丙泊酚tci個(gè)性化實(shí)施探討課件

1、丙泊酚丙泊酚TCI個(gè)性化實(shí)施探討個(gè)性化實(shí)施探討華中科技大學(xué)附屬協(xié)和醫(yī)院王 潔丙泊酚tci個(gè)性化實(shí)施探討TCI概念及原理概念及原理概念概念 靶控輸注（靶控輸注（TCI）是以藥代動(dòng)力）是以藥代動(dòng)力學(xué)和藥效動(dòng)力學(xué)原理為基礎(chǔ)，以血漿學(xué)和藥效動(dòng)力學(xué)原理為基礎(chǔ)，以血漿或效應(yīng)室的藥物濃度為指標(biāo)，由計(jì)算或效應(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，達(dá)到按機(jī)控制藥物輸注速率的變化，達(dá)到按臨床需要調(diào)節(jié)麻醉的目的。臨床需要調(diào)節(jié)麻醉的目的。 丙泊酚tci個(gè)性化實(shí)施探討原理原理丙泊酚三室模型丙泊酚三室模型丙泊酚tci個(gè)性化實(shí)施探討l以血漿或效應(yīng)室的靶濃度為調(diào)控指標(biāo)而不是以給以血漿或效應(yīng)室的靶濃度為調(diào)控指標(biāo)而

2、不是以給藥總量或速率為調(diào)控指標(biāo)藥總量或速率為調(diào)控指標(biāo)l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)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)間和累積劑量等室濃度、給藥時(shí)間和累積劑量等l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麻醉，提高靜脈麻醉控制水平 TCI原理原理丙泊酚tci個(gè)性化實(shí)施探討麻醉醫(yī)生從計(jì)算藥物劑量或輸注麻醉醫(yī)生從計(jì)算藥物劑量或輸注速度中解脫出來速度中解脫出來血藥濃度迅速達(dá)到所需要的濃度血藥濃度迅速達(dá)到所需要的濃度或藥效或藥效計(jì)算機(jī)控制維持穩(wěn)定的血藥濃度。計(jì)算機(jī)控制維持穩(wěn)定的血藥濃度。 TCI的優(yōu)勢(shì)

3、的優(yōu)勢(shì)丙泊酚tci個(gè)性化實(shí)施探討理想的理想的TCI麻醉麻醉u麻醉誘導(dǎo)迅速麻醉誘導(dǎo)迅速u術(shù)中鎮(zhèn)痛充分，鎮(zhèn)靜適中術(shù)中鎮(zhèn)痛充分，鎮(zhèn)靜適中u術(shù)后最短的蘇醒時(shí)間術(shù)后最短的蘇醒時(shí)間u確保無術(shù)中知曉確保無術(shù)中知曉u(píng)術(shù)后鎮(zhèn)痛充分術(shù)后鎮(zhèn)痛充分u全程完善的個(gè)體化給藥全程完善的個(gè)體化給藥丙泊酚tci個(gè)性化實(shí)施探討理想的超短效理想的超短效鎮(zhèn)靜藥鎮(zhèn)靜藥和鎮(zhèn)痛藥和鎮(zhèn)痛藥可靠的瞬時(shí)鎮(zhèn)靜深度、鎮(zhèn)痛深可靠的瞬時(shí)鎮(zhèn)靜深度、鎮(zhèn)痛深度監(jiān)測度監(jiān)測藥物靶濃度實(shí)時(shí)監(jiān)測藥物靶濃度實(shí)時(shí)監(jiān)測理想理想TCI的實(shí)現(xiàn)條件的實(shí)現(xiàn)條件丙泊酚tci個(gè)性化實(shí)施探討藥物靶濃度可通過藥代動(dòng)力學(xué)藥物靶濃度可通過藥代動(dòng)力學(xué)模型推算模型推算短效短效鎮(zhèn)靜藥鎮(zhèn)靜藥(丙泊酚

4、丙泊酚)與腦電監(jiān)測與腦電監(jiān)測指標(biāo)有良好相關(guān)性指標(biāo)有良好相關(guān)性腦電監(jiān)測：鎮(zhèn)靜深度監(jiān)測腦電監(jiān)測：鎮(zhèn)靜深度監(jiān)測BIS、麻醉深度監(jiān)測麻醉深度監(jiān)測ADI等等TCI的現(xiàn)有條件的現(xiàn)有條件丙泊酚tci個(gè)性化實(shí)施探討沒有理想的鎮(zhèn)痛監(jiān)測指標(biāo)沒有理想的鎮(zhèn)痛監(jiān)測指標(biāo)意識(shí)消失的丙泊酚效應(yīng)室濃度意識(shí)消失的丙泊酚效應(yīng)室濃度個(gè)體差異有個(gè)體差異有6倍倍藥物靶濃度與藥代動(dòng)力學(xué)模型藥物靶濃度與藥代動(dòng)力學(xué)模型推算濃度差推算濃度差30%BIS等腦電監(jiān)測抗干擾性能差等腦電監(jiān)測抗干擾性能差TCI尚存在的問題尚存在的問題丙泊酚tci個(gè)性化實(shí)施探討問題導(dǎo)致的后果問題導(dǎo)致的后果麻醉誘導(dǎo)麻醉誘導(dǎo)：用異丙酚和阿片類藥物，將：用異丙酚和阿片類藥物，將

5、BIS值維持在值維持在5060之間，患者對(duì)氣管插管有之間，患者對(duì)氣管插管有意識(shí)反應(yīng)意識(shí)反應(yīng) 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意識(shí)消失，部分人群意識(shí)消失，部分人群BIS值低于值低于40對(duì)對(duì)疼痛刺疼痛刺激激有內(nèi)隱記憶。有內(nèi)隱記憶。 臨床實(shí)踐中的問題臨床實(shí)踐中的問題在誘導(dǎo)中丙泊酚和瑞芬的靶濃度如何在誘導(dǎo)中丙泊酚和瑞芬的靶濃度如何選擇？選擇？在麻醉維持中調(diào)節(jié)丙泊酚靶濃度時(shí)有在麻醉維持中調(diào)節(jié)丙泊酚靶濃度時(shí)有沒有最低和最高濃度的限制？沒有最低和最高濃度的限制？什么時(shí)候該調(diào)節(jié)鎮(zhèn)靜藥什么時(shí)候該調(diào)節(jié)鎮(zhèn)靜藥(丙泊酚丙泊酚)，什，什么時(shí)候該調(diào)節(jié)鎮(zhèn)痛藥么時(shí)候該調(diào)節(jié)鎮(zhèn)痛藥(如瑞芬如

6、瑞芬)？麻醉醫(yī)生如何同時(shí)調(diào)節(jié)丙泊酚和阿片麻醉醫(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)量的完成麻麻醉醫(yī)生高質(zhì)量的完成麻醉必須會(huì)思考醉必須會(huì)思考丙泊酚tci個(gè)性化實(shí)施探討臨床應(yīng)用問題焦點(diǎn)：臨床應(yīng)用問題焦點(diǎn)：丙泊酚丙泊酚TCI靶濃度的個(gè)體化靶濃度的個(gè)體化麻醉輔助鎮(zhèn)痛藥物對(duì)丙泊酚麻醉輔助鎮(zhèn)痛藥物對(duì)丙泊酚TCI靶靶濃度有何影響？濃度有何影響？Stepwise丙泊酚丙泊酚TCI靶濃度麻醉誘導(dǎo)靶濃度麻醉誘導(dǎo)意識(shí)消失的丙泊酚個(gè)體效應(yīng)室濃度意識(shí)消失的丙泊酚個(gè)體效應(yīng)室濃度（OAA/S評(píng)分為評(píng)分為1分）作為鎮(zhèn)靜深度的判分）作為鎮(zhèn)靜深度的判斷指標(biāo)，指導(dǎo)丙泊酚用量斷指

7、標(biāo)，指導(dǎo)丙泊酚用量 術(shù)中丙泊酚術(shù)中丙泊酚TCI靶濃度不低于該濃度靶濃度不低于該濃度丙泊酚個(gè)體化靶濃度丙泊酚個(gè)體化靶濃度丙泊酚tci個(gè)性化實(shí)施探討OAA/S評(píng)分評(píng)分個(gè)體化指標(biāo)，不可能發(fā)生術(shù)中知曉個(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)麻醉深淺和感度，通過它可直接調(diào)節(jié)麻醉深淺和丙泊酚用量。丙泊酚用量。 簡單可行簡單可行 丙泊酚個(gè)體化靶濃度優(yōu)點(diǎn)丙泊酚個(gè)體化靶濃度優(yōu)點(diǎn)丙泊酚tci個(gè)性化實(shí)施探討個(gè)體化丙泊酚靶濃度麻醉 Anaesthetic stability s

8、ignificantly improved (0.43 +/- 0.44 vs. 1.31 +/- 0.78 丙泊酚每小時(shí)調(diào)節(jié)次數(shù), 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丙泊酚tci個(gè)性化實(shí)施探討鎮(zhèn)痛藥物與丙泊酚鎮(zhèn)痛藥物與丙泊酚TCI

9、丙泊酚tci個(gè)性化實(shí)施探討Future applications for TCI systemsAmong currently available analgesic drugs, alfentanil and remifentanil are considered to be the most suitable for administration by target controlled infusionAnaesthesia. 1998 Apr;53 Suppl 1:56-60.丙泊酚tci個(gè)性化實(shí)施探討短效鎮(zhèn)痛藥物瑞米芬太尼大劑量副短效鎮(zhèn)痛藥物瑞米芬太尼大劑量副作用明顯作用明顯大劑量阿

10、片類藥物鎮(zhèn)痛封頂效應(yīng)大劑量阿片類藥物鎮(zhèn)痛封頂效應(yīng)1.大劑量瑞米芬太尼麻醉蘇醒后疼痛大劑量瑞米芬太尼麻醉蘇醒后疼痛反跳反跳瑞芬太尼瑞芬太尼Anaesthesist. 2010 Feb;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)u 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 uWomen had a hi

11、gher propofol consumption than men. 丙泊酚tci個(gè)性化實(shí)施探討瑞芬太尼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丙泊酚tci個(gè)性化實(shí)施探討P

12、ropofol 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.

13、0 microg/ml), respectively Acta Anaesthesiol Scand. 2011 Jan;55(1):110-7丙泊酚tci個(gè)性化實(shí)施探討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 asso

14、ciated 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丙泊酚tci個(gè)性化實(shí)施探討 Dexmedetomidine on the adjuvant propofol requirement and intraoperative hemodynamics.RESULTS: The propofol infusion rate was significantly low

15、er 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 -

16、25.1 14.1%; P 0.05, respectively)Korean J Anesthesiol. 2012 Feb;62(2):113-8丙泊酚tci個(gè)性化實(shí)施探討 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) ca

17、n definitely decrease the BIS under stepwise propofolPharmacology. 2013;91(1-2):1-6丙泊酚tci個(gè)性化實(shí)施探討 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 mi

18、crog 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.丙泊酚tci個(gè)性化實(shí)施探討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 e