个性化全凭静脉麻醉的实施和展望课件.ppt

1、Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLATCI是什么？TCI TCI 是一种输注系统，容许麻醉医生按不同需要是一种输注系统，容许

2、麻醉医生按不同需要选择所要求的靶血药浓度需要选择所要求的靶血选择所要求的靶血药浓度需要选择所要求的靶血药浓度药浓度 通过通过调整靶浓度来控制麻醉的深浅调整靶浓度来通过通过调整靶浓度来控制麻醉的深浅调整靶浓度来控制麻醉的深浅控制麻醉的深浅 TCI TCI 不是完全的计算机控制麻醉不是完全的计算机控制麻醉不是完全的计算机控制麻醉不是完全的计算机控制麻醉Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of

3、PLA为什么使用TCI基本出发点基本出发点 使使静脉麻醉深浅静脉麻醉深浅的调节能像吸入麻醉利用标准挥的调节能像吸入麻醉利用标准挥发罐调节那样简单发罐调节那样简单 Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLATCI的优点-实践方面使用方便使用方便 操作简单操作简单 能持续显示所计算的血药浓度能持续显示所计算的血药浓度 对中断输注有补偿作用对中断输注有补偿作用 避免了对输注速率的复杂的计算

4、避免了对输注速率的复杂的计算Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLATCI的优点理论方面麻醉的控制麻醉的控制 麻醉深度的良好控制麻醉深度的良好控制 改善了对循环，呼吸功能的影响改善了对循环，呼吸功能的影响 诱导期的反应可作为预设麻醉维持的参考，比手诱导期的反应可作为预设麻醉维持的参考，比手控更精确控更精确Great physician with great spirits Grea

5、t love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA静脉麻醉使用历史静脉麻醉有百年历史静脉麻醉有百年历史根据经验调整药物根据经验调整药物丙泊酚在丙泊酚在 1986 1986 使用速度使用速度 612mg/kg/h612mg/kg/h10-8-6 10-8-6 方案出现（相当方案出现（相当于于TCI TCI 浓度浓度3434ug/mlug/ml）2019Diprifusor TCI2019Diprifusor TCI systemsystemGreat physician

6、 with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA1980s2019“Diprifusor”TCI系系统统上市上市靶控输注（靶控输注（Target-controlled infusion Target-controlled infusion）以药物代谢动力学和药效动力学原理为基础，通过以药物代谢动力学和药效动力学原理为基础，通过调节调节目标或目标或者靶位（血浆或效应室）的药物浓度来控制或者维持适当的麻醉者靶位（血浆或效应

7、室）的药物浓度来控制或者维持适当的麻醉深度，以满足临床麻醉的一种静脉给药方式。深度，以满足临床麻醉的一种静脉给药方式。得普利麻上市得普利麻上市“10-8-6”“10-8-6”给药给药方案方案Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医

8、院Wuhan General Hospital of GuangZhou Command of PLA 有比较才有差别 II级III级I 级级TCI重复静脉重复静脉 输注输注持续恒速持续恒速静脉输注静脉输注靶控输注靶控输注 Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA单次和重复静脉注射Great physician with great spirits Great love in gr

9、eat faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA单次+持续静脉给药Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA靶控输注Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuha

10、n General Hospital of GuangZhou Command of PLA三室药代动力学模型FatMuscles&Connective TissueInfusionEliminationV2V3VcentralK12K13K21K31K10Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 中央室（中央室（V1V1）代表血液或血浆；）代表血液或血浆；第二室第二室(V2)(V

11、2)代表高灌注组织；代表高灌注组织；第三室第三室(V3)(V3)代表低灌注组织。代表低灌注组织。血液并非药物的作用部位，药物的作用部位称为血液并非药物的作用部位，药物的作用部位称为“效应室效应室”Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA t t1/2ke01/2ke0是血浆和效应室药物浓度达到平是血浆和效应室药物浓度达到平衡的时间衡的时间 t1/2ke0t1/2ke0越小，则药物起

12、效越快越小，则药物起效越快 瑞芬太尼瑞芬太尼 1.3min 1.3min 异丙酚异丙酚 2.4 min 2.4 min 咪唑安定咪唑安定 4min 4min 芬太尼芬太尼 4.7min 4.7min Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 停止持续输注药物后，中央室药物浓度下降停止持续输注药物后，中央室药物浓度下降50%50%所需的时间所需的时间 随药物输注持续时间的延长而增大随

13、药物输注持续时间的延长而增大 预测静脉麻醉后恢复时间预测静脉麻醉后恢复时间Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA药物选择（药物选择（T1/2keoT1/2keo和和T1/2csT1/2cs都小的药物都小的药物-丙泊酚、丙泊酚、瑞芬太尼）瑞芬太尼）Great physician with great spirits Great love in great faith广州军区武汉总医

14、院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLATCI药物的选择 起效时间和消退时间均很短的药物最适合用于靶起效时间和消退时间均很短的药物最适合用于靶控输注，尽量选择控输注，尽量选择T1/2KT1/2Ke0e0和和T1/2csT1/2cs小的药物小的药物 目前临床使用的麻醉药物中，以丙泊酚和瑞芬太目前临床使用的麻醉药物中，以丙泊酚和瑞芬太尼的药代动力学特性最为适合尼的药代动力学特性最为适合 肌松药靶控颇有争议，而以肌松监测反馈调控输肌松药靶控颇有争议，而以肌松监测反馈调控输注模式为佳注模式为佳Great physician

15、 with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAAnesthetistSet targetpump control algorithmpharmacokinetic simulationpredicted concentrationdifferent modelsCpCekataria/paedfusorMarsh SchnidermintoGreat physician with great spirits Grea

16、t love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA推荐浓度推荐浓度术前药术前药无 4-8ug/ml有 2-6ug/ml年龄年龄20岁后，每十岁靶浓度下降0.24ug/ml靶浓度设定靶浓度设定3-6ug/ml，辅助镇痛药，辅助镇痛药大手术 3-6小手术 1.5-4.5不同人群不同人群ASA-3.5-5.3心脏病或ASA-2.8-3.4 年龄55岁 3.5诱导诱导维持维持实施实施TCI就是根据推荐参数就是根据推荐参数单纯进行输入吗？单纯进行输入吗？Great physic

17、ian with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA影响TCI的因素用药量Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAplasma target controlledeffect site target co

18、ntrolledGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLACp vs CeCp vs CeDiagram CeCp 效应室靶控效应室靶控（Ce）血浆靶控血浆靶控（Cp）Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of Guang

19、Zhou Command of PLAlag in effect sitelag in effect sitesuitable for the old and have a suitable for the old and have a stable circulationstable circulationsuitable for the small T1/2keo suitable for the small T1/2keo drugdruga quickly balance and inductiona quickly balance and inductionmore loading

20、dosemore loading dosecirculation fluctuationcirculation fluctuationsuitable to the hight T1/2keosuitable to the hight T1/2keo and stronge people and stronge peopleplasma target controlled effect site target controlledGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan

21、 General Hospital of GuangZhou Command of PLA不同药代动力学模型麻醉药麻醉药镇静镇痛丙泊酚丙泊酚SchniderKatariaMarsh瑞芬太尼瑞芬太尼舒芬太尼舒芬太尼MintoGepts肌松药罗库溴铵罗库溴铵SzenohradszkyGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAMarshMarsh和和SchnilderSchnilder两种

22、模型的比较两种模型的比较Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 同样体重同样体重/年龄年龄/身高患者，设定同等身高患者，设定同等浓度浓度丙泊酚丙泊酚 Marsh =Schinider Marsh =Schinider用药量用药量Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医

23、院Wuhan General Hospital of GuangZhou Command of PLA在极轻体重患者，在极轻体重患者，V1造成的初始剂量差距减小，但是造成的初始剂量差距减小，但是Schnider 模型模型预计血浆浓度下降更快。预计血浆浓度下降更快。在中国人群中低体重者比例很高。因此我们在中国人群中低体重者比例很高。因此我们发现发现Schnider model比比March model用量似乎更大。用量似乎更大。Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan G

24、eneral Hospital of GuangZhou Command of PLA Changes in the sedation score and Bispectral index Changes in the sedation score and Bispectral index correlated better with the Marsh than with the correlated better with the Marsh than with the Schnider effect site prediction in both study groupsSchnider

25、 effect site prediction in both study groups.（两组病例中，（两组病例中，MarshMarsh模型预测的效应室浓度与镇静评分和脑模型预测的效应室浓度与镇静评分和脑电双频指数变化的相关性优于电双频指数变化的相关性优于SchnilderSchnilder模型以效应室浓度预模型以效应室浓度预测的结果。）测的结果。）Anaesthesia,2019,62,pages 661666Anaesthesia,2019,62,pages 661666Great physician with great spirits Great love in great fait

26、h广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA同一模式下不同个体所需靶浓度是否相同？同一模式下不同个体所需靶浓度是否相同？如何观察与缩小不同靶控部位，不同模式，不同个体所造如何观察与缩小不同靶控部位，不同模式，不同个体所造成的差异？成的差异？Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA受试者之间

27、，意识消失时的最小受试者之间，意识消失时的最小(0.7ug/ml)和最大和最大(4.8ug/ml)效应室浓度效应室浓度存在大约存在大约6倍的个体差异，意识恢复时亦是如此倍的个体差异，意识恢复时亦是如此换言之，给予标准剂量丙泊酚的患者有可能镇静不足或者过度镇静换言之，给予标准剂量丙泊酚的患者有可能镇静不足或者过度镇静Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physicia

28、n with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA本研究提示，丙泊酚用药时应逐步给药直至意识消失，取代以往根据人群平均水平定量给予的方法。Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physicia

29、n with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA个体化医学个体化医学 因人而异，给药方案个体化因人而异，给药方案个体化 滴定法（滴定法（TitrationTitration）锁定患者意识消失时刻效应室浓度（锁定患者意识消失时刻效应室浓度（LOCLOC）Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan

30、General Hospital of GuangZhou Command of PLA滴定法（滴定法（TitrationTitration）Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 在麻醉诱导阶段，升阶梯滴定在麻醉诱导阶段，升阶梯滴定 患者睫毛反射消失、对口头指令和推肩膀患者睫毛反射消失、对口头指令和推肩膀无反应无反应(LOCLOC),),也就是个体最低有效剂量也就是个体最低有效

31、剂量 术中维持此浓度或略增术中维持此浓度或略增 避免术中知晓避免术中知晓 减少全麻药用量减少全麻药用量 预知苏醒时间预知苏醒时间Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA实施实施TCITCI可预知患者苏醒时间可预知患者苏醒时间Average difference betweenAverage difference between individualindividual effect

32、-site concentrations ateffect-site concentrations at return return and loss of consciousness wasand loss of consciousness was only only 0.17 0.17 0.32g/ml0.32g/mlGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA确保LOC的准确性

33、给予镇静剂、镇痛剂、肌松药等，这都能影响到异丙酚诱给予镇静剂、镇痛剂、肌松药等，这都能影响到异丙酚诱导时所需要的靶浓度。输注异丙酚前导时所需要的靶浓度。输注异丙酚前5min5min给予咪唑安定给予咪唑安定0.03mg/kg,0.03mg/kg,能够使病人意识消失所需靶浓度降低能够使病人意识消失所需靶浓度降低55%;55%;给给予芬太尼予芬太尼2ug/kg2ug/kg，使其降低，使其降低19%19%。血浆浓度。血浆浓度3ng/ml 3ng/ml 的芬太的芬太尼可降低尼可降低40%40%异丙酚的异丙酚的cp50cp50值值 Anesthesiology Great physician with g

34、reat spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 术前针不给咪唑安定和芬太尼；术前针不给咪唑安定和芬太尼；诱导时序贯给予：丙泊酚诱导时序贯给予：丙泊酚 -肌松药肌松药 -镇痛药。镇痛药。Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of

35、PLA the best option is to maintain propofol at the lower levels,and the adaptation of remifentanil to surgical needs.Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 意识消失时的效应室浓度（意识消失时的效应室浓度（LOCLOC）可以用来作为管）可以用来作为管理麻醉药物使用的

36、指导理麻醉药物使用的指导,术中维持这一浓度，或者术中维持这一浓度，或者略微增加略微增加 术中根据手术刺激（疼痛刺激）来调节瑞芬太尼术中根据手术刺激（疼痛刺激）来调节瑞芬太尼速度，这样可以减少丙泊酚用量，在手术结束停速度，这样可以减少丙泊酚用量，在手术结束停药后患者就能迅速清醒药后患者就能迅速清醒Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLATCITCI静脉麻醉时的最佳效应室浓度静脉麻醉时

37、的最佳效应室浓度输注时间Prop/fenProp/alfProp/sufProp/remi15mincoptimal4.51/1.894.18/1314.52/0.232.81/7.61苏醒时min13.312.313.37.560minCoptimal4.48/1.644.49/1144.14/1.202.70/7.71苏醒时min20.92018.89.45hcoptimal5.3/1.294.4/1184.18/0.22.63/8.01苏醒时min41.331.228.510.8Great physician with great spirits Great love in great

38、faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAEC05EC50EC95血浆浓度2.224.095.96效应室浓度1.533.335.89瑞芬太尼的靶控输注对疼痛刺激无反应时的瑞芬太尼的浓度（对疼痛刺激无反应时的瑞芬太尼的浓度（ng/mlng/ml）Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of P

39、LA 瑞芬太尼靶控输注推荐剂量瑞芬太尼靶控输注推荐剂量 2-8ng/ml抑制切皮等伤害刺激的抑制切皮等伤害刺激的Cp50是是4-6ng/mlGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA For age,elderly patients loose consciousness at propofol effect site concentrations that are about 30

40、%lower than in young adults patients.Anaesthesiology,Pharmacology,Intensive Care,Geneva University Hospitals,Geneva,Switzerland特殊人群特殊人群TCITCIGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA患者因急性腹膜炎急诊入室患者因急性腹膜炎急诊入室既往高血压，心

41、功能不全，一般情况差既往高血压，心功能不全，一般情况差心电图：窦性心动过速（心电图：窦性心动过速（139139次次/分）分）心脏彩超示：心脏彩超示：EF40%EF40%病例一病例一Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA入室时入室时NIBPNIBP：133/76 HR:97133/76 HR:97次次/分分 SPO2:97%SPO2:97%麻醉前麻醉前NIBP:111/73 HR:

42、97 SPO2:96%NIBP:111/73 HR:97 SPO2:96%插管前插管前NIBP:101/63 HR:101 SPO2:100%NIBP:101/63 HR:101 SPO2:100%插管后插管后NIBP:112/72 HR:92 SPO2:100%NIBP:112/72 HR:92 SPO2:100%Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 入室前无术前用药入室前无

43、术前用药 入室后开放上肢静脉，静滴乐加入室后开放上肢静脉，静滴乐加 丙泊酚选择丙泊酚选择marshmarsh模式行模式行TCITCIGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA麻醉诱导（三部曲）麻醉诱导（三部曲）丙泊酚丙泊酚 TCI TCI 1 1ug/ml-ug/ml-1 1.5ug/ml.5ug/ml -2 2ug/ml-ug/ml-2 2.5ug/ml.5ug/ml -3 3ug

44、/mlug/ml (滴定出此患者的滴定出此患者的CeCe为为2.3ug/ml2.3ug/ml）阿曲库铵阿曲库铵 15mg15mg 舒芬太尼舒芬太尼 20ug20ugGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA Induction Cp2.0ug/ml sulfentanyAtracuricum 3min intubationCp1.0ug/mlCp1.5ug/mlCp2.5ug/mlC

45、p3.0ug/ml sleepreduce the Ce1.0ug/ml wake uplose consciousness and lash reflexajust the remifentanil plasma controlledCe 2.3reduce the Cp to 2.3CpGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great

46、 spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广

47、州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA 患者手术时间为患者手术时间为3h20min3h20min 患者手术结束至清醒为患者手术结束至清醒为5min(5min(结束前结束前10min10min停药停药)手术结束后手术结束后15min15min拔管安返病房拔管安返病房

48、拔管后及拔管后拔管后及拔管后1.5D1.5D询问患者有无术中记忆询问患者有无术中记忆Great physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLA病例二病例二患者男，患者男，5454岁，岁，44Kg44Kg，160cm160cm 心梗史心梗史 心电图：部分导联心电图：部分导联T T波改变波改变 下壁异常下壁异常Q Q波波 心脏彩超：心脏彩超：EDV:134mLEDV:134mL，EF:33%EF:33%

49、，SV:44mLSV:44mLGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great sp

50、irits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区武汉总医院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith广州军区武汉总医院广州军区