Special Operations Forces Medical Handbook

5-155

and share the experience (and the praise for a hard job well done) with the families.

3. Do not be surprised if being at home brings back upsetting memories from the operation. It may be
   hard to talk about the memories from the operation, especially with those who were not there. This is
   very common, but try to talk to them anyway, and talk with teammates from the operation (best option).
   Do not hesitate to talk with a chaplain or with the community mental health or stress control team.

WHAT NOT TO DO
Do not keep these emotions inside. Do not withdraw. Do not desecrate or take souvenirs from the bodies.

NOTE: Source: When the Mission Requires Recovering Dead Bodies: How to prepare yourself, your
buddies, and the unit. Combat Stress Action Office; HSHA-PO, Department of Preventive Health Services,
AMEDDC&S, Fort Sam Houston, Texas.

Chapter 19: Anesthesia

Anesthesia: Total Intravenous Anesthesia (TIVA)

LTC Howard Burtnett, AN, USA & MAJ Steven Hendrix, AN, USA

What:
Induction and maintenance of general anesthesia using only the infusion of intravenous anesthetic medica-
tions.
Fundamental tenets of TIVA are:

1. The combination of medications selected for infusion must provide all the components of anesthesia:
   amnesia (hypnosis), analgesia, autonomic stability, and if required, areflexia (complete muscle
   relaxation). Table 5-12 lists examples of combinations that have been successfully used in the field
   environment.


2. Continuous infusion techniques provide more precise control over the pharmacological effects of the
   medications being administered, avoiding the autonomic “peaks and valleys” seen with intermittent
   bolus administration.


3. Vigilant titration, based on observed and anticipated patient response, is essential. Successful use
   of this technique allows for small increases in the anesthetic effect when necessary, as well as
   aggressive, but methodical downward titration of the infusion rates throughout the course of the
   anesthetic, resulting in a smooth emergence.

When:
As an alternative to inhalation anesthetics when:

1. Inhalation agents or their delivery devices (vaporizers) are unavailable


2. A patient requires high concentrations of oxygen and minimal drug-induced cardiovascular depression.

What You Need:

1. Normal monitoring capability (BP cuff, pulse oximeter, EKG and stethoscope). Peripheral nerve stimulator
   is desirable if infusing muscle relaxants.


2. Bag-Valve-Mask or other device capable of delivering positive-pressure ventilations


3. Endotracheal tube or other devices to assist in maintaining or securing the airway.


4. Established IV access and infuse maintenance fluids. Medications will be infused through this
   line, so it is imperative to have a patent line.


5. Infusion assisting devices, such as a Dial-A-Flow IV rate control clamp. Electronic infusion pumps are ideal
   but likely not available.


6. Intravenous anesthetic medications (Table 5-10). These recommended dosages are designed for healthy
   adult patients requiring acute surgical intervention. Do not confuse these dosages with those used for long
   term sedation/analgesia in critical care/intensive care situations. These dosages are not recommended