丙泊酚TCI个性化实施探讨

丙泊酚TCI个性化实施探讨,华中科技大学附属协和医院王 洁,TCI概念及原理,概念 靶控输注（TCI）是以药代动力学和药效动力学原理为基础，以血浆或效应室的药物浓度为指标，由计算机控制药物输注速率的变化，达到按临床需要调节麻醉的目的。,原理,丙泊酚三室模型,以血浆或效应室的靶浓度为调控指标而不是以给药总量或速率为调控指标给药后计算机屏幕实时显示目标血药浓度、效应室浓度、给药时间和累积剂量等麻醉医师可以像转动挥发器那样方便地控制静脉麻醉，提高静脉麻醉控制水平,TCI原理,麻醉医生从计算药物剂量或输注速度中解脱出来血药浓度迅速达到所需要的浓度或药效计算机控制维持稳定的血药浓度。,TCI的优势,理想的TCI麻醉,麻醉诱导迅速术中镇痛充分，镇静适中术后最短的苏醒时间确保无术中知晓术后镇痛充分全程完善的个体化给药,理想的超短效镇静药和镇痛药可靠的瞬时镇静深度、镇痛深度监测药物靶浓度实时监测,理想TCI的实现条件,药物靶浓度可通过药代动力学模型推算短效镇静药(丙泊酚)与脑电监测指标有良好相关性脑电监测：镇静深度监测BIS、麻醉深度监测ADI等,TCI的现有条件,没有理想的镇痛监测指标意识消失的丙泊酚效应室浓度个体差异有6倍药物靶浓度与药代动力学模型推算浓度差30%BIS等脑电监测抗干扰性能差,TCI尚存在的问题,问题导致的后果,麻醉诱导：用异丙酚和阿片类药物，将BIS值维持在5060之间，患者对气管插管有意识反应 4060是人群均值，部分人群BIS值高于60意识消失，部分人群BIS值低于40对疼痛刺激有内隐记忆。,临床实践中的问题,在诱导中丙泊酚和瑞芬的靶浓度如何选择？在麻醉维持中调节丙泊酚靶浓度时有没有最低和最高浓度的限制？,什么时候该调节镇静药(丙泊酚)，什么时候该调节镇痛药(如瑞芬)？麻醉医生如何同时调节丙泊酚和阿片类药靶浓度以保持平稳麻醉?,麻醉医生高质量的完成麻醉必须会思考,临床应用问题焦点：丙泊酚TCI靶浓度的个体化麻醉辅助镇痛药物对丙泊酚TCI靶浓度有何影响？,Stepwise丙泊酚TCI靶浓度麻醉诱导意识消失的丙泊酚个体效应室浓度（OAA/S评分为1分）作为镇静深度的判断指标，指导丙泊酚用量 术中丙泊酚TCI靶浓度不低于该浓度,丙泊酚个体化靶浓度,OAA/S评分,个体化指标，不可能发生术中知晓 对镇静深度可作出迅速判断，浓度定值的变化标志着个体对丙泊酚药物敏感度，通过它可直接调节麻醉深浅和丙泊酚用量。 简单可行,丙泊酚个体化靶浓度优点,个体化丙泊酚靶浓度麻醉,Anaesthetic stability significantly improved (0.43 +/- 0.44 vs. 1.31 +/- 0.78 丙泊酚每小时调节次数, P = 0.003) Time to extubation was significantly shorter (9.6 +/- 2.1 vs. 15.7 +/- 9.6 min P = 0.011). With FM-TCI, propofol consumption was significantly lower.,Eur J Anaesthesiol. 2008 Sep;25(9):741-7,镇痛药物与丙泊酚TCI,Future applications for TCI systems,Among currently available analgesic drugs, alfentanil and remifentanil are considered to be the most suitable for administration by target controlled infusion,Anaesthesia. 1998 Apr;53 Suppl 1:56-60.,短效镇痛药物瑞米芬太尼大剂量副作用明显大剂量阿片类药物镇痛封顶效应大剂量瑞米芬太尼麻醉苏醒后疼痛反跳,瑞芬太尼,Anaesthesist. 2010 Feb;59(2):126-34.,不同瑞芬浓度对丙泊酚TCI靶浓度影响,RESULTS: Narcotrend, D(2)/E(0) 0.2, 0.4, or 0.6 microg/kg remifentanil propofol concentration was 3.02+/-0.86, 1.93+/-0.53 and 1.60+/-0.55 microg/ml respectively Women had a higher propofol consumption than men.,瑞芬太尼vs芬太尼,RESULTS: Patients in group R exhibited a faster recovery. The incidence of nausea and vomiting was similar in the 2 groups.There was a reduction in the amount of propofol used in group R,Minerva Anestesiol. 2006 May;72(5):309-19,Propofol and sufentanil for gynecological laparoscopic surgery.,RESULTS: Sufentanil (0.2 ng/ml) skin incision(EC(50) ) and (EC(95) ) were 2.2 and 3.7 microg/ml, respectively. The predicted propofol EC(50) and EC(95) to maintain adequate were 2.6 microg/ml ( 2.3-2.7 microg/ml) and 3.6 microg/ml (3.3-4.0 microg/ml), respectively,Acta Anaesthesiol Scand. 2011 Jan;55(1):110-7,Ketamine effect on bispectral index during propofol-remifentanil anaesthesia.,RESULTS: 0.2 mg kg(-1) ketamine administered over a 5 min period did not increase the BIS value over the next 15 min.0.5 mg kg(-1) is associated with an increase in the bispectral index (BIS) values that can lead to an overdose of hypnotic agents,Br J Anaesth. 2009 Mar;102(3):336-9,Dexmedetomidine on the adjuvant propofol requirement and intraoperative hemodynamics.,RESULTS: The propofol infusion rate was significantly lower in the DEX group than in group C (63.9 16.2 vs. 96.4 10.0 g/kg/min, respectively; P 0.001). The changes in MAP% at T-induction, T-trachea and T-incision in group DEX (-10.0 3.9%, -9.4 4.6% and -11.2 6.3%, respectively) were significantly less than those in group C (-27.6 13.9%, -21.7 17.1%, and -25.1 14.1%; P 0.05, respectively),Korean J Anesthesiol. 2012 Feb;62(2):113-8,Dexmedetomidine on bispectral index understepwise propofol target-controlled infusion.,RESULTS: loading dose of dexmedetomidine of 1.0 gkg(-1), not 0.5 gkg(-1) or less, over 10 min followed by 0.5 gkg(-1)h(-1) can definitely decrease the BIS under stepwise propofol,Pharmacology. 2013;91(1-2):1-6,Interaction of propofol and dexmedetomidine during esophagogastroduodenoscopy in children.,RESULTS: The EC50 +/- SE values in the control and DEX groups were 3.7 +/- 0.4 microg x ml(-1) and 3.5 +/- 0.2 microg x ml(-1), respectively. There was no significant shift in the propofol concentration-response curve in the presence of 1 microg x kg(-1)dexmedetomidine.,Paediatr Anaesth. 2009 Feb;19(2):138-44.,ketamine - propofol, fentanyl - propofol andbutorphanol-propofol on LMA insertion.,RESULTS: total dose of propofol required in Group PK was 160.37 15.75mg, in Group PF 156.22 17.18 mg and in Group PB 140.08 18.97 mg.butorphanol to propofol provided absolute jaw relaxation and excellent insertion conditions with stable haemodynamics Side effects like coughing