TCI的理論與實踐BalancedAnesthesia

MusclerelaxationLossofConsciousnessAnalgesia全身麻醉吸入維持或靜脈維持椎管內(nèi)麻醉或神經(jīng)阻滯全身麻醉TCI/TIVA的優(yōu)點Controldepthofsedationpre-inductionLesspollutionintheOTandenvironmentNolivertoxicityLessPONVAccesstoairwayunrestrictedbydrugdeliveryCanbecontinuedforpost-opsedationNoincreaseinF-ions;safewithsodalimeMaintainhypoxicvasoconstrictionreflexSafeinpatientsatriskformalignanthyperthermiaTCIsystem:predictsbloodandeffectsitecalculatedconcentrations,similartothewaythatend-tidalmonitormeasuresgasexhaledfromthepatientTCI的發(fā)展:Propofol給藥方式

手動給藥M,40yr,70kg,170cm.Propofolmanual:Effectsiteconcentration>2.8ug/ml2mg/kg1mg/kg1mg/kg1mg/kgPropofol:持續(xù)輸注M,40yr,70kg,170cm.Propofolbolus+infusion:Effectsiteconcentration>2.8ug/ml2mg/kg8mg/kg/hrPropofol:TCIM,40yr,70kg,170cm.PropofolTCI3.5ug/mlPlasmaTCI3.5ug/mlEffectTCI3.5ug/mlTCI成功的理論和物質(zhì)基礎13Pharmacokineticmodelwith3compartments

2132PharmacokineticsetwitheffectsitecompartmentT1/2KeoPharmacokineticAndPharmacodynamicParametersOfPropofolAndTheOpioidsBart-JanLichtenbelt,etal.ClinPharmacokinet2004;43(9):577-593TimeToPeakEffectContextSensitiveHalfTimeTCI泵：計算值和實際值準嗎？TCIsystem:predictsbloodandeffectsitecalculatedconcentrations,similartothewaythatend-tidalmonitormeasuresgasexhaledfromthepatient.PropofolEC50(Lossofconsciousness)

EC50(EC05–EC95)Cp

European5.2(3.1-7.3)

(μg/ml)

Chinese3.83(2.86-4.80)

CeEuropean2.8(1.5-4.1)

(μg/ml)Chinese2.23(1.29-3.18)

BISEuropean

70.9(88.8-52.9)

Chinese57.9(11.28)

AEPIEuropean54.3(68.6-40.0)

KennyGNC.BJA2003;90(2):127XUZhi-peng

etal.

INTERNATIONALJOURNALOFANESTHESIOLOGYANDRESUSCITATION2006Vol.27No.3P.144-148

EC50~EC95ofRemifentanilforTetanicStimuli

-----China2004

EC05EC50EC95Cp（ng/ml）2.22（2.00-2.42）4.09（3.99-4.20）5.96（5.79-6.16）Ce（ng/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)EC50~EC95ofSufentanilforVariousStimuli

Sufentanil（ng/ml）EC05EC50EC95Intubation0.090.200.16－0.240.83Tetanic0.060.130.10－0.150.19Incision0.060.130.11－0.150.20YANGNing,ZUOMingzhang.CHINESEJOURNALOFANESTHESIOLOGY2006Vol.26No.11P.987-979DosePKvariability±70％PDvariability±300-400％Response

麻醉醫(yī)生的臨床觀察和判斷很重要！Propofol10mg/kg/h3-5mcg/mlPropofol1mcg/ml?

麻醉深度監(jiān)測老年患者危重患者大手術

丙泊酚誘導:ASA1-2，PTCI和ETCI都安全

丙泊酚誘導：老年\危重患者選擇PTCI

采用階梯式誘導TCIstartedwithplasmaconcentrationofpropofol1μg/ml,monitorBPandHRWaitforeffect-siteconcentrationIncreasepropofolCp0.5-1.0μg/ml/eachuntilLOC如何做好丙泊酚和瑞芬的雙通道TCI？M,40yr,70kg,170cm.RemifentanilPlasmaTCI:5ng/mlRemifentanilEffectTCI:5ng/mlPropofol/RemifentanilTCI:InductionPropofolPTCI3.5μg/mlRemifentanilPTCI6ng/mlM,40yr,170cm,70kgIntubationPropofol/RemifentanilTCI:MaintenanceM,40yr,170cm,70kgRemifentanilPTCI4-8ng/mlPropofolPTCI2.8-4.0μg/mlInductionIntubationSkinincisionEndofSurgeryPropofol/RemifentanilTCI:EmergenceM,40yr,170cm,70kgRemifentanilPTCI4-8ng/mlPropofolPTCI2.8-4.0μg/mlInductionIntubationSkinincisionEndofSurgeryAnalgesictransitionPropofolandRemifentanilinTCIRemifentanilPTCIInduction:4-8ng/mlMaintenance:4-8ng/mlEmergence:Analgesictransition鎮(zhèn)痛轉(zhuǎn)換和多模式鎮(zhèn)痛Minorsurgery:Localinfiltration,NASIDSModeratesurgery:Localinfiltration,Epidural,NASIDS,Morphine,Sufentanil(0.1ug/kg)Majorsurgery:Localinfiltration,Epidural,NASIDS,Morphine,Sufentanil(0.1ug/kg)如何做好丙泊酚和舒芬的雙通道TCI？

M,40yr,70kg,170cm.SufentanilPlasmaTCI:0.3ng/mlSufentanilEffectTCI:0.3ng/mlPropofolwithSufentanil/RemifentanilTCIManagement

---TCIInduction:Timetopeakeffect

050100%maxCe4080120160PAM(mmHG)0481216intubationsufentanilpropofol05010004812164080120160%maxCeintubationsufentanilpropofoltime(mn)time(mn)PropofolwithSufentanilinTCI:Induction:TimetopeakeffectOptimisationOfInductionTiming050100time(min)%maxCE4080120160PAM(mmHg)0481216intubationsufentanilpropofol

SufentanilinTCI:InductionM,40yr,170cm,70kgM,40yr,170cm,70kgSufentanilETCI5PropofolPTCI1.5ug/ml3.5ug/ml0.3ng/mlIntubationSufentanilinTCI:MaintenanceandEmergenceM,40yr,170cm,70kgSufentanilETCIPropofolPTCIInductionIntubatingSkinincisionEndofSurgery0.08ng/ml1.5ug/ml3.5ug/ml

SufentanilinTCIETCIInduction:0.25-0.3ng/ml;0.35-0.5ng/ml(Cardiacsurgery)Maintenance:0.15-0.25ng/mlEmergence:Sufentanil0.1-0.06ng/mlNASIDSLocalinfiltration,Epidural,NeverblockPostoperative:PCAMorphine:Bolus1mg,Lockouttime5-6min,Max10-12mg/hr,Basalinfusion0.5-0.25mg/hTCI的注意事項：確保TCI泵正常工作藥物濃度設置正確確保藥物盡快進入患者體內(nèi)密切監(jiān)測和觀察對老年\危重\大手術患者，推薦使用麻醉深度監(jiān)測儀，如BIS監(jiān)測Input：BodyweightAgeGenderHeight

Drugs：Propofol(Cp)＋Remifentanil(Cp)

Propofol(Cp)+Sufentanil(Ce)

AnestheticssedativesopioidspropofolsufentanilremifentanilMarshSchniderGeptsMintoSufentanilandRemifentanilinTCIPropofol+RemifentanilPropofol+SufentanilInduction

3.0-3.5g/ml4-8ng/ml

3-4g/ml0.25-0.3

ng/mlMaintenance2.5-3.0g/ml4.0-8.0ng/ml3.0-4.0

g/ml0.14-0.25

ng/mlEmergenceAnalgesictransition00.06-0.08ng/mlOurPractice—IVLine

監(jiān)測麻醉深度TCI-IVA

Inhalationalanesthesia

BP、HRBP、HR

MovementMovement

PredictedCpandCeMeasuredET-inhalatonalagents

BISBIS+=竟安?新一代丙泊酚制劑降低注射痛降低血脂減少肝臟負荷Agilia