Is TIVA better than

inhalation agents for

elective brain surgery?
Siti Chasnak Saleh
Dept. Anesthesiology Airlangga
Univ/ Dr. Soetomo Hosp.
Surabaya
04/21/15

TIVA vs
INHALATION

Propofol (+opioid:
fentanyl/remifenta
nil)

Sefovlurane
(+ opioid:
fentanyl/remifenta
nil)
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Goals of Anesthetic
Management for Brain Surgery

Hemodynamic stability
Minimize changes in intracranial pressure
Maintain cerebral perfusion pressure
Neuroprotection
Provide optimal condition for surgery
Smooth emergence
Rapid awakening

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Ideal Anesthetic Agent

Maintain CBF without affecting autoregulation
Preserve hemodynamic stability (especially CPP)
Minimize detrimental changes in ICP
Preserve reactivity of cerebral arterioles to
PaCO2 changes
Decrease CMRO2 with cerebral protection effects
Devoid of seizure activity
Devoid of arrhythmogenic effect

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Ideal IV anesthetic drug

Pharmacodynamic

Wide therapeutic ratio

Minimal cardiorespiratory & motor side-effects
Rapid, predictable, smooth onset
Painless & non-irritant
Stable at room temperature
Rapid recovery (no rebound or emergence
effects)
No adrenal or immune suppression
Low potential for anaphylaxis
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Pharmacokinetic
Rapid redistribution & biotransformation
Inactive metabolites
Clearance independent of duration of
administration
Duration of action unaffected by reduced
renal or
hepatic function
Rapid recovery

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Estimated changes in (CBF) and the

(CMRO2) caused by volatile anesthetics

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Changes in (CBF) and the (CMRO2 )

caused by I V agents

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Effects of Anesthetic
Agents

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TIVA vs Inhalation for

Neurosurgery

The differences were of minimal relevance in elective

patients.
The specific choice of anesthetic agents may not be the
most crucial aspect of successful neuroanesthetic practice
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Sevoflurane
Cerebral pressure
autoregulation was preserved
during 0.2 and 1.5 MAC of
sevoflurane anesthesia in
human.
Favouring its use in
neuroanesthetic practice.
Gupta et al. BJA 1997; 79:469-472
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TIVA vs Inhalation
Propofol

: reduced rCBF and rCMRO2

comparably at BIS value of 40

Sevoflurane: reduced rCBF less than propofol

reduced fCMRO2 to an extent
similar to propofol; does not
increase ICP

Anesthesiology 2003; 99:603-613

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Kaisti et al. Anesthesiology 2003; 99:60313

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PROPOFOL
In patients without intracranial
pathology, cerebral pressure
autoregulation and CO2 reactivity are
intact during propofol-induced EEG
silence
Is this true for patients with
intracranial pathology?
Matta,et al. BJA 1995;74:159-163
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PROPOFOL and BRAIN TRAUMA

Propofol reduced ICP in patients with
severe brain trauma.
Propofol may decrease CPP (its effect on
MAP )
Propofol exerts no consistent effect on CVR
Propofol does not alter cerebral
arteriovenous oxygen content difference

Anesthesiology 1990; 73:404-409

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CAROTID CLAMPING
1st Interpretation
The most importance during
carotid clamping is cerebral
blood flow, not arterial
pressure. Sevoflurane is
the preferred agent.

Anesthesiology 2007; 106:56-64

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2nd Interpretation

If the increased flow with

sevoflurane is interpreted
as luxury perfusion, it
could be argued that
propofol is the preferred
agent.

Anesthesiology 2007; 106:56-64

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Anesthesiology 2001;95:616-626
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Volatile
Propofol
anesth
Volatile anesth
Propofol
(iso/sevo)
agents (iso/sevo)

CO2 reactivity

+ (maintain)

ICP

CMRO2

CBF & CBV

PONV

< iso/sevo

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COST
BENEFIT?

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CONCLUSION-1
For all agents, the ultimate condition of the patient
will be deternined by the sum of the effects of the
chosen agent on CBF, CMRO2, CO2 reactivity, MAP,
and CBV.
The ultimate effects of volatile agents on ICP/CPP
are less predictable
The effect of propofol on intracranial dynamics are
more predictable than volatile agents

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CONCLUSION-2
Propofol reduces intracranial pressure in patients with
severe brain trauma and ICP to or less that 15 mmHg
TIVA is preverable , at least until the dura is opened.
The CO2 reactivity during anethesia with volatile
anesthetic agents is significantly higher inhalation
anesthesia is preverable in brain tumor surgery.

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