The Benefits of Low‑Volume TIVA: Clinical, Operational, and Environmental Advantages

Total Intravenous Anaesthesia (TIVA) has undergone significant refinement in recent years, with advances in target‑controlled infusion (TCI), novel agents, and monitoring technologies enabling anaesthetists to deliver anaesthesia with greater precision and lower total drug volumes. Low‑volume TIVA systems are designed to optimise dosing, and are frequently used in specialised, high-precision cases where minimising waste and maximising accuracy is critical, including paediatric or neonatal, and in some cases, adult, anaesthesia.Below, we explore the core benefits of low‑volume TIVA, supported by the latest available evidence.

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1. Improved Haemodynamic Stability Through Precise Dosing

Modern TIVA systems, including TCI pumps and depth‑of‑anaesthesia monitoring, allow clinicians to titrate drugs more accurately, avoiding unnecessarily high infusion rates.

• Recent reviews have highlighted how precision delivery reduces fluctuations in haemodynamics, leading to smoother induction and maintenance phases.
• By using only the amount required to achieve target effect-site concentration, low‑volume TIVA reduces risks associated with oversedation, including hypotension and delayed emergence.

Clinical translation:
Lower drug volumes → fewer haemodynamic swings → safer anaesthesia for high‑risk, frail, or elderly patients.

2. Faster Recovery and Enhanced Postoperative Quality

Low‑volume TIVA, particularly when using agents such as propofol, dexmedetomidine, or remimazolam, can support faster emergence profiles.

• A 2023 review reported that TIVA’s pharmacokinetic precision contributes to more predictable recovery and reduced residual sedation compared to volatile anaesthesia .
• Reduced overall infusion volume reduces the body’s metabolic load, potentially speeding clearance and improving early postoperative cognitive function.

Clinical translation:
Optimised, lower-volume dosing → quicker wake-up → improved theatre flow and patient experience.

3. Lower Incidence of Postoperative Nausea and Vomiting (PONV)

TIVA is already well-documented to reduce PONV compared to inhalational agents. Reducing total infusion volume further decreases systemic drug load, enhancing this effect.

• TIVA regimens in obese patients showed significantly lower PONV rates than volatile anaesthesia, even with standard dosing volumes, highlighting the advantage of minimising exposure further when clinically appropriate.
• Smaller total drug volumes correlate with lower plasma levels of emetogenic metabolites.

Clinical translation:
Low‑volume TIVA = even lower PONV risk → better recovery scores, especially in ambulatory or ERAS pathways.

4. Reduced Drug Consumption Lowers Cost and Medication Error Risk

Lower-volume TIVA reduces overall drug usage, supporting:

• Cost‑effectiveness: Less propofol, opioid, or adjunct consumption across high‑volume surgical lists.
• Operational safety: Handling fewer syringes and infusion bags reduces opportunities for mislabelling or dosing errors.

The BMJ 2024 editorial emphasised the role of safety checklists (e.g., Peruse Before You Infuse) to improve standardisation—an approach made even more effective when fewer drugs and lower volumes are required.

Clinical translation:
Low‑volume regimens reduce cognitive load and streamline workflows.

5. Environmental Benefits: Extending Sustainability Gains of TIVA

A landmark 2024 sustainability analysis showed that TIVA already has a 20‑fold lower carbon footprint than mixed volatile/intravenous techniques, even with standard drug volumes .

Reducing drug volume further amplifies sustainability benefits by:

• Cutting pharmaceutical manufacturing impact
• Reducing plastic packaging waste
• Minimising unused-waste disposal after cases

Clinical translation:
Low‑volume TIVA is an ideal tool for hospitals’ carbon‑reduction strategies and Green Theatre initiatives.

6. Enhanced Safety in Procedures Requiring Neuromonitoring

Using lower volumes of hypnotic or analgesic infusions can help maintain adequate conditions for neurophysiological monitoring, such as during spinal or neuro-oncological procedures.

• A 2025 RCT demonstrated that optimised dosing (e.g., adding esketamine to lower propofol/remifentanil requirements) enhanced both stability and monitoring quality while reducing total drug use.

Clinical translation:
Minimising drug volume preserves neuromonitoring signal integrity → safer spine and cranial surgery.

7. Supports Opioid‑Sparing and Multimodal Analgesia

Lower total drug volume often accompanies multimodal strategies, including adjuncts such as dexmedetomidine, ketamine, or lidocaine.

Studies show:

• Newer TIVA models emphasise opioid reduction, with emerging adjuncts (e.g., remimazolam, ciprofol) reducing propofol needs and overall infusion volume.
• Reduced opioid volume lowers risks of respiratory depression and hastens recovery.

Clinical translation:
Low‑volume, opioid‑sparing TIVA → a safer, more comfortable postoperative course.

Conclusion

Low‑volume TIVA represents an important evolution in anaesthetic practice:
smaller drug volumes with bigger clinical benefits.

By combining precision dosing, modern infusion technology, and multimodal strategies, anaesthetists can achieve:

• smoother haemodynamics
• faster recovery
• less PONV
• improved neuromonitoring conditions
• lower drug costs and waste
• reduced environmental impact

As TIVA adoption grows globally, low‑volume approaches will become integral to delivering sustainable, high‑quality, patient‑centred anaesthesia.

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References

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  Domene SS, Fulginiti D, Thompson A, Vargas VPS, Rodriguez LC, Tolentino-Colón MD, et al. Inhalation anesthesia and total intravenous anesthesia (TIVA) regimens in patients with obesity: an updated systematic review and meta-analysis of randomized controlled trials. J Anesth Analg Crit Care. 2025;5:15.

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