丙泊酚tci个性化实施探讨ppt课件

1、丙泊酚丙泊酚TCI个性化实施讨论个性化实施讨论华中科技大学附属协和医院王 洁TCI概念及原理概念及原理概念概念 靶控输注靶控输注TCI是以药代动是以药代动力学和药效动力学原理为根底，以血力学和药效动力学原理为根底，以血浆或效应室的药物浓度为目的，由计浆或效应室的药物浓度为目的，由计算机控制药物输注速率的变化，到达算机控制药物输注速率的变化，到达按临床需求调理麻醉的目的。按临床需求调理麻醉的目的。 原理原理丙泊酚三室模型丙泊酚三室模型l以血浆或效应室的靶浓度为调控目的而不是以给以血浆或效应室的靶浓度为调控目的而不是以给药总量或速率为调控目的药总量或速率为调控目的l给药后计算机屏幕实时显示目的血药

2、浓度、效应给药后计算机屏幕实时显示目的血药浓度、效应室浓度、给药时间和累积剂量等室浓度、给药时间和累积剂量等l麻醉医师可以像转动挥发器那样方便地控制静脉麻醉医师可以像转动挥发器那样方便地控制静脉麻醉，提高静脉麻醉控制程度麻醉，提高静脉麻醉控制程度 TCI原理原理麻醉医生从计算药物剂量或输注麻醉医生从计算药物剂量或输注速度中解脱出来速度中解脱出来血药浓度迅速到达所需求的浓度血药浓度迅速到达所需求的浓度或药效或药效计算机控制维持稳定的血药浓度。计算机控制维持稳定的血药浓度。 TCI的优势的优势理想的理想的TCI麻醉麻醉u麻醉诱导迅速麻醉诱导迅速u术中镇痛充分，镇静适中术中镇痛充分，镇静适中u术后最

3、短的清醒时间术后最短的清醒时间u确保无术中知晓确保无术中知晓u术后镇痛充分术后镇痛充分u全程完善的个体化给药全程完善的个体化给药理想的超短效镇静药和镇痛药理想的超短效镇静药和镇痛药可靠的瞬时镇静深度、镇痛深可靠的瞬时镇静深度、镇痛深度监测度监测药物靶浓度实时监测药物靶浓度实时监测理想理想TCI的实现条件的实现条件药物靶浓度可经过药代动力学药物靶浓度可经过药代动力学模型推算模型推算短效镇静药短效镇静药(丙泊酚丙泊酚)与脑电监测与脑电监测目的有良好相关性目的有良好相关性脑电监测：镇静深度监测脑电监测：镇静深度监测BIS、麻醉深度监测麻醉深度监测ADI等等TCI的现有条件的现有条件没有理想的镇痛监测

4、目的没有理想的镇痛监测目的认识消逝的丙泊酚效应室浓度认识消逝的丙泊酚效应室浓度个体差别有个体差别有6倍倍药物靶浓度与药代动力学模型药物靶浓度与药代动力学模型推算浓度差推算浓度差30%BIS等脑电监测抗干扰性能差等脑电监测抗干扰性能差TCI尚存在的问题尚存在的问题问题导致的后果问题导致的后果麻醉诱导：用异丙酚和阿片类药物，将麻醉诱导：用异丙酚和阿片类药物，将BIS值维持在值维持在5060之间，患者对气管插管有之间，患者对气管插管有认识反响认识反响 4060是人群均值，部分人群是人群均值，部分人群BIS值高于值高于60认识消逝，部分人群认识消逝，部分人群BIS值低于值低于40对疼痛刺对疼痛刺激有内

5、隐记忆。激有内隐记忆。 临床实际中的问题临床实际中的问题在诱导中丙泊酚和瑞芬的靶浓度如何在诱导中丙泊酚和瑞芬的靶浓度如何选择？选择？在麻醉维持中调理丙泊酚靶浓度时有在麻醉维持中调理丙泊酚靶浓度时有没有最低和最高浓度的限制？没有最低和最高浓度的限制？什么时候该调理镇静药什么时候该调理镇静药(丙泊酚丙泊酚)，什，什么时候该调理镇痛药么时候该调理镇痛药(如瑞芬如瑞芬)？麻醉医生如何同时调理丙泊酚和阿片麻醉医生如何同时调理丙泊酚和阿片类药靶浓度以坚持平稳麻醉类药靶浓度以坚持平稳麻醉? 麻醉医生高质量的完成麻麻醉医生高质量的完成麻醉必需会思索醉必需会思索临床运用问题焦点：临床运用问题焦点：丙泊酚丙泊酚T

6、CI靶浓度的个体化靶浓度的个体化麻醉辅助镇痛药物对丙泊酚麻醉辅助镇痛药物对丙泊酚TCI靶浓度有何影响？靶浓度有何影响？Stepwise丙泊酚丙泊酚TCI靶浓度麻靶浓度麻醉诱导醉诱导认识消逝的丙泊酚个体效应室认识消逝的丙泊酚个体效应室浓度浓度OAA/S评分为评分为1分作分作为镇静深度的判别目的，指点为镇静深度的判别目的，指点丙泊酚用量丙泊酚用量 术中丙泊酚术中丙泊酚TCI靶浓度不低于靶浓度不低于该浓度该浓度丙泊酚个体化靶浓度丙泊酚个体化靶浓度OAA/S评分评分个体化目的，不能够发生术中知晓个体化目的，不能够发生术中知晓 对镇静深度可作出迅速判别，浓度定对镇静深度可作出迅速判别，浓度定值的变化标志

7、着个体对丙泊酚药物敏值的变化标志着个体对丙泊酚药物敏感度，经过它可直接调理麻醉深浅和感度，经过它可直接调理麻醉深浅和丙泊酚用量。丙泊酚用量。 简单可行简单可行 丙泊酚个体化靶浓度优点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 丙泊酚每小时调理次数, P = 0.003) Time to extubation was significantly shorter (9.6 +/- 2.1 vs. 15.7 +/- 9.6 min P = 0.

8、011). With FM-TCI, propofol consumption was significantly lower. Eur J Anaesthesiol. 2021 Sep;25(9):741-7镇痛药物与丙泊酚镇痛药物与丙泊酚TCIFuture applications for TCI systemsAmong currently available analgesic drugs, alfentanil and remifentanil are considered to be the most suitable for administration by target co

9、ntrolled infusionAnaesthesia. 1998 Apr;53 Suppl 1:56-60.短效镇痛药物瑞米芬太尼大剂量副作用短效镇痛药物瑞米芬太尼大剂量副作用明显明显大剂量阿片类药物镇痛封顶效应大剂量阿片类药物镇痛封顶效应大剂量瑞米芬太尼麻醉清醒后疼痛反跳大剂量瑞米芬太尼麻醉清醒后疼痛反跳瑞芬太尼瑞芬太尼Anaesthesist. 2021 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 co

10、ncentration 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

11、 propofol used in group R Minerva Anestesiol. 2006 May;72(5):309-19Propofol 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 adequa

12、te 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. 2021 Jan;55(1):110-7Ketamine effect on bispectral index during propofol-remifentanil anaesthesia.RESULTS: 0.2 mg kg(-1) ketamine administered over a 5 min period did not increase t

13、he 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. 2021 Mar;102(3):336-9 Dexmedetomidine on the adjuvant propofol requirement and intraoperative hemodynamics.RESULTS: The pr

14、opofol 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 i

15、n group C (-27.6 13.9%, -21.7 17.1%, and -25.1 14.1%; P 0.05, respectively)Korean J Anesthesiol. 2021 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 fo

16、llowed by 0.5 gkg(-1)h(-1) can definitely decrease the BIS under stepwise propofolPharmacology. 2021;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) an

17、d 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. 2021 Feb;19(2):-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