丙泊酚TCI个性化实施探讨课件

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50－60之间，患者对气管插管有意识反应40－60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。

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?

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镇痛药物与丙泊酚TCIFutureapplicationsforTCIsystemsAmongcurrentlyavailableanalgesicdrugs,alfentanilandremifentanilareconsideredtobethemostsuitableforadministrationbytargetcontrolledinfusionAnaesthesia.1998Apr;53Suppl1:56-60.Anaesthesist.2010Feb;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,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):309-19Ketamineeffectonbispectralindexduringpropofol-remifentanilanaesthesia.RESULTS:

0.2mgkg(-1)ketamineadministeredovera5minperioddidnotincreasetheBISvalueoverthenext15min.0.5mgkg(-1)isassociatedwithanincreaseinthebispectralindex(BIS)valuesthatcanleadtoanoverdoseofhypnoticagents

BrJAnaesth.2009Mar;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.2012Feb;62(2):113-8Dexmedetomidineonbispectralindexunder

stepwisepropofoltarget-controlledinfusion..RESULTS:

loadingdoseofdexmedetomidineof1.0µg•kg(-1),not0.5µg•kg(-1)orless,over10minfollowedby0.5µg•kg(-1)•h(-1)candefinitelydecreasetheBISunderstepwisepropofolPharmacology.2013;91(1-2):1-6ketamine-propofol,fentanyl-propofoland

butorphanol-propofolonLMAinsertion.RESULTS:

totaldoseofpropofolrequiredinGroupPKwas160.37±15.75mg,inGroupPF156.22±17.18mgandinGroupPB140.08±18.97mg.butorphanoltopropofolprovidedabsolutejawrelaxationandexcellentinsertionconditionswithstablehaemodynamicsSideeffectslikecoughing,gagging,lacrimationandlaryngospasmwerelower.JAnaesthesiolClinPharmacol.2011Jan;27(1):74-8.初步结果（靶效浓度）：诱导浓度麻醉维持浓度清醒浓度0.4-0.5