IntravenousAnaesthesia：静脉麻醉.ppt

MinimalandModerateSedation T J Gan M B F R C A M H S Li Ac ProfessorofAnesthesiologyViceChairforClinicalResearchDukeUniversityMedicalCenter Content Whysedation CurrentsedationpracticeGuidelinesfromprofessionalsocietygoverningsedationpracticePharmacologicpropertiesofsedativesMonitoringofpatientsundergoingsedationClinicaldataonfospropofolforsedation ProceduralSedation Over40millionproceduresperformedeachyearwithmoderatesedationAbout23millionsendoscopicproceduresperformedannuallyDependingoftheintendedlevelofsedation sedationisperformedbytrainednursesaswellasanesthesiapersonnelApproximatelytwo thirdsoftheendoscopicproceduralsedationperformedbynonanesthesiapersonnel ImportanceofSedation ReliefofanxietyandfearReliefofdiscomfortIncreasepatientcompliancewithscreening surveillanceguidelinesEnhancequalityoftheexaminationMinimizerisksandphysicalinjurytothepatientsImproveoverexperienceandsatisfaction CommonSedationSites ColonoscopyBronchoscopyGastroscopycardiaccatheterizationOfficebasedoutpatientsurgeryEmergencydepartment Colonoscopy SafeComplicationscanoccurMajorityarecardiopulmonarycomplications e g oversedation hypoventilation aspiration vasovagalCVcomplicationrate 2 4 1000Patientsatrisk elderly morbidlyobese Overviewofagentsusedforminimaltomoderatesedation 8 CharacteristicsofanIdealSedative Rapidonsetofactionallowsrapidrecoveryafterdiscontinuation1Effectiveatprovidingadequatesedationwithpredictabledoseresponse1 2Easytoadminister1 3Lackofdrugaccumulation1Fewadverseeffects1 3Minimaladverseinteractionswithotherdrugs1 3Predictabledoseresponse2Cost effective3 1OstermannME etal JAMA 2000 283 1451 1459 2Jacobietal CritCareMed 2002 30 119 141 3DastaJF etal Pharmacother 2006 26 798 805 4NelsonLE etal Anesthesiol 2003 98 428 436 PharmacologicalAgentsinMAC HypnoticsMidazolamPropofolMethohexitalKetamineNitrousoxideDexmedetomidine AnalgesicsOpioidsFentanylMeperidineHydromorphoneMorphineLocalanestheticsNSAIDS CurrentSedationPractice 99 ofcolonoscopiesareperformedwithsedation75 withbenzodiazepineandopioid25 withpropofolandopioid93 sedationwithpropofolperformedwiththepresenceofanesthesiaprofessional Cohenetal AmJGastroenterol2006 101 967 74 SedationStandardDrugsUsedinSedation OpioidandBenzodiazepinecombinationBenefits1 1 4Effectivein85 ofpatientsReversaldrugsavailableChallengesSignificantpharmacodynamicvariabilityDruginteractionsPotentialforrespiratorydepression CohenL Gastroenterology2007 133 675 701 ChallengesContinued ChallengesDelayedrecovery not clearheaded PatientsunabletorecallpostproceduraldiscussionsPotentialfornauseaandvomiting drowsinessDurationofeffectmaypersistformorethan24hours JonasDE AMJGastroenterol2007 102 2401 10 Midazolam HighlylipophilicOnsetofactionin1to2minutesOffset rapidredistributionT1 2 1 8 6 4hrsMetabolism hepaticandrenalroutesProlongedactioninelderly hepaticandrenallyimpaired 65 usehalfdoses Midazolam widerangeofmidazolambloodlevelsassociatedwithadequatesedationAlcoholics decreasedsensitivitytodrugElderly greaterdepressanteffectsStimulatoryeffectsinsomepatientscytochromeP450 CYP 3A4oxidases Diazepam longerhalf lifeagreaterchanceofphlebitishaslessamnesticpropertiesinitialbolusof2 5to5 0mg Incrementaldosesof2 5mgcanbegivenin3to4minuteintervals Opioids FentanylSyntheticopioidFastonset25 50mcg totaldoses 200mcgTitratetocomfortMeperidine50 100mgHydromorphone PharmacologicalAntagonists FlumazenilForreversingbenzodiazepinesDoesnotreverserespiratorydepression0 2mgbolusesupto3mgRiskofresedationNaloxoneCentralopioidantagonistShortacting renarcotizationrisk40 100mcgRiskofpulmonaryedema http www asahq org publicationsAndServices standards 20 pdf 2004 ContinuumofDepthofSedation Standardsforproceduralmonitoringforminimaltomoderatesedation EvaluationofPatientsUndergoingSedation HistoryandphysicalexamReviewofcurrentmedicationsandallergiesAssessmentofcardiopulmonarystatusPatientinstruction e g NPO Sedation relatedriskfactors Sedation relatedriskfactorsinclude significantmedicalconditionssuchasextremesofage severepulmonary cardiac renalorhepaticdisease pregnancy theabuseofdrugsoralcoholuncooperativepatientsapotentiallydifficultairwayforintubation Monitoring Patientsundergoingendoscopicprocedureswithmoderateordeepsedationmusthavecontinuousmonitoringbefore during andaftertheadministrationofsedatives Standardmonitoringheartrate ECG bloodpressure respiratoryrate andoxygensaturation MonitoringforSedation Nurse PatientinteractionSedationScores Ramsay OAAS SMonitorsPulseoximetryETCO2Depthofsedationmonitor EEGbasedBIS Sedline AEP Entropy Observer sAssessmentofAlertness SedationScale OAAS PostproceduralManagement Post proceduralmonitoringincludingobservationandvitalsignmonitoringPost procedurewritteninstructionsforpatients GuidelinestatementsbyASA AGA ASGE AAAASF andothersprofessionalsocietiesonconscioussedation ProfessionalSocietiesGuidelines ASA AGA ASGE AAAASF AANAallhavespecificguidelinesonsedationforendoscopicproceduresPurposeistoensurepatientsafety Whatarethenationalorganizations positions TheAmericanAssociationfortheAccreditationofAmbulatorySurgicalFacilities AAAASF hasexplicitlytakenthepositionthatpropofol unlikeotherintravenoussedation maynotbeadministeredbyaregisterednurse ASAandAANA ThejointASA AANAstatementonpropofoluseindicatesthat personnelwhoadministerpropofolshouldbequalifiedtorescuepatientswhoselevelofsedationbecomesdeeperthaninitiallyintendedandwhoenter ifbriefly astateofgeneralanesthesia JCAHO TheJointCommissiononAccreditationofHealthcareOrganizations JCAHO requiresthatcliniciansintendingtoadministerdeepsedationbequalifiedtorescuepatientsfromgeneralanesthesiaandbecompetenttomanageanunstablecardiovascularsystemaswellasacompromisedairwayandinadequateoxygenationandventilation AGA ACGandASGE TheAmericanGastroenterologicalAssociation AGA theAmericanCollegeofGastroenterology ACG andtheAmericanSocietyforGastrointestinalEndoscopy ASGE issuedajointstatementsupportingnurse administeredpropofolbynonanesthesiologistsforendoscopy MildtomoderatesedationNonanesthesiologypersonnelDeepsedationandgeneralanesthesiaAnesthesiapersonnel ApprovedDrugsforMonitoredAnesthesiaCare Propofol highlylipophilicLargeVdTriphasicdistributionRapidredistribution 2 3minMetabolismSloweliminationfromadiposetissues AdvanatgesofPropofol RapidonsetRapidoffsetOptimalsedationlevelAntiemetic PropofolMetabolism Eliminatedassulfateand orglucuronideconjugatesintheurineLessthan0 3 excretedastheparentcompoundExtrahepaticmetabolismHepaticandrenaldysfunctiondonotsignificantlyalterthepharmacokineticsofpropofolElderly lowerVdandlowerclearance lowerdosesneeded Cautiononsedation Sedationisacontinuumrapid profoundchangesinsedativedepthnon anesthesiapersonnelwhoadministerpropofolshouldbequalifiedtorescuepatientsfromdeeperlevelofsedationeducationandtrainingtomanagethepotentialmedicalcomplicationsofsedation anesthesia AdverseEffectsofPropofol IVinjectionsitepainHypotensionespeciallyinhypovolemiaHypoxiaMicrobialcontaminationlipidemia 3daysofinfusionGreendiscolorationoftheurine Pharmacodynamicsandpharmacokineticsoffospropofol Fospropofol newsedative hypnoticagentFospropofol watersolubleprodrugofpropofolDevelopedinanattempttoreducethedisadvantagesofthelipidemulsionofpropofolenzymaticactionofalkalinephosphatasesinthevascularendothelium FospropofolDisodiumMetabolism EnzymaticLiberationofPropofol FechnerJ etal Anesthesiology 2003 99 303 1313 Water solubleprodrugofpropofolwithdifferentiatedPK PDAlkalinephosphataseiswidelydistributedinbodyFospropofoldisodiumisrapidlyandcompletelymetabolized fospropofoldisodium SulphationGlucuronidation UrinaryExcretion alkaline phosphatase Propofol Formaldehyde Phosphate OH O H H O P O O O O O O O O P Fospropofol PKandPD Non linear 6compartmentswithaneffectsitecompartmentlongerhalf life largerVd andadelayedonsetofactioncomparedwithpropofollowerpeakconcentrationsandmoreprolongedplasmaconcentrationsNopainoninjectioninthearmParasthesiaanditchingintheperinealregion FospropofolPD SinglebolusandBISLevels FospropofolDosesandBISLevels Clinicalprofilesoffospropofol Dosetitration Thesolutionforasteepconcentration responserelationshipAdministersmallfractionsofinitialdosePhaseII IIIstudiesforAquavandonicelyfollowthisguidelineFospropofol6 5mg kgasinitialdosefollowedby ofthisdose 1 6mg min every4minutesuptoamaximumof3repeatdoses Sedationfailure rateofapproximately20 Atleast15minuteswouldberequiredtoreach sedationfailure decision FospropofolSedationSuccessduringColonoscopyCohenLB AlimentaryPharmacology Therapeutics27 7 597 608 Figure1 Sedationsuccess Theprimaryendpointofthisstudywassedationsuccess whereahighlysignificantdose dependenttrendwasobservedacrossfospropofoldosinggroupsinthemodifiedintent to treatpopulation P 0 001byCochran Armitagetrendtest Thesedationsuccessrateswere24 35 69 and96 intheFP2 0 FP5 0 FP6 5andFP8 0groupsrespectively P 0 05vs FP2 0andFP5 0 FospropofolSedationduringColonoscopy Outcomes PatientsandPhysiciansSatisfaction FospropofolforColonoscopy AdverseEvents FospropofolforBronchoscopy Useoffospropofolforotherproceduresrequiringminimaltomoderatesedation ModifiedObserver sAssessmentofAlertness SedationScale MOAA S 1 Respondsonlyafterpainfultrapeziussqueeze 0 Doesnotrespondtopainfultrapeziussqueeze 2 Respondsonlyaftermildproddingorshaking 3 Respondsonlyafternameiscalledloudlyand orrepeatedly 4 Lethargicresponsetonamespokeninnormaltone 5 Alert Respondsreadilytonamespokeninnormaltone Score Responsiveness DynamicContinuumofSedation ChernikDA etal JClinPsychopharmacol 1990 10 244 251 ASAPracticeGuidelines Anesthesiology 2002 96 1004 1017 ProcedureTypesandDuration 1 0 8 3 2 4 8 6 5 10 8 1 13 10 6 18 14 6 21 17 1 22 17 9 27 22 Patients n N 123 Fospropofol6 5mg kg DurationofProcedure min 45 Arteriovenousfistula 26 7 8 Dilatation Curettage 56 24 29 5 Lithotripsy 32 8 12 Ureteroscopy 26 4 14 Transesophagealechocardiogram 105 26 43 5 Bunionectomy 31 3 12 Hysteroscopy 26 12 17 5 Arthroscopy 25 2 4 Esophagogastroduodenoscopy Max Min Median Procedure AdverseEvents Majorityofadverseevents AEs weremildtomoderateSeriousAEs n 4 n 2atrialseptaldefect n 1apneaandcardiacarrest n 1increasedammoniaandhepaticencephalopathyTreatment relatedAEsMostcommonwereperinealparesthesias 53 7 andpruritus 26 0 Sedation relatedAEs 5patients 4 1 Hypoxemia n 1 1minandmanagedwithverbalstimulationandchinlift Hypotension n 4 occurredduringthedosingandrecoveryperiods Bradycardia n 1concurrentlywithhypotensionandmanagedwithatropine Nodeathsreportedandnoprocedurediscontinuedduetoadverseevent HepaticandRenalImpairment MSURG523 20 123 16 patientshadpreviousorexistinghepaticdisease minimal severe 5 123 4 patientshadsevererenalimpairment creatinineclearance11 36mL min AdverseeventratesweresimilartooverallpopulationTreatment relatedAEsweresimilartootherpatients paresthesia50 pruritus30 Nosedation relatedadverseeventsreported Forgeneralanesthesiaormonitoredanesthesiacare MAC sedation DIPRIVANInjectableEmulsionshouldbeadministeredonlybypersonstrainedintheadministrationofgeneralanesthesiaandnotinvolvedintheconductofthesurgical