丙泊酚TCI個性化實施探討TCI概念及原理概念

靶控輸注（TCI）是以藥代動力學(xué)和藥效動力學(xué)原理為基礎(chǔ)，以血漿或效應(yīng)室的藥物濃度為指標(biāo)，由計算機控制藥物輸注速率的變化，達到按臨床需要調(diào)節(jié)麻醉的目的。

原理丙泊酚三室模型麻醉醫(yī)生從計算藥物劑量或輸注速度中解脫出來血藥濃度迅速達到所需要的濃度或藥效計算機控制維持穩(wěn)定的血藥濃度。TCI的優(yōu)勢理想的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)后最短的蘇醒時間確保無術(shù)中知曉術(shù)后鎮(zhèn)痛充分全程完善的個體化給藥理想的超短效鎮(zhèn)靜藥和鎮(zhèn)痛藥可靠的瞬時鎮(zhèn)靜深度、鎮(zhèn)痛深度監(jiān)測藥物靶濃度實時監(jiān)測理想TCI的實現(xiàn)條件沒有理想的鎮(zhèn)痛監(jiān)測指標(biāo)意識消失的丙泊酚效應(yīng)室濃度個體差異有6倍藥物靶濃度與藥代動力學(xué)模型推算濃度差30%BIS等腦電監(jiān)測抗干擾性能差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，患者對氣管插管有意識反應(yīng)40－60是人群均值，部分人群BIS值高于60意識消失，部分人群BIS值低于40對疼痛刺激有內(nèi)隱記憶。

臨床實踐中的問題在誘導(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)丙泊酚靶濃度時有沒有最低和最高濃度的限制？麻醉醫(yī)生高質(zhì)量的完成麻醉必須會思考臨床應(yīng)用問題焦點：丙泊酚TCI靶濃度的個體化麻醉輔助鎮(zhèn)痛藥物對丙泊酚TCI靶濃度有何影響？Stepwise丙泊酚TCI靶濃度麻醉誘導(dǎo)意識消失的丙泊酚個體效應(yīng)室濃度（OAA/S評分為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體化靶濃度OAA/S評分個體化指標(biāo)，不可能發(fā)生術(shù)中知曉對鎮(zhèn)靜深度可作出迅速判斷，濃度定值的變化標(biāo)志著個體對丙泊酚藥物敏感度，通過它可直接調(diào)節(jié)麻醉深淺和丙泊酚用量。簡單可行丙泊酚個體化靶濃度優(yōu)點個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.2008Sep;25(9):741-7FutureapplicationsforTCIsystemsAmongcurrentlyavailableanalgesicdrugs,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.2010Feb;59(2):126-34.不同瑞芬濃度對丙泊酚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.Propofolandsufentanilforgynecological

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),respectively

ActaAnaesthesiolScand.2011Jan;55(1):110-7Ketamineeffectonbispectralindexduringpropofol-remifentanilanaesthesia.RESULTS:

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

BrJAnaesth.2009Mar;102(3):336-9Interactionofpropofolanddexmedetomidine

duringesophagogastroduodenoscopyinchildren.RESULTS:

TheEC50+/-SEvaluesinthecontrolandDEXgroupswere3.7+/-0.4microgxml(-1)and3.5+/-0.2microgxml(-1),respectively.Therewasnosignificantshiftinthepropofolconcentration-responsecurveinthepresenceof1microgxkg(-1)dexmedetomidine.PaediatrAnaesth.2009Feb;19(2):138-44.ketamine-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.初步結(jié)果（靶效濃度）：誘導(dǎo)濃度麻醉維持濃度清醒濃度0.4-0.5