TCI的理論與實(shí)踐

1、TCI的理論與實(shí)踐的理論與實(shí)踐Beijing Hospital AnesthBalanced Anesthesia Muscle relaxationLoss of ConsciousnessAnalgesia全身麻醉全身麻醉Beijing Hospital Anesth 吸入維持靜脈誘導(dǎo) 靜脈維持靜脈誘導(dǎo) 吸入維持 靜脈維持靜脈誘導(dǎo)靜脈誘導(dǎo) 吸入維持或靜脈維持吸入維持或靜脈維持 椎管內(nèi)麻醉或神經(jīng)阻滯椎管內(nèi)麻醉或神經(jīng)阻滯全身麻醉Beijing Hospital Anesth TCI/TIVA的優(yōu)點(diǎn)Control depth of sedation pre-inductionLess pollu

2、tion in the OT and environment No liver toxicityLess PONVAccess to airway unrestricted by drug deliveryCan be continued for post-op sedationNo increase in F- ions; safe with soda limeMaintain hypoxic vasoconstriction reflexSafe in patients at risk for malignant hyperthermiaTCI system: predicts blood

3、 and effect site calculated concentrations, similar to the way that end-tidal monitor measures gas exhaled from the patientBeijing Hospital Anesth TCI的發(fā)展的發(fā)展: Propofol給藥方式給藥方式手動(dòng)給藥Mg/kg持續(xù)輸注Mg/kg/hrTCI PTCI/ETCIg/mlClosed loop TCI ?Beijing Hospital Anesth 手動(dòng)給藥手動(dòng)給藥3020100Concentration 礸/ml109876543210In

4、fusion Rate(ml/hr)10009008007006005004003002001000M, 40 yr, 70kg, 170cm.Propofol manual : Effect site concentration 2.8 ug/ml2mg/kg1mg/kg1mg/kg1mg/kgBeijing Hospital Anesth Propofol: 持續(xù)輸注持續(xù)輸注3020100Concentration 礸/ml109876543210Infusion Rate(ml/hr)10009008007006005004003002001000M, 40 yr, 70kg, 170c

5、m.Propofol bolus+infusion : Effect site concentration 2.8 ug/ml2mg/kg8mg/kg/hrBeijing Hospital Anesth Propofol: TCI3020100Concentration 礸/ml109876543210Infusion Rate(ml/hr)100090080070060050040030020010003020100Concentration 礸/ml109876543210Infusion Rate(ml/hr)10009008007006005004003002001000M, 40 y

6、r, 70kg, 170cm.Propofol TCI 3.5 ug/mlPlasma TCI 3.5 ug/mlEffect TCI 3.5 ug/mlBeijing Hospital Anesth TCI成功的理論和物質(zhì)基礎(chǔ)成功的理論和物質(zhì)基礎(chǔ)藥物的進(jìn)步：PropofolRemifentanilSufentanil丙泊酚和阿片類藥物PK和PD:三室模式效應(yīng)室EC50EC95封效應(yīng)時(shí)間時(shí)量相關(guān)半衰期TCI泵雙通道TCI泵麻醉深度監(jiān)測(cè)儀（BIS）Beijing Hospital Anesth1 1 13 3 3 2 2 2Beijing Hospital Anesth1 1 13 3 32 2

7、 2Beijing Hospital AnesthPharmacokinetic And Pharmacodynamic Parameters Of Propofol And The OpioidsBart-Jan Lichtenbelt, et al.Clin Pharmacokinet 2004; 43 (9): 577-593Beijing Hospital Anesth Time To Peak EffectBeijing Hospital AnesthContext Sensitive Half TimeBeijing Hospital Anesth TCI泵：計(jì)算值和實(shí)際值準(zhǔn)嗎？泵

8、：計(jì)算值和實(shí)際值準(zhǔn)嗎？TCI system: predicts blood and effect site calculated concentrations, similar to the way that end-tidal monitor measures gas exhaled from the patient.Beijing Hospital AnesthPropofol EC50 (Loss of consciousness)Propofol EC50 (Loss of consciousness) EC50 (EC05 EC95) Cp European 5.2 (3.1-7.3

9、) (g/ml) Chinese 3.83 (2.86-4.80) Ce European 2.8 (1.5-4.1) (g/ml) Chinese 2.23 (1.29-3.18) BIS European 70.9 (88.8-52.9) Chinese 57.9 (11.28) AEPI European 54.3 (68.6-40.0) Kenny GNC. BJA 2003;90(2):127XU Zhi-peng et al. INTERNATIONAL JOURNAL OF ANESTHESIOLOGY AND RESUSCITATION 2006 Vol.27 No.3 P.1

10、44-148 Beijing Hospital Anesth EC50EC95 of Remifentanil for Tetanic Stimuli -China 2004EC05EC50EC95Cp（ng/mlng/ml）2.22（2.00-2.42）4.09（3.99-4.20）5.96（5.79-6.16）Ce（ng/mlng/ml）1.53（1.44-1.61） 3.33（3.29-3.38）5.89（5.78-6.00）BIS81.9(81.15-82.77)65.5(65.05-65.90)49.0(48.19-49.78)Beijing Hospital AnesthEC50E

11、C95 of Sufentanil for Various Stimuli Sufentanil（ng/ml）EC05EC50EC95Intubation0.040.83Tetanic0.050.19Incision0.050.20YANG Ning, ZUO Mingzhang. CHINESE JOURNAL OF ANESTHESIOLOGY 2006 Vol.26 No.11 P.987-979Beijing Hospital AnesthDosePK variability 70PD variability 30

12、0-400Response 麻醉醫(yī)生的臨床觀察和判斷很重要！Propofol10mg/kg/h 3-5mcg/mlPropofol 1mcg/ml ?Beijing Hospital Anesth 麻醉深度監(jiān)測(cè)麻醉深度監(jiān)測(cè)老年患者危重患者大手術(shù)Beijing Hospital Anesth 丙泊酚誘導(dǎo)丙泊酚誘導(dǎo): ASA 1-2，PTCI和和ETCI都安全都安全 Beijing Hospital Anesth 丙泊酚丙泊酚誘導(dǎo)：老年誘導(dǎo)：老年危重患者選擇危重患者選擇PTCI 采用采用階梯式誘導(dǎo)階梯式誘導(dǎo)TCI started with plasma concentration of propo

13、fol 1 g/ml, monitor BP and HR Wait for effect-site concentrationIncrease propofol Cp 0.5-1.0 g/ml/each until LOCBeijing Hospital Anesth如何做好丙泊酚和瑞芬的雙通道如何做好丙泊酚和瑞芬的雙通道TCI？100Concentration ng/ml876543210Infusion Rate(ml/hr)10009008007006005004003002001000100Concentration ng/ml109876543210Infusion Rate(ml

14、/hr)10009008007006005004003002001000M, 40 yr, 70kg, 170cm.Remifentanil Plasma TCI: 5 ng/mlRemifentanil Effect TCI: 5 ng/mlBeijing Hospital Anesth3020100Concentration 礸/ml6543210Infusion Rate(ml/hr)100090080070060050040030020010003020100Concentration ng/ml109876543210Infusion Rate(ml/hr)1000900800700

15、6005004003002001000Propofol / Remifentanil TCI: InductionPropofol PTCI 3.5g/mlRemifentanil PTCI 6ng/mlM, 40yr, 170cm, 70kgIntubationBeijing Hospital AnesthPropofol / Remifentanil TCI: Maintenance1201101009080706050403020100Concentration ng/ml109876543210Infusion Rate(ml/hr)10009008007006005004003002

16、0010001201101009080706050403020100Concentration 礸/ml6543210Infusion Rate(ml/hr)10009008007006005004003002001000M, 40yr, 170cm, 70kgRemifentanil PTCI 4-8ng/mlPropofol PTCI 2.8-4.0 g/mlInductionIntubationSkin incisionEnd of SurgeryBeijing Hospital AnesthPropofol / Remifentanil TCI: Emergence1201101009

17、080706050403020100Concentration ng/ml109876543210Infusion Rate(ml/hr)100090080070060050040030020010001201101009080706050403020100Concentration 礸/ml6543210Infusion Rate(ml/hr)10009008007006005004003002001000M, 40yr, 170cm, 70kgRemifentanil PTCI 4-8ng/mlPropofol PTCI 2.8-4.0 g/mlInductionIntubationSki

18、n incisionEnd of SurgeryAnalgesic transitionBeijing Hospital Anesth Propofol and Remifentanil in TCIRemifentanil PTCI1. Induction: 4-8ng/ml2. Maintenance: 4-8ng/ml3. Emergence: Analgesic transition 鎮(zhèn)痛轉(zhuǎn)換和多模式鎮(zhèn)痛鎮(zhèn)痛轉(zhuǎn)換和多模式鎮(zhèn)痛1. Minor surgery: Local infiltration, NASIDS2. Moderate surgery: Local infiltratio

19、n, Epidural, NASIDS, Morphine, Sufentanil (0.1ug/kg)3. Major surgery: Local infiltration, Epidural, NASIDS, Morphine, Sufentanil (0.1ug/kg)Beijing Hospital Anesth如何做好丙泊酚和舒芬的雙通道如何做好丙泊酚和舒芬的雙通道TCI？ 3020100Concentration ng/ml0.20.10Infusion Rate(ml/hr)100090080070060050040030020010003020100Conc

20、entration ng/ml0Infusion Rate(ml/hr)10009008007006005004003002001000M, 40 yr, 70kg, 170cm.Sufentanil Plasma TCI: 0.3ng/mlSufentanil Effect TCI: 0.3ng/mlBeijing Hospital AnesthPropofol with Sufentanil / Remifentanil TCI Management -TCI Induction: Time to

21、Beijing Hospital Anesth050100% max Ce4080120160PAM(mm HG)0 04 48 812121616intubationsufentanilpropofol0 050501001000 04 48 81212161640408080120120160160% max Ceintubationsufentanilpropofoltime (mn)time (mn)Propofol with Sufentanil in TCI : Induction: Time to Beijing Hospital AnesthOptimisation Of In

22、duction Timing050100time (min)%max CE4080120160PAM (mmHg)0 04 48 812121616intubationsufentanilpropofolBeijing Hospital AnesthSufentanil in TCI: Induction100Concentration 礸/ml109876543210Infusion Rate(ml/hr)10009008007006005004003002001000M, 40yr, 170cm, 70kg100Concentration ng/ml10

23、.0.20.10Infusion Rate(ml/hr)10009008007006005004003002001000M, 40yr, 170cm, 70kgSufentanil ETCI5Propofol PTCI1.5ug/ml3.5ug/ml0.3ng/mlIntubationBeijing Hospital AnesthSufentanil in TCI: Maintenance and Emergence1201101009080706050403020100Concentration ng/ml0.20.10Infusion

24、 Rate(ml/hr)100090080070060050040030020010001201101009080706050403020100Concentration 礸/ml109876543210Infusion Rate(ml/hr)10009008007006005004003002001000M, 40yr,170cm,70kgSufentanil ETCIPropofol PTCIInductionIntubatingSkin incisionEnd of Surgery0.08ng/ml1.5ug/ml3.5ug/mlBeijing Hospital Anesth Sufen

25、tanil in TCIETCIInduction: 0.25-0.3ng/ml; 0.35-0.5ng/ml (Cardiac surgery)Maintenance: 0.15-0.25 ng/mlEmergence: Sufentanil 0.1-0.06 ng/ml NASIDS Local infiltration, Epidural, Never blockPostoperative: PCA Morphine: Bolus 1 mg, Lockout time 5-6 min, Max 10-12mg/hr, Basal infusion 0.5-0.25mg/hBeijing

26、Hospital Anesth TCI的注意事項(xiàng)：的注意事項(xiàng)：1. 確保確保TCI泵正常工作泵正常工作2. 藥物濃度設(shè)置正確藥物濃度設(shè)置正確3. 確保藥物盡快進(jìn)入患者體內(nèi)確保藥物盡快進(jìn)入患者體內(nèi)4. 密切監(jiān)測(cè)和觀察密切監(jiān)測(cè)和觀察5. 對(duì)老年對(duì)老年危重危重大手術(shù)患者，推薦使用麻醉深度監(jiān)大手術(shù)患者，推薦使用麻醉深度監(jiān)測(cè)儀，如測(cè)儀，如BIS監(jiān)測(cè)監(jiān)測(cè)Beijing Hospital AnesthBeijing Hospital Anesth Input：Body weightAgeGenderHeightBeijing Hospital Anesth Drugs： Propofol (Cp) Remi

27、fentanil (Cp) Propofol (Cp) + Sufentanil (Ce)Beijing Hospital Anesth AnestheticssedativesopioidspropofolsufentanilremifentanilMarshSchniderGeptsMintoBeijing Hospital AnesthSufentanil and Remifentanil in TCIPropofol+RemifentanilPropofol+SufentanilInduction 3.0-3.5 g/ml4-8ng/ml 3-4 g/ml 0.25-0.3 ng/mlMaintenance2.5-3.0 g/ml 4.0-8.0 ng/ml 3.0-4.0 g/ml 0.14-0.25 ng/mlEmergence Analgesic transition0 0.06-0.08 ng/mlBeijing Hospital AnesthOur PracticeIV LineBeijing Hospital Anesth 監(jiān)測(cè)麻醉深度監(jiān)測(cè)麻醉深度 TCI-IVA Inhalational anesthesia BP、HR BP、HR Move