhalative anesthesia. The aim of our study is to determine, if the risk to develop POD differs depending on the anesthetic agent given and if this correlates with a longer duration of intraoperative burst suppression. Methods: In this secondary analysis of the SuDoCo trail [ISRCTN 36437985] 1277 patients, older than 60 years undergoing general anesthesia were included. We preprocessed and analyzed the raw EEG files from each patient and evaluated the intraoperative burst suppression duration. In a logistic regression analysis, we assessed the impact of burst suppression duration and anesthetic agent used for maintenance on the risk to develop POD. Results: 18.7% of patients developed POD. Burst suppression duration was prolonged in POD patients (POD 27.5 min ± 21.3 min vs. NoPOD 21.4 ± 16.2 min, p < 0.001), for each minute of prolonged intraoperative burst suppression activity the risk to develop POD increased by 1.1% (OR 1.011, CI 95% 1.000-1.022, p = 0.046). Burst suppression duration was prolonged under propofol anesthesia as compared to sevoflurane and desflurane anesthesia (propofol 32.5 ± 20.3 min, sevoflurane 17.1 ± 12.6 min and desflurane 20.1 ± 16.0 min, p < 0.001). However, patients receiving desflurane anesthesia had a 1.8fold higher risk to develop POD, as compared to propofol anesthesia (OR 1.766, CI 95% 1.049-2.974, p = 0.032). Conclusion: We found a significantly increased risk to develop POD after desflurane anesthesia in older patients, even though burst suppression duration was shorter under desflurane anesthesia as compared to propofol anesthesia. Our finding might help to explain some discrepancies in studies analyzing the impact of burst suppression duration and EEG-guided anesthesia on the risk to develop POD.
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Propofol is the preferred anaesthetic for induction and maintenance of sedation in critically ill mechanically ventilated COVID-19 patients. However, during the outbreak of the COVID-19 pandemic, regular supply chains could not keep up with the sudden increase in global demand, causing drug shortages. Propofol is formulated as an oil-in-water emulsion which is administered intravenously. This study explores the extemporaneous preparation of a propofol emulsion without specialized manufacturing equipment to temporally alleviate such shortages. A commercially available lipid emulsion (IVLE, SMOFlipid 20 %), intended for parenteral nutrition, was used to create a propofol loaded nanoemulsion via addition of liquid propofol drug substance and subsequent mixing. Critical quality attributes such as mean droplet size and the volume-weighted percentage of large-diameter (>5µm) droplets were studied. The evolution of droplet size and propofol distribution was monitored in situ and non-destructively, maintaining sterility, using Spatially Resolved Dynamic Light Scattering and Near Infrared Spectroscopy, respectively. Using response surface methodology, an optimum was found for a 4 % w/v propofol formulation with a â¼15 min mixing time in a flask shaker at a 40° shaking angle. This study shows that extemporaneous compounding is a viable option for emergency supply of propofol drug product during global drug shortages.
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COVID-19 , Propofol , Humanos , Propofol/química , Emulsiones , Pandemias , Nutrición ParenteralRESUMEN
The coronavirus disease (COVID-19) was first detected in Wuhan, China, in the month of December 2019. Further, in March 2020, the COVID-19 epidemic was described by the World Health Organisation (WHO) as a global pandemic. COVID-19 quickly spread around the world in the following months, affecting about 2.5 million individuals by April 2020. World markets, including the pharmaceutical industry, were devastated by this pandemic. Although no specific solution for this emerging infectious disease is currently available, the pharmaceutical industry is helping policymakers meet unmet COVID-19 desires, ranging from research and advancement initiatives on possible prevention methods to the management of the supply chain of drugs in times of crisis. Changes in demand, commodity shortages, contact adjustments, etc., are hindering developments in the mechanism of technology, research and development and are putting an impact on the health market of COVID-19. Other implications of COVID-19 on the physical condition and pharmaceutical market may include acceptance delays, heading to self-sufficiency in the delivery chain, etc. In addition, the pharmaceutical markets are battling to sustain natural consumer flows, as the latest pandemic has had an effect on access to essential drugs at reasonable rates, which is the key priori-ty of all pharmaceutical systems.Copyright © 2022 Bentham Science Publishers.
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The COVID-19 pandemic has affected millions of people in the entire world and caused a shortage of several drugs, including propofol. Therefore, several protocols for propofol synthesis have been published in recent years. Herein, we present a process starting from paracetamol, a very common and abundant active pharmaceutical ingredient. Since the first three steps (Friedel-Crafts double alkylation, acetyl deprotection, and diazotization) are done in acidic media, a one-pot approach was developed. Furthermore, we observed that the extraction of the final product can be simplified by steam-distillation, leading to propofol in 47% isolated yield with high purity. This presented process could be an example of active pharmaceutical ingredient reuse since similar results were observed with commercial paracetamol tablets (with excipients) regardless of expiration date. © 2023 American Chemical Society.
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The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.
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Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.
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The severe form of SARS-CoV-2 pneumonia (COVID-19) occurs in most cases with acute respiratory distress syndrome (ARDS), requiring the use of sedation during mechanical ventilation, with propofol being the most widely used for its pharmacokinetics and pharmacodynamics. Propofol is a widely used anesthetic in intensive care units (ICU). Its use can cause an infrequent but extremely serious adverse effect, known as propofol infusion syndrome (PRIS), which is closely associated with the speed of infusion coupled with risk factors specific to the patient, the clinical features of PRIS are hemodynamic instability, lactic acidosis and with progression to multi-organ dysfunction. We present a case of SIP in a patient with acute respiratory distress syndrome (ARDS) secondary to SARS-CoV-2 who develops this complication associated with sedation, discusses clinical pathophysiology and considerations that should be taken into account when using it in continuous infusion. © 2023, Colegio Mexicano de Anestesiologia A.C.. All rights reserved.
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Introduction: The bispectral index monitors the unawareness component of balanced anaesthesia and gives us the depth of Anesthesia.It reflects the response of the brain to a variety of hypnotic and inhaled anaesthesia agents. The aim of this study was to see the effect of different MAC values of isoflurane on the bispectral index and hemodynamic variations at different MAC values. Material(s) and Method(s): This prospective study was conducted on 20 patients at tertiary care center for 6 months. After induction of Anesthesia, following parameters were recorded: noninvasive blood pressure measurement, heart rate, oxygen saturation, ETCo2 and BIS values. The BIS was continuously monitored and when the MAC values of isoflurane were 0.5, 0.7, 1, 1.2 and 1.5 corresponding BIS values and all the other haemodynamic parameters were noted. Result(s): In 11 patients out of 20 patients satisfactory BIS of 40-60 was achieved at MAC 0.5. In 16 out of 20 patients satisfactory BIS 40-60 was achieved at 0.7 MAC. In all the 20 patients satisfactory BIS was achieved at 1 MAC.In 2 out of 20 patients we couldn't proceed beyond 1.0 MAC because of the fall in MAP to <65mm of Hg. In 4 out of 20 patients we couldn't proceed beyond 1.2MAC because of the fall in MAP to <65mm of Hg. Conclusion(s): Isoflurane produced satisfactory BIS of 40-60 in 16 patients at 0.7 MAC and in all the 20 patients at 1 MAC.Use of BIS in our study helped in better titration of Isoflurane according to patient's individual needs thereby we avoided light plane of anaesthesia or deep hypnosis and the adverse effects associated with it. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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The proceedings contain 112 papers. The topics discussed include: pediatric sedation for magnetic resonance imaging. the use of intranasal dexmedetomidine to enable a nurse-led, no intravenous access pediatric sedation for radiological procedures at a district general hospital;outcomes in octogenarians undergoing head and neck cancer surgery in a tertiary referral center;the environmental sustainability of propofol use and wastage in total intravenous anesthesia practice;are our patients opioid aware? an audit of take-home analgesia at Charing Cross Hospital, London;evaluating the clinical use of nitrous oxide in our pediatric theatre;implementing a dedicated COVID-19 post intensive care unit follow-up clinic to improve the follow-up of patients in a district general hospital;move to NRfit: the impact of the introduction of new epidural needles on post-dural puncture headache rate;and creating an emergency induction checklist for doctors providing last-minute cover across multiple hospital sites.
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The COVID-19 pandemic has affected millions of people in the entire world and caused a shortage of several drugs, including propofol. Therefore, several protocols for propofol synthesis have been published in recent years. Herein, we present a process starting from paracetamol, a very common and abundant active pharmaceutical ingredient. Since the first three steps (Friedel-Crafts double alkylation, acetyl deprotection, and diazotization) are done in acidic media, a one-pot approach was developed. Furthermore, we observed that the extraction of the final product can be simplified by steam-distillation, leading to propofol in 47% isolated yield with high purity. This presented process could be an example of active pharmaceutical ingredient reuse since similar results were observed with commercial paracetamol tablets (with excipients) regardless of expiration date. © 2023 American Chemical Society.
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Target-controlled infusion pumps and depth of anaesthesia monitors have made total intravenous anaesthesia (TIVA) easy, safe, and precise. The merits of TIVA were highlighted during the coronavirus disease 2019 (COVID-19) pandemic, confirming its potential further in the post-COVID clinical practice as well. Ciprofol and remimazolam are newer drugs that are being tried with a hope to upgrade the practice of TIVA. While research on safe and effective drugs continues, TIVA is being practised with a combination of drugs and adjuncts to overcome the disadvantages of each and to provide complete and balanced anaesthesia with additional benefits in recovery and pain relief postoperatively. Modulation of TIVA for the special population groups is still under process. Advancement in digital technology with mobile apps has increased the scope of TIVA in day-to-day use. The formulation and update of guidelines can establish a safe and efficient practice of TIVA.