1、Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLATCI是什么？ TCI 是一種輸注系統(tǒng)，允許麻醉醫(yī)生按不同需求選擇所要求的靶血藥濃度需求

2、選擇所要求的靶血藥濃度經(jīng)過(guò)經(jīng)過(guò)調(diào)整靶濃度來(lái)控制麻醉的深淺調(diào)整靶濃度來(lái)控制麻醉的深淺TCI 不是完全的計(jì)算機(jī)控制麻醉不是完全的計(jì)算機(jī)控制麻醉Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA為什么運(yùn)用TCI根本出發(fā)點(diǎn)根本出發(fā)點(diǎn) 使靜脈麻醉深淺的調(diào)理能像吸入麻醉利用使靜脈麻醉深淺的調(diào)理能像吸入麻醉利用規(guī)范揮發(fā)罐調(diào)理那樣簡(jiǎn)單規(guī)范揮發(fā)罐調(diào)理那樣簡(jiǎn)單 Great physician with grea

3、t spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLATCI的優(yōu)點(diǎn)-實(shí)際方面運(yùn)用方便運(yùn)用方便操作簡(jiǎn)單操作簡(jiǎn)單能繼續(xù)顯示所計(jì)算的血藥濃度能繼續(xù)顯示所計(jì)算的血藥濃度對(duì)中斷輸注有補(bǔ)償作用對(duì)中斷輸注有補(bǔ)償作用防止了對(duì)輸注速率的復(fù)雜的計(jì)算防止了對(duì)輸注速率的復(fù)雜的計(jì)算Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hosp

4、ital of GuangZhou Command of PLATCI的優(yōu)點(diǎn)實(shí)際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對(duì)循環(huán)，呼吸功能的影響改善了對(duì)循環(huán)，呼吸功能的影響誘導(dǎo)期的反響可作為預(yù)設(shè)麻醉維持的參考，誘導(dǎo)期的反響可作為預(yù)設(shè)麻醉維持的參考，比手控更準(zhǔn)確比手控更準(zhǔn)確Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA靜脈麻醉運(yùn)用歷史 靜脈麻醉有百年歷史靜脈麻醉有百

5、年歷史 根據(jù)閱歷調(diào)整藥物根據(jù)閱歷調(diào)整藥物 丙泊酚在丙泊酚在 1986 1986 運(yùn)用速度運(yùn)用速度 612mg/kg/h612mg/kg/h 10-8-6 10-8-6 方案出現(xiàn)相當(dāng)方案出現(xiàn)相當(dāng)于于TCI TCI 濃度濃度34ug/ml34ug/ml 19961996DiprifusorDiprifusor TCI TCI systemsystemGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of P

6、LA1980s1996“DiprifusorTCI系統(tǒng)上市系統(tǒng)上市靶控輸注靶控輸注Target-controlled infusion Target-controlled infusion 以藥物代謝動(dòng)力學(xué)和藥效動(dòng)力學(xué)原理為根底，以藥物代謝動(dòng)力學(xué)和藥效動(dòng)力學(xué)原理為根底，經(jīng)過(guò)調(diào)理目的或者靶位血漿或效應(yīng)室的藥經(jīng)過(guò)調(diào)理目的或者靶位血漿或效應(yīng)室的藥物濃度來(lái)控制或者維持適當(dāng)?shù)穆樽砩疃龋詽M物濃度來(lái)控制或者維持適當(dāng)?shù)穆樽砩疃龋詽M足臨床麻醉的一種靜脈給藥方式。足臨床麻醉的一種靜脈給藥方式。得普利麻上市得普利麻上市“10-8-610-8-6給藥給藥方案方案Great physician with great

7、 spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 有比較才有差別 II級(jí)III級(jí)I 級(jí)級(jí)TCI反復(fù)靜脈反復(fù)靜脈 輸注輸注繼續(xù)恒速繼續(xù)恒速靜脈輸注靜脈輸注靶控輸注靶控輸注 Great phy

8、sician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA單次和反復(fù)靜脈注射Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA單次+繼續(xù)靜脈給藥Great physician with great spirits

9、Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA靶控輸注Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA三室藥代動(dòng)力學(xué)模型FatMuscles &Connective TissueInfusionEliminationV2V3VcentralK1

10、2K13K21K31K10Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 中央室中央室V1V1代表血液或血漿；代表血液或血漿； 第二室第二室 (V2) (V2) 代表高灌注組織；代表高灌注組織； 第三室第三室 (V3) (V3) 代表低灌注組織。代表低灌注組織。 血液并非藥物的作用部位，藥物的作用部位稱(chēng)為血液并非藥物的作用部位，藥物的作用部位稱(chēng)為“效應(yīng)室效應(yīng)室Great physicia

11、n with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA t1/2ke0 t1/2ke0是血漿和效應(yīng)室藥物濃度到達(dá)是血漿和效應(yīng)室藥物濃度到達(dá)平衡的時(shí)間平衡的時(shí)間 t1/2ke0 t1/2ke0越小，那么藥越小，那么藥物起效越快物起效越快 瑞芬太尼瑞芬太尼 1.3min 1.3min 異丙酚異丙酚 2.4 2.4 minmin 咪唑安定咪唑安定 4min 4min 芬太尼芬太尼 4.7min 4.7min Great phys

12、ician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 停頓繼續(xù)輸注藥物后，中央室藥物濃度下降停頓繼續(xù)輸注藥物后，中央室藥物濃度下降50%50%所需的時(shí)間所需的時(shí)間 隨藥物輸注繼續(xù)時(shí)間的延伸而增大隨藥物輸注繼續(xù)時(shí)間的延伸而增大 預(yù)測(cè)靜脈麻醉后恢復(fù)時(shí)間預(yù)測(cè)靜脈麻醉后恢復(fù)時(shí)間Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)

13、武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA藥物選擇藥物選擇T1/2keoT1/2keo和和T1/2csT1/2cs都小的藥物都小的藥物-丙泊酚、丙泊酚、瑞芬太尼瑞芬太尼Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLATCI藥物的選擇 起效時(shí)間和衰退時(shí)間均很短的藥物最適宜用于靶起效時(shí)間和衰退時(shí)間均很短的藥物最適宜用于靶控輸注

14、，盡量選擇控輸注，盡量選擇T1/2Ke0T1/2Ke0和和T1/2csT1/2cs小的藥物小的藥物 目前臨床運(yùn)用的麻醉藥物中，以丙泊酚和瑞芬太目前臨床運(yùn)用的麻醉藥物中，以丙泊酚和瑞芬太尼的藥代動(dòng)力學(xué)特性最為適宜尼的藥代動(dòng)力學(xué)特性最為適宜 肌松藥靶控頗有爭(zhēng)議，而以肌松監(jiān)測(cè)反響調(diào)控輸肌松藥靶控頗有爭(zhēng)議，而以肌松監(jiān)測(cè)反響調(diào)控輸注方式為佳注方式為佳Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAA

15、nesthetistSet targetpump control algorithmpharmacokinetic simulationpredicted concentrationdifferent modelsCpCekataria/paedfusorMarsh Schnider mintoGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA引薦濃度引薦濃度術(shù)前藥術(shù)前藥無(wú)無(wú) 4-8ug/m

16、l有有 2-6ug/ml年齡年齡20歲后，每十歲靶濃度下降歲后，每十歲靶濃度下降0.24ug/ml靶濃度設(shè)定靶濃度設(shè)定3-6ug/ml，輔助鎮(zhèn)痛藥，輔助鎮(zhèn)痛藥大手術(shù)大手術(shù) 3-6小手術(shù)小手術(shù) 1.5-4.5不同人群不同人群ASA- 3.5-5.3心臟病或心臟病或ASA- 2.8-3.4 年齡年齡55歲歲 3.5誘導(dǎo)誘導(dǎo)維持維持實(shí)施實(shí)施TCI就是根據(jù)引薦參數(shù)就是根據(jù)引薦參數(shù)單純進(jìn)展輸入嗎？單純進(jìn)展輸入嗎？Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospi

17、tal of GuangZhou Command of PLA影響TCI的要素用藥量Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAplasma target controlledeffect site target controlledGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)

18、院Wuhan General Hospital of GuangZhou Command of PLACp vs CeCp vs CeDiagram CeCp 效應(yīng)室靶控效應(yīng)室靶控CeCe血漿靶控血漿靶控CpCpGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAlag in effect sitelag in effect sitesuitable for the old and have

19、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 dosemore loading dosecirculation fluctuationcirculation fluctuationsuitable to the hi

20、ght 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廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA不同藥代動(dòng)力學(xué)模型麻醉藥麻醉藥鎮(zhèn)靜鎮(zhèn)痛丙泊酚丙泊酚SchniderKataria

21、Marsh瑞芬太尼瑞芬太尼舒芬太尼舒芬太尼MintoGepts肌松藥羅庫(kù)溴銨羅庫(kù)溴銨SzenohradszkyGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAMarshMarsh和和SchnilderSchnilder兩種模型的比較兩種模型的比較Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)

22、武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 同樣體重同樣體重/ /年齡年齡/ /身高患者，設(shè)定同等濃度丙泊酚身高患者，設(shè)定同等濃度丙泊酚 Marsh = Schinider Marsh = Schinider用藥量用藥量Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA在極輕體重患者，在極輕體重患者，V1呵斥的初始劑量差距減

23、小，但是呵斥的初始劑量差距減小，但是Schnider 模型模型估計(jì)血漿濃度下降更快。在中國(guó)人群中低體重者比例很高。因此我們估計(jì)血漿濃度下降更快。在中國(guó)人群中低體重者比例很高。因此我們發(fā)現(xiàn)發(fā)現(xiàn)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廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA Changes in the sedation score and B

24、ispectral 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 groups.Schnider effect site prediction in both study groups. 兩組病例中，兩組病例中，MarshMarsh模型預(yù)測(cè)的效應(yīng)室濃度

25、與鎮(zhèn)靜評(píng)分和腦模型預(yù)測(cè)的效應(yīng)室濃度與鎮(zhèn)靜評(píng)分和腦電雙頻指數(shù)變化的相關(guān)性優(yōu)于電雙頻指數(shù)變化的相關(guān)性優(yōu)于SchnilderSchnilder模型以效應(yīng)室濃度預(yù)模型以效應(yīng)室濃度預(yù)測(cè)的結(jié)果。測(cè)的結(jié)果。 Anaesthesia, 2007, 62, pages Anaesthesia, 2007, 62, pages 661666661666Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA同一方式下

26、不同個(gè)體所需靶濃度能否一樣？同一方式下不同個(gè)體所需靶濃度能否一樣？如何察看與減少不同靶控部位，不同方式，不同個(gè)體所呵如何察看與減少不同靶控部位，不同方式，不同個(gè)體所呵斥的差別？斥的差別？Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA受試者之間，認(rèn)識(shí)消逝時(shí)的最小受試者之間，認(rèn)識(shí)消逝時(shí)的最小(0.7ug/ml)和最大和最大(4.8ug/ml)效應(yīng)室濃度效應(yīng)室濃度存在大約存在大約6倍的個(gè)體差別

27、，認(rèn)識(shí)恢復(fù)時(shí)亦是如此倍的個(gè)體差別，認(rèn)識(shí)恢復(fù)時(shí)亦是如此換言之，給予規(guī)范劑量丙泊酚的患者有能夠鎮(zhèn)靜缺乏或者過(guò)度鎮(zhèn)靜換言之，給予規(guī)范劑量丙泊酚的患者有能夠鎮(zhèn)靜缺乏或者過(guò)度鎮(zhèn)靜Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan Gene

28、ral Hospital of GuangZhou Command of PLA本研討提示，丙泊酚用藥時(shí)應(yīng)逐漸給藥直至認(rèn)識(shí)消逝，取代以往根據(jù)人群平均程度定量給予的方法。Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan Gene

29、ral Hospital of GuangZhou Command of PLA個(gè)體化醫(yī)學(xué)個(gè)體化醫(yī)學(xué) 因人而異，給藥方案?jìng)€(gè)體化因人而異，給藥方案?jìng)€(gè)體化 滴定法滴定法TitrationTitration 鎖定患者認(rèn)識(shí)消逝時(shí)辰效應(yīng)室濃度鎖定患者認(rèn)識(shí)消逝時(shí)辰效應(yīng)室濃度LOCLOCGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA滴定法滴定法TitrationTitrationGreat physi

30、cian with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 在麻醉誘導(dǎo)階段，升階梯滴定在麻醉誘導(dǎo)階段，升階梯滴定 患者睫毛反射消逝、對(duì)口頭指令和推肩膀患者睫毛反射消逝、對(duì)口頭指令和推肩膀無(wú)反響無(wú)反響(LOC),(LOC),也就是個(gè)體最低有效劑量也就是個(gè)體最低有效劑量 術(shù)中維持此濃度或略增術(shù)中維持此濃度或略增 防止術(shù)中知曉防止術(shù)中知曉 減少全麻藥用量減少全麻藥用量 預(yù)知清醒時(shí)間預(yù)知清醒時(shí)間Great physician w

31、ith great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA實(shí)施實(shí)施TCITCI可預(yù)知患者清醒時(shí)間可預(yù)知患者清醒時(shí)間Average difference between individual Average difference between individual effect-site concentrations at return effect-site concentrations at return and loss of

32、 consciousness was only and loss of consciousness was only 0.17 0.17 0.32g/ml0.32g/mlGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA確保LOC的準(zhǔn)確性 給予鎮(zhèn)靜劑、鎮(zhèn)痛劑、肌松藥等，這都能影響到異丙酚誘給予鎮(zhèn)靜劑、鎮(zhèn)痛劑、肌松藥等，這都能影響到異丙酚誘導(dǎo)時(shí)所需求的靶濃度。輸注異丙酚前導(dǎo)時(shí)所需求的靶濃度。輸

33、注異丙酚前5min5min給予咪唑安定給予咪唑安定0.03mg/kg, 0.03mg/kg, 可以使病人認(rèn)識(shí)消逝所需靶濃度降低可以使病人認(rèn)識(shí)消逝所需靶濃度降低55%;55%;給給予芬太尼予芬太尼2ug/kg2ug/kg，使其降低，使其降低19%19%。血漿濃度。血漿濃度3ng/ml 3ng/ml 的芬太的芬太尼可降低尼可降低40%40%異丙酚的異丙酚的cp50cp50值值 Anesthesiology Anesthesiology Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuha

34、n General Hospital of GuangZhou Command of PLA 術(shù)前針不給咪唑安定和芬太尼；術(shù)前針不給咪唑安定和芬太尼； 誘導(dǎo)時(shí)序貫給予：丙泊酚誘導(dǎo)時(shí)序貫給予：丙泊酚 - -肌松藥肌松藥 - -鎮(zhèn)痛藥。鎮(zhèn)痛藥。Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA the best option is to maintain propofol at the lowe

35、r levels, and the adaptation of remifentanil to surgical needs.Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 認(rèn)識(shí)消逝時(shí)的效應(yīng)室濃度認(rèn)識(shí)消逝時(shí)的效應(yīng)室濃度LOCLOC可以用來(lái)作為管可以用來(lái)作為管理麻醉藥物運(yùn)用的指點(diǎn)理麻醉藥物運(yùn)用的指點(diǎn), ,術(shù)中維持這一濃度，或者術(shù)中維持這一濃度，或者略微添加略微添加 術(shù)中根據(jù)手術(shù)刺激疼痛刺激

36、來(lái)調(diào)理瑞芬太尼術(shù)中根據(jù)手術(shù)刺激疼痛刺激來(lái)調(diào)理瑞芬太尼速度，這樣可以減少丙泊酚用量，在手術(shù)終了停速度，這樣可以減少丙泊酚用量，在手術(shù)終了停藥后患者就能迅速清醒藥后患者就能迅速清醒Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLATCITCI靜脈麻醉時(shí)的最正確效應(yīng)室濃度靜脈麻醉時(shí)的最正確效應(yīng)室濃度輸注時(shí)間Prop/fenProp/alfProp/sufProp/remi15mincoptimal

37、4.51/1.894.18/1314.52/0.232.81/7.61蘇醒時(shí)min13.312.313.37.560minCoptimal4.48/1.644.49/1144.14/1.202.70/7.71蘇醒時(shí)min20.92018.89.45hcoptimal5.3/1.294.4/1184.18/0.22.63/8.01蘇醒時(shí)min41.331.228.510.8Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou

38、 Command of PLAEC05EC50EC95血漿濃度2.224.095.96效應(yīng)室濃度1.533.335.89瑞芬太尼的靶控輸注對(duì)疼痛刺激無(wú)反響時(shí)的瑞芬太尼的濃度對(duì)疼痛刺激無(wú)反響時(shí)的瑞芬太尼的濃度ng/mlng/mlGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 瑞芬太尼靶控輸注引薦劑量瑞芬太尼靶控輸注引薦劑量 2-8ng/ml 2-8ng/ml抑制切皮等損傷刺激的抑制切皮等損

39、傷刺激的Cp50Cp50是是4-6ng/ml4-6ng/mlGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA For age, elderly patients loose consciousness at propofol effect site concentrations that are about 30% lower than in young adults patients.

40、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廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA患者因急性腹膜炎急診入室患者因急性腹膜炎急診入室既往高血壓，心功能不全，普通情況差既往高血壓，心功能不全，普通情況差心電圖：竇

41、性心動(dòng)過(guò)速次心電圖：竇性心動(dòng)過(guò)速次/ /分分心臟彩超示：心臟彩超示：EF40%EF40%病例一病例一Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA入室時(shí)入室時(shí)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:97 SPO2:96%NIBP:111/73 HR:97 SPO2:96%

42、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廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 入室前無(wú)術(shù)前用藥入室前無(wú)術(shù)前用藥 入室后開(kāi)放上肢靜脈，靜滴樂(lè)加入室后開(kāi)放上肢靜脈，靜滴樂(lè)加 丙泊酚

43、選擇丙泊酚選擇marshmarsh方式行方式行TCITCIGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA麻醉誘導(dǎo)三部曲麻醉誘導(dǎo)三部曲 丙泊酚丙泊酚 TCI 1ug/ml-1.5ug/ml TCI 1ug/ml-1.5ug/ml -2ug/ml-2.5ug/ml -2ug/ml-2.5ug/ml -3ug/ml -3ug/ml ( (滴定出此患者的滴定出此患者的CeCe為為2.3ug/ml

44、2.3ug/ml 阿曲庫(kù)銨阿曲庫(kù)銨 15mg 15mg 舒芬太尼舒芬太尼 20ug 20ugGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA Induction Cp2.0ug/ml sulfentanyAtracuricum 3min intubationCp1.0ug/mlCp1.5ug/mlCp2.5ug/mlCp3.0ug/ml sleepreduce the Ce1.0ug/ml

45、 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廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州

46、軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of Gu

47、angZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA 患者手術(shù)時(shí)間為患者手術(shù)時(shí)間為3h20min3h20min 患者手術(shù)終了至清醒為患者手術(shù)終了至清醒為5min(5min(終了前終了前10min10min停藥停藥) ) 手術(shù)終了后手術(shù)終了后15min15min拔管安返病房拔管安返病房 拔管后及拔管后拔管后及拔管后1.5D1.5D訊問(wèn)患者有無(wú)術(shù)中記憶訊

48、問(wèn)患者有無(wú)術(shù)中記憶Great physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLA病例二病例二患者男，患者男，5454歲，歲，44Kg44Kg，160cm160cm心梗史心梗史心電圖：部分導(dǎo)聯(lián)心電圖：部分導(dǎo)聯(lián)T T波改動(dòng)波改動(dòng) 下壁異常下壁異常Q Q波波心臟彩超：心臟彩超：EDV:134mLEDV:134mL，EF:33%EF:33%，SV:44mLSV:44mLGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZhou Command of PLAGreat physician with great spirits Great love in great faith廣州軍區(qū)武漢總醫(yī)院廣州軍區(qū)武漢總醫(yī)院Wuhan General Hospital of GuangZh