丙泊酚tci個(gè)性化實(shí)施探討

丙泊酚TCI個(gè)性化實(shí)施探討華中科技大學(xué)附屬協(xié)和醫(yī)院王潔TCI概念及原理概念靶控輸注〔TCI〕是以藥代動(dòng)力學(xué)和藥效動(dòng)力學(xué)原理為根底，以血漿或效應(yīng)室的藥物濃度為指標(biāo)，由計(jì)算機(jī)控制藥物輸注速率的變化，到達(dá)按臨床需要調(diào)節(jié)麻醉的目的。原理丙泊酚三室模型以血漿或效應(yīng)室的靶濃度為調(diào)控指標(biāo)而不是以給藥總量或速率為調(diào)控指標(biāo)給藥后計(jì)算機(jī)屏幕實(shí)時(shí)顯示目標(biāo)血藥濃度、效應(yīng)室濃度、給藥時(shí)間和累積劑量等麻醉醫(yī)師可以像轉(zhuǎn)動(dòng)揮發(fā)器那樣方便地控制靜脈麻醉，提高靜脈麻醉控制水平TCI原理麻醉醫(yī)生從計(jì)算藥物劑量或輸注速度中解脫出來血藥濃度迅速到達(dá)所需要的濃度或藥效計(jì)算機(jī)控制維持穩(wěn)定的血藥濃度。TCI的優(yōu)勢(shì)理想的TCI麻醉麻醉誘導(dǎo)迅速術(shù)中鎮(zhèn)痛充分，鎮(zhèn)靜適中術(shù)后最短的蘇醒時(shí)間確保無術(shù)中知曉術(shù)后鎮(zhèn)痛充分全程完善的個(gè)體化給藥理想的超短效鎮(zhèn)靜藥和鎮(zhèn)痛藥可靠的瞬時(shí)鎮(zhèn)靜深度、鎮(zhèn)痛深度監(jiān)測(cè)藥物靶濃度實(shí)時(shí)監(jiān)測(cè)理想TCI的實(shí)現(xiàn)條件藥物靶濃度可通過藥代動(dòng)力學(xué)模型推算短效鎮(zhèn)靜藥(丙泊酚)與腦電監(jiān)測(cè)指標(biāo)有良好相關(guān)性腦電監(jiān)測(cè)：鎮(zhèn)靜深度監(jiān)測(cè)BIS、麻醉深度監(jiān)測(cè)ADI等TCI的現(xiàn)有條件沒有理想的鎮(zhèn)痛監(jiān)測(cè)指標(biāo)意識(shí)消失的丙泊酚效應(yīng)室濃度個(gè)體差異有6倍藥物靶濃度與藥代動(dòng)力學(xué)模型推算濃度差30%BIS等腦電監(jiān)測(cè)抗干擾性能差TCI尚存在的問題問題導(dǎo)致的后果麻醉誘導(dǎo)：用異丙酚和阿片類藥物，將BIS值維持在50－60之間，患者對(duì)氣管插管有意識(shí)反響40－60是人群均值，局部人群BIS值高于60意識(shí)消失，局部人群BIS值低于40對(duì)疼痛刺激有內(nèi)隱記憶。

臨床實(shí)踐中的問題在誘導(dǎo)中丙泊酚和瑞芬的靶濃度如何選擇？在麻醉維持中調(diào)節(jié)丙泊酚靶濃度時(shí)有沒有最低和最高濃度的限制？什么時(shí)候該調(diào)節(jié)鎮(zhèn)靜藥(丙泊酚)，什么時(shí)候該調(diào)節(jié)鎮(zhèn)痛藥(如瑞芬)？麻醉醫(yī)生如何同時(shí)調(diào)節(jié)丙泊酚和阿片類藥靶濃度以保持平穩(wěn)麻醉?

麻醉醫(yī)生高質(zhì)量的完成麻醉必須會(huì)思考臨床應(yīng)用問題焦點(diǎn)：丙泊酚TCI靶濃度的個(gè)體化麻醉輔助鎮(zhèn)痛藥物對(duì)丙泊酚TCI靶濃度有何影響？Stepwise丙泊酚TCI靶濃度麻醉誘導(dǎo)意識(shí)消失的丙泊酚個(gè)體效應(yīng)室濃度〔OAA/S評(píng)分為1分〕作為鎮(zhèn)靜深度的判斷指標(biāo)，指導(dǎo)丙泊酚用量術(shù)中丙泊酚TCI靶濃度不低于該濃度丙泊酚個(gè)體化靶濃度OAA/S評(píng)分個(gè)體化指標(biāo)，不可能發(fā)生術(shù)中知曉對(duì)鎮(zhèn)靜深度可作出迅速判斷，濃度定值的變化標(biāo)志著個(gè)體對(duì)丙泊酚藥物敏感度，通過它可直接調(diào)節(jié)麻醉深淺和丙泊酚用量。簡(jiǎn)單可行丙泊酚個(gè)體化靶濃度優(yōu)點(diǎn)個(gè)體化丙泊酚靶濃度麻醉Anaestheticstabilitysignificantlyimproved(0.43+/-0.44vs.1.31+/-0.78丙泊酚每小時(shí)調(diào)節(jié)次數(shù),P=0.003)Timetoextubationwassignificantlyshorter(9.6+/-2.1vs.15.7+/-9.6minP=0.011).WithFM-TCI,propofolconsumptionwassignificantlylower.EurJAnaesthesiol.2021Sep;25(9):741-7鎮(zhèn)痛藥物與丙泊酚TCIFutureapplicationsforTCIsystemsAmongcurrentlyavailableanalgesicdrugs,alfentanilandremifentanilareconsideredtobethemostsuitableforadministrationbytargetcontrolledinfusionAnaesthesia.1998Apr;53Suppl1:56-60.短效鎮(zhèn)痛藥物瑞米芬太尼大劑量副作用明顯大劑量阿片類藥物鎮(zhèn)痛封頂效應(yīng)大劑量瑞米芬太尼麻醉蘇醒后疼痛反跳瑞芬太尼Anaesthesist.2021Feb;59(2):126-34.不同瑞芬濃度對(duì)丙泊酚TCI靶濃度影響RESULTS:Narcotrend,D(2)/E(0)0.2,0.4,or0.6microg/kgremifentanilpropofolconcentrationwas3.02+/-0.86,1.93+/-0.53and1.60+/-0.55microg/mlrespectivelyWomenhadahigherpropofolconsumptionthanmen.瑞芬太尼vs芬太尼RESULTS:PatientsingroupRexhibitedafasterrecovery.Theincidenceofnauseaandvomitingwassimilarinthe2groups.TherewasareductionintheamountofpropofolusedingroupRMinervaAnestesiol.2006May;72(5):309-19Propofolandsufentanilforgynecological

laparoscopicsurgery.RESULTS:Sufentanil(0.2ng/ml)skinincision(EC(50))and(EC(95))were2.2and3.7microg/ml,respectively.ThepredictedpropofolEC(50)andEC(95)tomaintainadequatewere2.6microg/ml(2.3-2.7microg/ml)and3.6microg/ml(3.3-4.0microg/ml),respectivelyActaAnaesthesiolScand.2021Jan;55(1):110-7Ketamineeffectonbispectralindexduringpropofol-remifentanilanaesthesia.RESULTS:

0.2mgkg(-1)ketamineadministeredovera5minperioddidnotincreasetheBISvalueoverthenext15min.0.5mgkg(-1)isassociatedwithanincreaseinthebispectralindex(BIS)valuesthatcanleadtoanoverdoseofhypnoticagentsBrJAnaesth.2021Mar;102(3):336-9Dexmedetomidineontheadjuvantpropofolrequirementandintraoperativehemodynamics..RESULTS:

ThepropofolinfusionratewassignificantlylowerintheDEXgroupthaningroupC(63.9±16.2vs.96.4±10.0μg/kg/min,respectively;P<0.001).ThechangesinMAP%atT-induction,T-tracheaandT-incisioningroupDEX(-10.0±3.9%,-9.4±4.6%and-11.2±6.3%,respectively)weresignificantlylessthanthoseingroupC(-27.6±13.9%,-21.7±17.1%,and-25.1±14.1%;P<0.05,respectively)KoreanJAnesthesiol.2021Feb;62(2):113-8Dexmedetomidineonbispectralindexunder

stepwisepropofoltarget-controlledinfusion..RESULTS:

loadingdoseofdexmedetomidineof1.0μg?kg(-1),not0.5μg?kg(-1)orless,over10minfollowedby0.5μg?kg(-1)?h(-1)candefinitelydecreasetheBISunderstepwisepropofolPharmacology.2021;91(1-2):1-6Interactionofpropofolanddexmedetomidine

duringesophagogastroduodenoscopyinchildren.RESULTS:

TheEC50+/-SEvaluesinthecontrolandDEXgroupswere3.7+/-0.4microgxml(-1)and3.5+/-0.2microgxml(-1),respectively.Therewasnosignificantshiftinthepropofolconcentration-responsecurveinthepresenceof1microgxkg(-1)dexmedetomidine.PaediatrAnaesth.2021Feb;19(2):138-44.ketamine-propofol,fentanyl-propofoland

butorphanol-propofolonLMAinsertion.RESULTS:

totaldoseofpropofolrequiredinGroupPKwas160.37±15.75mg,inGroupPF156.22±17.18mgandinGroupPB140.08±18.97mg.butorphanoltopropofolprovidedabsolutejawrelaxationandexcellentinserti