When my classmates (and now fellow new grads) and I started clinical almost of all of us wanted to run lots of TIVA cases, mostly prop/remi bases anesthesia.

I'm not quite sure why, it just seemed like the "cool" thing to do. As our OR time increased and we started to work as staff at the many different sites we visited, many (?most) of my classmates only came to love TIVA more, it was often viewed as the "Cadillac" of anesthetics techniques.

I, on the other hand, went a different direction, and found myself rarely doing TIVA cases (even when prop became plentiful again). My reasoning for not using a TIVA technique more often is as follows:

1.) I observed a large variation in patient response to propofol. I believe this is due to genetic variation in hepatic metabolism. While it doesn't really show when you give an induction dose, once you start relying on metabolism (and not just redistribution), dramatic differences in intraop prop requirements between patients become apparent. Comparing this to highly reliable (dose wise) PIAs with end-tidal monitoring, prop based TIVA is going to be more challenging.

2.) The community hospitals where I was training did not have BIS monitoring - so determining just how deep I was running a patient was challenging at times.

3.) Prop is controlled at these sites - so I had to pull it out of the narc dispensing machine and waste it at the end. This combined with setting up the pumps added to turnover pressure for me and was more labor intensive.

4.) I found the IV pumps to be less reliable than my good ol' vaporizer.

5.) When I used remifent I found my patient were always apnic - not ideal with LMAs and it made long acting narcotic titration difficult.

6.) With longer cases (2hrs plus), I struggled to know when to turn the stuff off....

Basically, I found it to be a PITA to setup, a PITA to run in the OR, and for most patients I just didn't see an advantage.

HOWEVER: One of the sites where I will be eventually credentialed has a chief MDA that loves TIVA. While he doesn't micromanage, a number of the senior CRNAs share his infatuation for TIVA. As a result, it's a very pro-TIVA culture. For example, a female having lap surgery is getting TIVA there no questions asked.

I figure, while there, I will do at least some of my cases with a TIVA technique. So, what I'm really looking for is some advice/tricks/words of wisdom from the NA TIVA experts.

My main concern is when you turn this stuff off.....For short cases, I'm not worried. However, it's a 2-3hrs lap gyn cases that I think will more challenging.

Here's one guideline that someone told me (maybe on here?) that seems to be OK, but maybe a little too aggressive?

For a 30minute case, turn the prop off 15minutes before end of the case, for every extra 30 minutes add 5 minutes onto your turn off time time. So for a 2 hr case you would turn off the prop off 30 minutes before the end. BTW, good luck guessing when they have 30 minutes left

Lastly, I typically start people at 80mcg/kg/min prop with 0.3mcg/kg/min remi as separate infusions. What do you guys think about this dosing?