How Culture Enables Practice: Facilitators and Barriers to the Use of Total Intravenous Anesthesia in Pediatric Anesthesia

INTRODUCTION: Total intravenous anesthesia (TIVA) in children has gained popularity due to potential advantages, including decreased respiratory adverse events, postoperative nausea and vomiting, and emergence agitation. British Columbia Children's Hospital (BCCH) has a reputation for TIVA use, training, and advocacy, including intravenous induction. AIM: To inform practice change and education by exploring how institutional culture impacts TIVA adoption, particularly regarding intravenous cannulation in awake children. METHODS: Current and former BCCH anesthesiologists and trainees were surveyed and interviewed about TIVA practices at BCCH and at their current institutions. The survey covered demographics, practice settings, past and current methods for induction and maintenance of anesthesia, factors contributing to technique selection, TIVA barriers and facilitators, and implementation factors. Semi-structured interviews conducted with a subset of participants were analyzed using deductive and inductive thematic analysis. RESULTS: Twenty-six participants completed the survey: 21 attending physicians, 2 fellows, and 3 residents; 58% with < 10 years' and 23% with > 20 years' anesthesia practice. Most participants (92%) practised in an academic setting, caring for a median [interquartile range] 400 [200-500] children annually. Most (96%) indicated their BCCH experience had changed their practice, with a greater effect on using intravenous anesthesia for maintenance than induction. Changes were influenced by a positive experience (77%), supportive environment (42%), and scientific evidence (42%). Choice of anesthetic technique depended on patient factors (89%), institutional expectations (46%), pharmacology (42%), and patient preference (39%), but not parental preference (15%). Interviews with 11 participants focused on intervention bundles to enable success, expectation-setting, family education, equipment and staff availability, and supportive workflows. CONCLUSION: Training in a TIVA institution can have a profound effect on using TIVA in children and drive changes in anesthetic practice elsewhere. Introducing TIVA requires a supportive culture, appropriate equipment, and the personalization of approaches, and may benefit from understanding factors in change management.