Transcript 2013-04-02 TCI

靶控輸注
(Target-Controlled Infusion)
徐永偉
2013.4.2
治療之目的
“The therapeutic objective is to achieve
adequate drug concentrations at specific
sites of action to produce the desired
effect.”
Schwinn DA, Shafer SL
適量之濃度，在適當之作用部位，
產生適當之效果
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科技與安全
Cruise Control
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Automatic Landing
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科技的進展
TargetControlled
Infusion
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大綱
什麼是TCI (Target-Controlled Infusion)
TCI 的發展史
TCI 的學理根據
TCI 的優點
TCI 如何操作
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什麼是 TCI
TCI是一種電腦程式控制的輸注系統，以
藥物動力學和藥效動力學為基礎
允許按不同需要，選擇所要到達的血中
或腦部濃度，並通過調整標靶濃度來控
制麻醉的深淺
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杜克大學 CACI Pump (1980s)
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TCI, Work Station 2004
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TCI的發展史
1996年AstraZeneca公司『Diprifusor』，最早在歐
洲上市的TCI系統
美國FDA尚未通過 TCI 在美國上市
歐洲的全身麻醉，約有30~40%是接受TCI輸注
2005年衛生署核准TCI系統在台上市
馬偕醫院是全臺灣最早使用TCI系統的醫院 (2005)
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TCI的學理根據
 藥物動力學 Pharmacokinetics
– Body對藥物做了些什麼
– 分佈、代謝、 排除
 藥效動力學 Pharmacodynamics
– 藥物對Body做了些什麼
– 催眠、止痛
– 肌肉鬆弛
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Cruise Control
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藥物動力學
Concentration : 在單位體積內的藥物量
（如 propofol ; ug/ml）
常以 ug/ml, ng/ml 表示
C = 25 / 50
= 0.5 ug / ml
25 ug
50 ml
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25 ug in
50 ml
100 ug
50 ml
C = 100 / 50
= 2 ug / ml
100 ug in
50 ml
藥物動力學
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TCI 的原理
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Egan TD:Anesthesiology 2003; 99:1214–9
TCI pump
Fresenius-Kabi
Alaris
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Basic of Pharmacokinetic 基礎藥物動力學
Development of PK model
K31
Measure Plasma Conc.
V3
K13
V1
K12
V2
K21
K10
Population Pharmacokinetics
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V1 = Central compartment
V2 = Peripheral compartment
V3 = Peripheral compartment
kij = equilibrium constant
70 Kg patient, after propofol 140mg Bolus
10
●
9
C(t) = A·e -a t + B ·e -b t + C ·e - t
●
Concentration (ug/ml)
8
7
k21
6
●
k13
V2
5
V1
k12
V3
k31
k10
4
3
●
2
●
1
●
●
●
●
●
10
15
20
25
30
0
-5
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0
5
Time (min)
Basic of Pharmacokinetic 基礎藥物動力學
TCI : B E T 運算
Cp
Vc
V2
V1
Bolus +
Elimination + Transfer
Vc
V2
V1
Vc
V2
Bolus
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Vc
V2
Vc
V2
V1
V1
Time
V1
BET 運算模式
Bolus: Loading dose to fill the predicted intial
volume of distribution (V1)
B = V 1 · Cp
Elimination: Constant infusion to match the
clearance of drug
E = V1 · Cp · Clp
Transfer: An exponentially decreasing
infusion to match the transfer of the drug
from V1 to V2
T = V1 · Cp · k12 · e-k21 · t
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TCI 操作
Setup 藥物空針
設定基本資料：體重、年紀、性別、身高
選定輸注模式
調整TCI濃度
手術結束前約20分鐘評估關藥時間
(Target 0 ug/ml)
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3 compartments
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Context-Sensitive Half-Time
Factors influencing the
Context-Sensitive HalfTime
– Size of V2 and V3
compartments
– Rate of transfer
between V1 and V2-V3
– Duration of infusion
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Context-Sensitive Half Time
Context = Infusion Duration
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Hughes et al. Anesthesiology 76:334–341, 1992.
Propofol PK 參數
Marsh and Schnider Models
Marsh
Schnider
V1
0.228 L/kg
4.27 L
K10 (min-1)
0.119
0.0443+0.0107*(BW-77)0.0159*(LBM-59)+0.0062*(HT-177)
K12 (min-1)
0.112
0.302-0.0056*(Age-53)
K13 (min-1)
0.0419
0.196
K21 (min-1)
0.005
1.29-0.024*(Age-53)
K31 (min-1)
0.0033
0.0035
Keo (min-1)
1.21
0.456
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BW=body weight, LBM= lean body mass, HT= height
Propofol in TIVA-TCI
Target effect site
–3~5μg/ml
–Start TCI since induction: stable HR/BP
Arousable concentration (甦醒濃度)
–0.8~1.5μg/ml
–Factors: age, ASA, opioids/ sedatives
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TCI的優點
誘導平穩，維持劑量調整方便
甦醒迅速且恢復質量高，可預期性強
術後噁心，嘔吐發生率低
無手術室環境污染
給藥不受氣道條件限制
沒有惡性高熱
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