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1、TCI的理论与实践,Balanced Anesthesia,Muscle relaxation,Loss of Consciousness,Analgesia,全身麻醉,吸入维持或静脉维持椎管内麻醉或神经阻滞,全身麻醉,TCI/TIVA的优点,Control depth of sedation pre-inductionLess pollution in the OT and environment No liver toxicityLess PONVAccess to airway unrestricted by drug deliveryCan be continued for post-
2、op sedationNo increase in F-ions;safe with soda limeMaintain hypoxic vasoconstriction reflexSafe in patients at risk for malignant hyperthermiaTCI system:predicts blood and effect site calculated concentrations,similar to the way that end-tidal monitor measures gas exhaled from the patient,TCI的发展:Pr
3、opofol给药方式,手动给药,M,40 yr,70kg,170cm.Propofol manual:Effect site concentration 2.8 ug/ml,2mg/kg,1mg/kg,1mg/kg,1mg/kg,Propofol:持续输注,M,40 yr,70kg,170cm.Propofol bolus+infusion:Effect site concentration 2.8 ug/ml,2mg/kg,8mg/kg/hr,Propofol:TCI,M,40 yr,70kg,170cm.Propofol TCI 3.5 ug/ml,Plasma TCI 3.5 ug/ml
4、,Effect TCI 3.5 ug/ml,TCI成功的理论和物质基础,1,3,Pharmacokinetic model with 3 compartments,2,1,3,2,Pharmacokinetic set with effect site compartment,T1/2 Keo,Pharmacokinetic And Pharmacodynamic Parameters Of Propofol And The Opioids,Bart-Jan Lichtenbelt,et al.Clin Pharmacokinet 2004;43(9):577-593,Time To Peak
5、 Effect,Context Sensitive Half Time,TCI泵：计算值和实际值准吗？,TCI system:predicts blood and effect site calculated concentrations,similar to the way that end-tidal monitor measures gas exhaled from the patient.,Propofol EC50(Loss of consciousness),EC50(EC05 EC95)Cp European 5.2(3.1-7.3)(g/ml)Chinese 3.83(2.86
6、-4.80)Ce European 2.8(1.5-4.1)(g/ml)Chinese 2.23(1.29-3.18)BIS European 70.9(88.8-52.9)Chinese 57.9(11.28)AEPI European 54.3(68.6-40.0),Kenny GNC.BJA 2003;90(2):127XU Zhi-peng et al.INTERNATIONAL JOURNAL OF ANESTHESIOLOGY AND RESUSCITATION 2006 Vol.27 No.3 P.144-148,EC50EC95 of Remifentanil for Teta
7、nic Stimuli-China 2004,EC50EC95 of Sufentanil for Various Stimuli,YANG Ning,ZUO Mingzhang.CHINESE JOURNAL OF ANESTHESIOLOGY 2006 Vol.26 No.11 P.987-979,Dose,PK variability 70,PD variability 300-400,Response,麻醉医生的临床观察和判断很重要！,Propofol10mg/kg/h 3-5mcg/ml,Propofol 1mcg/ml?,麻醉深度监测,老年患者危重患者大手术,丙泊酚诱导:ASA 1
8、-2，PTCI和ETCI都安全,丙泊酚诱导：老年危重患者选择PTCI 采用阶梯式诱导,TCI started with plasma concentration of propofol 1 g/ml,monitor BP and HR Wait for effect-site concentrationIncrease propofol Cp 0.5-1.0 g/ml/each until LOC,如何做好丙泊酚和瑞芬的双通道TCI？,M,40 yr,70kg,170cm.,Remifentanil Plasma TCI:5 ng/ml,Remifentanil Effect TCI:5 ng
9、/ml,Propofol/Remifentanil TCI:Induction,Propofol PTCI 3.5g/ml,Remifentanil PTCI 6ng/ml,M,40yr,170cm,70kg,Intubation,Propofol/Remifentanil TCI:Maintenance,M,40yr,170cm,70kg,Remifentanil PTCI 4-8ng/ml,Propofol PTCI 2.8-4.0 g/ml,Induction,Intubation,Skin incision,End of Surgery,Propofol/Remifentanil TC
10、I:Emergence,M,40yr,170cm,70kg,Remifentanil PTCI 4-8ng/ml,Propofol PTCI 2.8-4.0 g/ml,Induction,Intubation,Skin incision,End of Surgery,Analgesic transition,Propofol and Remifentanil in TCI,Remifentanil PTCIInduction:4-8ng/mlMaintenance:4-8ng/mlEmergence:Analgesic transition镇痛转换和多模式镇痛Minor surgery:Loc
11、al infiltration,NASIDSModerate surgery:Local infiltration,Epidural,NASIDS,Morphine,Sufentanil(0.1ug/kg)Major surgery:Local infiltration,Epidural,NASIDS,Morphine,Sufentanil(0.1ug/kg),如何做好丙泊酚和舒芬的双通道TCI？,M,40 yr,70kg,170cm.,Sufentanil Plasma TCI:0.3ng/ml,Sufentanil Effect TCI:0.3ng/ml,Propofol with Suf
12、entanil/Remifentanil TCI Management-TCI Induction:Time to peak effect,time(mn),time(mn),Propofol with Sufentanil in TCI:Induction:Time to peak effect,Optimisation Of Induction Timing,0,50,100,time(min),%max CE,40,80,120,160,PAM(mmHg),intubation,sufentanil,propofol,Sufentanil in TCI:Induction,M,40yr,
13、170cm,70kg,M,40yr,170cm,70kg,Sufentanil ETCI,5,Propofol PTCI,1.5ug/ml,3.5ug/ml,0.3ng/ml,Intubation,Sufentanil in TCI:Maintenance and Emergence,M,40yr,170cm,70kg,Sufentanil ETCI,Propofol PTCI,Induction,Intubating,Skin incision,End of Surgery,0.08ng/ml,1.5ug/ml,3.5ug/ml,Sufentanil in TCI,ETCIInduction
14、:0.25-0.3ng/ml;0.35-0.5ng/ml(Cardiac surgery)Maintenance:0.15-0.25 ng/mlEmergence:Sufentanil 0.1-0.06 ng/ml NASIDS Local infiltration,Epidural,Never blockPostoperative:,TCI的注意事项：,确保TCI泵正常工作药物浓度设置正确确保药物尽快进入患者体内密切监测和观察对老年危重大手术患者，推荐使用麻醉深度监测仪，如BIS监测,Input：Body weightAgeGenderHeight,Drugs：Propofol(Cp)Rem
15、ifentanil(Cp)Propofol(Cp)+Sufentanil(Ce),Anesthetics,sedatives,opioids,propofol,sufentanil,remifentanil,Marsh,Schnider,Gepts,Minto,Sufentanil and Remifentanil in TCI,Our PracticeIV Line,监测麻醉深度,TCI-IVA Inhalational anesthesia BP、HR BP、HR Movement Movement Predicted Cp and Ce Measured ET-inhalatonal a
16、gents BIS BIS,+=,竟安新一代丙泊酚制剂降低注射痛降低血脂减少肝脏负荷,AgiliaTIVA直觉性的一代TIVATCI双模式可选完备的TCI模型-既可镇静，亦可肌松药库服务,好“马”+好“鞍”=麻醉更简单,更方便更精确更安全麻醉效果更好,Our PracticeIV Line,Our Practice 工欲善其事，必先利其器,Patient Safety,Pump problem,Surgery,Stimulation,Intubation,Incision,Awakening,Remifentanil,Propofol,Muscle relaxation,2 2,4 4,Anx
17、iety,My Practise:Propofol/remifentanil TCAnaesthesia,Propofol Remifentanilg/ml ng/ml,Surgery,Stimulation,Intubation,Incision,Awakening,Sufentanil,Propofol,Muscle relaxation,2 0.2,4 0.4,Anxiety,My Practise:Propofol/Sufentanil TCAnaesthesia,Propofol Sufentanil g/ml ng/ml,Thank you for your attention!,
