丙泊酚tci個性化實施探討

丙泊酚TCI個性化實施探討華中科技大學附屬協(xié)和醫(yī)院王潔TCI概念及原理概念靶控輸注〔TCI〕是以藥代動力學和藥效動力學原理為根底，以血漿或效應室的藥物濃度為指標，由計算機控制藥物輸注速率的變化，到達按臨床需要調節(jié)麻醉的目的。原理丙泊酚三室模型以血漿或效應室的靶濃度為調控指標而不是以給藥總量或速率為調控指標給藥后計算機屏幕實時顯示目標血藥濃度、效應室濃度、給藥時間和累積劑量等麻醉醫(yī)師可以像轉動揮發(fā)器那樣方便地控制靜脈麻醉，提高靜脈麻醉控制水平TCI原理麻醉醫(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到達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麻醉麻醉誘導迅速術中鎮(zhèn)痛充分，鎮(zhèn)靜適中術后最短的蘇醒時間確保無術中知曉術后鎮(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)條件藥物靶濃度可通過藥代動力學模型推算短效鎮(zhèn)靜藥(丙泊酚)與腦電監(jiān)測指標有良好相關性腦電監(jiān)測：鎮(zhèn)靜深度監(jiān)測BIS、麻醉深度監(jiān)測ADI等TCI的現(xiàn)有條件沒有理想的鎮(zhèn)痛監(jiān)測指標意識消失的丙泊酚效應室濃度個體差異有6倍藥物靶濃度與藥代動力學模型推算濃度差30%BIS等腦電監(jiān)測抗干擾性能差TCI尚存在的問題問題導致的后果麻醉誘導：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響40－60是人群均值，局部人群BIS值高于60意識消失，局部人群BIS值低于40對疼痛刺激有內隱記憶。

臨床實踐中的問題在誘導中丙泊酚和瑞芬的靶濃度如何選擇？在麻醉維持中調節(jié)丙泊酚靶濃度時有沒有最低和最高濃度的限制？什么時候該調節(jié)鎮(zhèn)靜藥(丙泊酚)，什么時候該調節(jié)鎮(zhèn)痛藥(如瑞芬)？麻醉醫(yī)生如何同時調節(jié)丙泊酚和阿片類藥靶濃度以保持平穩(wěn)麻醉?

麻醉醫(yī)生高質量的完成麻醉必須會思考臨床應用問題焦點：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靶濃度麻醉誘導意識消失的丙泊酚個體效應室濃度〔OAA/S評分為1分〕作為鎮(zhèn)靜深度的判斷指標，指導丙泊酚用量術中丙泊酚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，不可能發(fā)生術中知曉對鎮(zhèn)靜深度可作出迅速判斷，濃度定值的變化標志著個體對丙泊酚藥物敏感度，通過它可直接調節(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丙泊酚每小時調節(jié)次數(shù),P=0.003)Timetoextubationwassignificantlyshorter(9.6+/-2.1vs.15.7+/-9.6minP=0.011).WithFM-TCI,propofolconsumptionwassignificantlylower.EurJAnaesthesiol.2021Sep;25(9):741-7鎮(zhèn)痛藥物與丙泊酚TCIFutureapplicationsforTCIsystemsAmongcurrentlyavailableanalgesicdrugs,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)痛封頂效應大劑量瑞米芬太尼麻醉蘇醒后疼痛反跳瑞芬太尼Anaesthesist.2021Feb;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.瑞芬太尼vs芬太尼RESULTS:PatientsingroupRexhibitedafasterrecovery.Theincidenceofnauseaandvomitingwassimilarinthe2groups.TherewasareductionintheamountofpropofolusedingroupRMinervaAnestesiol.2006May;72(5):309-19Propofolandsufentanilforgynecological

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),respectivelyActaAnaesthesiolScand.2021Jan;55(1):110-7Ketamineeffectonbispectralindexduringpropofol-remifentanilanaesthesia.RESULTS:

0.2mgkg(-1)ketamineadministeredovera5minperioddidnotincreasetheBISvalueoverthenext15min.0.5mgkg(-1)isassociatedwithanincreaseinthebispectralindex(BIS)valuesthatcanleadtoanoverdoseofhypnoticagentsBrJAnaesth.2021Mar;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.2021Feb;62(2):113-8Dexmedetomidineonbispectralindexunder

stepwisepropofoltarget-controlledinfusion..RESULTS:

loadingdoseofdexmedetomidineof1.0μg?kg(-1),not0.5μg?kg(-1)orless,over10minfollowedby0.5μg?kg(-1)?h(-1)candefinitelydecreasetheBISunderstepwisepropofolPharmacology.2021;91(1-2):1-6Interactionofpropofolanddexmedetomidine

duringesophagogastroduodenoscopyinchildren.RESULTS:

TheEC50+/-SEvaluesinthecontrolandDEXgroupswere3.7+/-0.4microgxml(-1)and3.5+/-0.2microgxml(-1),respectively.Therewasnosignificantshiftinthepropofolconcentration-responsecurveinthepresenceof1microgxkg(-1)dexmedetomidine.PaediatrAnaesth.2021Feb;19(2):138-44.ketamine-propofol,fentanyl-propofoland

butorphanol-propofolonLMAinsertion.RESULTS:

totaldoseofpropofolrequiredinGroupPKwas160.37±15.75mg,inGroupPF156.22±17.18mgandinGroupPB140.08±18.97mg.butorphanoltopropofolprovidedabsolutejawrelaxationandexcellentinserti