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The role of total intravenous anaesthesia for caesarean delivery

      I read with interest the excellent informative and thoughtful review article by Metodiev and Lucas
      • Metodiev Y.
      • Lucas D.N.
      The role of total intravenous anaesthesia for caesarean delivery.
      on total intravenous anaesthesia (TIVA) for caesarean birth.
      I wish to comment on some important articles from the 1990s that were not cited. Although these research studies were published before the concept of TIVA (and target-controlled infusions) using propofol had been fully developed, it seems appropriate to mention the seminal research
      • Gregory M.A.
      • Gin T.
      • Yau G.
      • Leung R.K.
      • Chan K.
      • Oh T.E.
      Propofol infusion anaesthesia for caesarean section.
      • Gin T.
      • Yau G.
      • Chan K.
      • Gregory M.A.
      • Oh T.E.
      Disposition of propofol infusions for Caesarean section.
      • Yau G.
      • Gin T.
      • Ewart E.M.
      • Kotur C.F.
      • Leung R.K.
      • Oh T.E.
      Propofol for induction and maintenance of anaesthesia at caesarean section. A comparison with thiopentone/enflurane.
      • Gin T.
      • Gregory M.A.
      • Buckley T.
      • Chan K.
      • Oh T.E.
      The pharmacokinetics of propofol in women undergoing elective caesarean section.
      on the use of propofol infusions for general anaesthesia for caesarean birth by the research group led by Tony Gin in Hong Kong. In one study propofol infusions (the ‘lower dose’ group coupled with inhaled nitrous oxide) based on a fixed weight-based induction dose and maintenance with descending dose regimens were compared with thiopentone followed by enflurane.
      • Gregory M.A.
      • Gin T.
      • Yau G.
      • Leung R.K.
      • Chan K.
      • Oh T.E.
      Propofol infusion anaesthesia for caesarean section.
      In this same study the higher propofol dose (TIVA) group had higher maternal blood pressure and heart rate, earlier immediate maternal recovery but lower early neonatal neurobehavioural scores compared with the thiopentone and inhalational anaesthesia group. These innovative studies, some pharmacokinetic,
      • Gregory M.A.
      • Gin T.
      • Yau G.
      • Leung R.K.
      • Chan K.
      • Oh T.E.
      Propofol infusion anaesthesia for caesarean section.
      • Yau G.
      • Gin T.
      • Ewart E.M.
      • Kotur C.F.
      • Leung R.K.
      • Oh T.E.
      Propofol for induction and maintenance of anaesthesia at caesarean section. A comparison with thiopentone/enflurane.
      • Gin T.
      • Gregory M.A.
      • Buckley T.
      • Chan K.
      • Oh T.E.
      The pharmacokinetics of propofol in women undergoing elective caesarean section.
      conducted shortly after the introduction of propofol, acknowledged its rapid placental transfer
      • Gin T.
      • Gregory M.A.
      • Chan K.
      • Oh T.E.
      Maternal and fetal levels of propofol at caesarean section.
      and raised the possibility of greater early neonatal depression with propofol infusions if associated with a long induction-to-delivery interval.
      • Yau G.
      • Gin T.
      • Ewart E.M.
      • Kotur C.F.
      • Leung R.K.
      • Oh T.E.
      Propofol for induction and maintenance of anaesthesia at caesarean section. A comparison with thiopentone/enflurane.
      Metodiev and Lucas
      • Metodiev Y.
      • Lucas D.N.
      The role of total intravenous anaesthesia for caesarean delivery.
      discuss the potential benefits of TIVA and note the absence of recent research in the obstetric anaesthesia setting. They speculate as to whether TIVA might supplant intravenous induction followed by inhalational general anaesthesia in the future in some circumstances. Despite the clearly established benefits of TIVA in the non-obstetric population and its occasional reported use in specific obstetric circumstances, the potential problems related to postoperative pain management after intra-operative remifentanil infusion for caesarean surgery and the optimal dosing methods that minimise maternal awareness and neonatal depression remain largely unexplored.
      I strongly agree with Metodiev and Lucas
      • Metodiev Y.
      • Lucas D.N.
      The role of total intravenous anaesthesia for caesarean delivery.
      that TIVA for caesarean birth is understudied but not that it is underutilised. It is incumbent on obstetric anaesthesiologists to not widely embrace techniques such as TIVA until there is sufficient information regarding appropriate dosing algorithms, pharmacokinetics, and most importantly maternal and neonatal outcomes. In my opinion, the time is overdue for this hiatus in research across the past 30 years to be addressed.

      Declaration of interests

      None.

      References

        • Metodiev Y.
        • Lucas D.N.
        The role of total intravenous anaesthesia for caesarean delivery.
        Int J Obstet Anesth. 2022; 50103548https://doi.org/10.1016/j.ijoa.2022.103548
        • Gregory M.A.
        • Gin T.
        • Yau G.
        • Leung R.K.
        • Chan K.
        • Oh T.E.
        Propofol infusion anaesthesia for caesarean section.
        Can J Anaesth. 1990; 37: 514-520https://doi.org/10.1007/BF03006318
        • Gin T.
        • Yau G.
        • Chan K.
        • Gregory M.A.
        • Oh T.E.
        Disposition of propofol infusions for Caesarean section.
        Can J Anaesth. 1991; 38: 31-36https://doi.org/10.1007/BF03009160
        • Yau G.
        • Gin T.
        • Ewart E.M.
        • Kotur C.F.
        • Leung R.K.
        • Oh T.E.
        Propofol for induction and maintenance of anaesthesia at caesarean section. A comparison with thiopentone/enflurane.
        Anaesthesia. 1991; 46: 20-23https://doi.org/10.1111/j.1365-2044.1991.tb09307.x
        • Gin T.
        • Gregory M.A.
        • Buckley T.
        • Chan K.
        • Oh T.E.
        The pharmacokinetics of propofol in women undergoing elective caesarean section.
        Br J Anaesth. 1990; 64: 148-153https://doi.org/10.1093/bja/64.2.148
        • Gin T.
        • Gregory M.A.
        • Chan K.
        • Oh T.E.
        Maternal and fetal levels of propofol at caesarean section.
        Anaesth Intensive Care. 1990; 18: 180-184https://doi.org/10.1177/0310057X9001800204