新版TCI的临床应用.ppt

文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,什么是理想的麻醉状态？,意识消失,(Loss of conscicusness),镇痛,（Analgesia）,肌松,(Muscle relaxation),平衡麻醉,吸入麻醉,全凭静脉麻醉,静吸复合麻醉,术中知晓越来越受到关注,较好的静脉麻醉药和静脉输注技术是减低术中知晓的有效措施。,文献报道术中知晓的发生率越来越低,TCI,药,代动力学,基础,Conc(t)=Ae,-a t,+B e,-b t,+C e,-,t,V1,V3,V2,k,12,k,21,k,13,k,31,k,10,0,0.5,1,-5,0,5,10,15,20,时,间,(min),浓,度,测,量值,单,次给药,BET-,输,注,方案,Time(min),0,20,40,60,80,100,120,-30,0,30,60,90,120,150,180,210,240,Infusion rate(mg/min),0,1,2,3,4,5,6,Concentration(g/mL),Bolus,decreasing infusion,constant infusion,Propofol,Target=4 g/mL,Bolus,Elimination,Transfer,0,2,4,6,8,10,-10,0,10,20,30,40,50,60,Time(min),Propofol(g/mL),Bolus:2 mg/kg,Bolus+Infusion,Infusion:10 mg/kg/h,剂,量,浓度调整,:,手动方式,vs.TCI,0,1,2,3,4,5,6,0,20,40,60,80,100,120,靶,浓度,:3 g/ml,单,次给药,:70 mg,输,注速率,:10-9-8 mg/min,输,注速率,:10 mg/min,靶,浓度,:4 g/ml,输,注速率,:8(6)mg/min,靶,浓度,:3 g/ml,时,间,min,浓度,g/ml,TCI:,输,注速率,异丙酚,血浆,治疗浓度水平,轻,度镇静,:0.5-1.0 g/ml,深,度,镇静,:1.0-1.5 g/ml,小,手术,+,阿片药,:2.0-4.0 g/ml,大,手术,+阿,片药,:3.0-6.0 g/ml,苏,醒,:1.0-1.5 g/ml(,阿,片药的浓度水平,l!),苏,醒时间,0,1,2,3,4,5,6,0,20,40,60,80,100,120,时,间,min,浓,度,g/ml,24 min,10 min,5 min,苏,醒,浓度,1.5 g/ml,12 min,苏,醒浓度,1.0 g/ml,0,2,4,6,8,10,12,-10,0,10,20,30,Time(min),EEG MEF(Hz),0,5,10,15,20,Propofol(g/mL),EEG,Propofol,单,次给药,:140 mg,血浆浓度,&,效应室,浓度,0,1,2,3,4,0,5,10,15,20,time(min),Conc.(g/mL),0,50,100,150,200,Inf.rate(mg/min),血,浆浓度,效,应室浓度,输,注速率,D=260 mg,TCI-,靶,:,3 g/ml,血,浆浓度为靶浓度,0,2,4,6,8,0,5,10,15,20,time(min),Conc.(g/mL),0,50,100,150,200,Inf.rate(mg/min),血,浆,浓度,效,应室浓度,输,注速率,D=290 mg,E-TCI,靶,:3 g/ml,效,应室浓度,为,靶浓度,效,应室靶控输注,(ETCI),靶,:,效,应,室,浓度,优,势,:,起效快迅速达到,效应,浓度而不,会,引起药物过量,缺,点,:,血浆浓度,的,过度攀升,会增加,不良反应,模,型比较,:Marsh vs.Schnider,Marsh,Schnider,Vc(L)*,16.0,4.3,CL(L/min)*,1.90,1.69,联,合,变量,体,重,体,重,瘦,体重,（去脂体重,）,年,龄,性,别,*,:,男,性30岁，,70 kg,175 cm,Vc=0.228*,体,重,CL=0.027*,体,重,V2=18.9-0.39*(,年,龄,-53),CL=1.89+0.046*(,体,重,-77)-0.068*(,瘦,体重,-59)+0.026*(,身,高,-177),CL2=0.836-0.024*(,年,龄,-53),Marsh vs.Schnider:,正,常病人,Time(min),30 Years,Propofol/Remifentanil,给,药,方案,首先要决定是,以,镇痛,还,是,以,镇静为主的麻醉方式,!,Propofol(EC,50,-EC,95,):2.5-2.8 g/ml,Remifentanil(EC,50,-EC,95,):1.,单,次给药,1.5-2 g/kg(?)2.,输,注,速率,13-22 g/kg/h3.,输,注速率,11.5-19 g/kg/h,苏,醒,时间,:,7-11 min,Vuyk,J.:TCI:Supplementation and drug interactions,Anesthesia 58(1998),靶控输注,/,闭环输注,:,历史,1945:1982,靶,控输注,(Schttler,Schwilden,Stoeckel),1986,脑电图,-,控制,“,闭环,-,全凭静脉麻醉,(Schwilden,Schttler),TIVA/TCI,过,去时,TIVA/TCI,现,在时,2004,1997,良好的,靶控输注管理,的必要条件,药代动力学,模型,基,础,不同的,靶控输注系统,给药方案,药物相互作用,TCI-,质量,和,费用,TCI-,可控性,闭,环输注,靶控方案,麻,醉控制,Fresenius Kabi Symposium on TIVA and TCI,围术期镇痛、急性创伤、疾病引起的疼痛,癌性疼痛、非恶性慢性疼痛性疾病,各种检查、诊断性穿刺等，如胃、肠镜检查,安装,没固定,固定,Fresenius Kabi Symposium on TIVA and TCI,围术期镇痛、急性创伤、疾病引起的疼痛,癌性疼痛、非恶性慢性疼痛性疾病,各种检查、诊断性穿刺等，如胃、肠镜检查,开机,Fresenius Kabi Symposium on TIVA and TCI,围术期镇痛、急性创伤、疾病引起的疼痛,癌性疼痛、非恶性慢性疼痛性疾病,各种检查、诊断性穿刺等，如胃、肠镜检查,开机,Fresenius Kabi Symposium on TIVA and TCI,围术期镇痛、急性创伤、疾病引起的疼痛,癌性疼痛、非恶性慢性疼痛性疾病,各种检查、诊断性穿刺等，如胃、肠镜检查,开机,确认,Fresenius Kabi Symposium on TIVA and TCI,围术期镇痛、急性创伤、疾病引起的疼痛,癌性疼痛、非恶性慢性疼痛性疾病,各种检查、诊断性穿刺等，如胃、肠镜检查,开机,Fresenius Kabi Symposium on TIVA and TCI,围术期镇痛、急性创伤、疾病引起的疼痛,癌性疼痛、非恶性慢性疼痛性疾病,各种检查、诊断性穿刺等，如胃、肠镜检查,开机,确认,Fresenius Kabi Symposium on TIVA and TCI,围术期镇痛、急性创伤、疾病引起的疼痛,癌性疼痛、非恶性慢性疼痛性疾病,各种检查、诊断性穿刺等，如胃、肠镜检查,开机,