Experimental Anesthetic Agents & TIVA

While propofol, etomidate, and ketamine dominate, novel agents are in development to address limitations (e.g., hemodynamic instability, adrenal suppression). Here’s a glimpse:

Experimental IV Induction Agents

1. Fospropofol (Aquavan®):

   • Mechanism: Water-soluble propofol prodrug.
   • Advantages: Less injection pain, smoother recovery.
   • Status: Approved for procedural sedation (not general anesthesia). Limited by delayed onset (4–8 min).
   • Potential: May replace propofol in outpatient settings.

2. ABP-700 (Cyclopropyl Methoxycarbonyl Etomidate):

   • Mechanism: Ultra-short-acting etomidate analog.
   • Advantages: No adrenal suppression, rapid metabolism.
   • Status: Phase III trials. Shows promise for RSI in critical care.
   • Potential: Safer alternative to etomidate in sepsis.

3. Remimazolam:

   • Mechanism: Benzodiazepine derivative metabolized by tissue esterases.
   • Advantages: Rapid recovery, minimal cardiorespiratory depression.
   • Status: Approved in Japan/EU for sedation; under investigation for induction.
   • Potential: Ideal for elderly or cardiac patients.

Brief Note on TIVA (Total Intravenous Anesthesia)

• What is TIVA?: Anesthesia maintained solely with IV agents (e.g., propofol + remifentanil), avoiding inhalational gases.
• Indications:
  • Malignant hyperthermia susceptibility.
  • Neurosurgery (to avoid cerebral vasodilation).
  • PONV-prone patients.
• Advantages: Rapid titration, reduced pollution, better hemodynamic control.
• Disadvantages: Requires infusion pumps, risk of awareness (use BIS monitoring), PRIS with prolonged propofol.
• Agents Used: Propofol (hypnotic) + opioid (e.g., remifentanil) ± dexmedetomidine.

Read here in detail about TIVA implementation in modern anesthesia practice

Future Outlook: TIVA is gaining traction with target-controlled infusion (TCI) systems. Experimental agents like ABP-700 may further refine induction safety.

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External Sources

1. UpToDate: Intravenous Induction Agents for Anesthesia

   • Comprehensive review of pharmacology, dosing, and evidence-based use.
   • Link (Subscription required).

2. OpenAnesthesia: Induction Agents

   • Free educational resource with case-based discussions and guidelines.
   • Link.

3. NICE Guidelines: Anaesthesia for Adults Having Surgery

   • Covers TIVA, induction agent selection, and safety protocols.
   • Link.

Final Note: Mastery of IV induction requires balancing pharmacology, patient physiology, and clinical context. Stay updated with emerging agents to optimize safety!