Basic knowledge & Clinical experience on

TCI : Target Controlled Infusion .

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TIVA : Why ? What ? Basic principle of TIVA & TCI TCI : Pharmacokinetics & Model Induction, maintenance & emergence TCI : Advantage & clinical application TCI: Precaution & pitfalls

Disadvantage of Inhalations
Environment Environment 1
Global warming Work place pollution

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Technique Technique

Inhalations Inhalations

2
Specific equipment anesthetic machine + vaporizer Special ventilatory technique & compromised airway seals : bronchoscopy,

3
Nausea-vomiting Emergence dysphoria

ICP, IOP Inhibit autoregulation & HPV(hypoxic pul vasoconstriction) Trigger MH

Definition
TIVA :
Total Intravenous anesthesia the use of IV agents exclusively to provide

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propofol, thiopentone, midazolam Hypnosis dexmedetomidine,

a complete anesthetic condition

Balanced anesthesia

Analgesia

opioids Morphine, fentanyl, remifentanil dexmedetomidine, ketamine, NSAID

Immobility

non-depolarize muscle relaxant

Development of delivery systems

AIM
maintenance of optimum & stable anesthetic condition

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Bolus + elimination

st 1

2nd
stable

plasma
concentration Single injection, Intermittent injection, Continuous iv. drip Infusion pump Syringe pump

Control rate
Elimination

Development of delivery systems

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2nd

Infusion pump Syringe pump : control rate

Controllable infusion rate

Intermediate blood supply : muscle Rich blood supply

Poor bl.supply :fat

TIVA-MCI: manually controlled infusion

are used to designate manual adjustment of infusion rates for anesthesia syringe pumps

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Initial infusion rate 10 min Subsequence adjustment so as to maintain a stable level of anesthesia

Less Pain Start >10 mins. >2 hrs. 8 5 3

With N2O 10 7 5

Without N2O 12 9 7
mg/kg/hr

duration
Not easy to control Time-consuming calculation No compensate for interrupted infusion

stop 10 15 20

1 . 3 . 4 .

Delayed emergence !!! Require skill & experience

Development of delivery systems

AIM

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maintenance of optimum & stable anesthetic condition

st 1

2nd

3rd

Single injection, intermittent injection, Continuous iv. drip

Infusion pump Syringe pump TIVA:MCI

Target controlled Infusion TIVA: TCI

Target controlled infusion : TCI

is an infusion system which allows the anaesthetist to

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select the target blood concentration

required for a particular effect, and then to control depth of anaesthesia by adjusting the requested

target concentration

Open, three-compartment model

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Variable rate

Cp : plasma Marsh model

Cet : effect target Schneider model

TCI: basic principle

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Anesthesiologist selects and inputs targets blood concentration

Patient

1.Age 2.BW 3.Height 4.Sex

TCI Subsystem Microprocessor +pharmacokinetic program

Infusion pump incorporating

infusion rates are altered automatically according to a validated pharmacokinetic model (Propofol :Marsh, Schnider, Remifentanil : Minto model)

TCI: pharmacokinetic model

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Drug specific : Remifentanil : Minto model Propofol : Schneider model A drug : different PK Propofol : Marsh model Schneider model

Model

B.E.T.scheme
AIM
To achieve a chosen concentration

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Bolus
Fill central compartment
Bolus dose = Ct x V1

Target
concentration

Elimination
Compensate for metabolism & elimination

= Ct x CL=Ct x K10 x V1

Transfer
Compensate for peripheral distribution

Decreasing infusion rate = Ct x V1(k12 e(-k21t)+k13e(-k31t))

Drug for TCI : hypnotics

2 hrs.infusion 100 mins

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3 hrs.infusion 25 mins

Drug for TCI : analgesics

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Ideal for TCI

Open loopTCI: propofol

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1st
Fresofol in Syringe 50 ml Extension , 3-way

2nd
Syringe TCI Schneider model Key patient data

3rd
select Target Cet

TCI-propofol concentration
Cet 2-3 g/ml loss of eyelash reflex Cet 4-8 g/ml for anesthetic procedure Intubation, LMA

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CP50 2.73.4 g/ml loss of response to verbal or tactile stimuli*

Target = ?

Target concn based on Level of stimulation Drug interaction Desired clinical endpoint Individual variability
* : Vuyk J et al. Anesthesiology 1992; 77: 3.

Crankshaw DP et al. Anaesth Intensive Care 1994; 22: 481. Smith C et al. Anesthesiology 1994; 81: 820.

TCI for induction & intubation

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Premedication : MO 5-10 mg, midazolam 1-2 mg Induction : propofol Cet 2-3 g/ml Check for loss of consciousness : eyelash reflex Check for ventilation if OK muscle relaxation 45-60 sec

Intubation : Non-depolarize muscle relaxant 90-180 sec Propofol Cet 4-8 g/ml

After taping endotracheal tube : no stimuli Cet 2-3 g/ml next painful stimuli : before skin incision Cet 4-6 g/ml

TCI for maintenance

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titrate by trick

Use TCI syringe as a iv. vaporizer for Fresofol Titrate depth of anesthesia to optimum level

severity of stimuli : more severeCet, less severe:Cet clinical signs : HR, BP, movement, sweating, pupil size depth monitor: BIS, CSI

Propofol Cet before noxious stimuli Propofol Cet after a period of infusion To achieve hemodynamic stability

remember

Adequate analgesics & muscle relaxant supplement Blood & Volume replacement Check for signs of awareness

Prepare for emergence

Propofol Cet maintenance 3-5 g/ml 4 g/ml Set wake up concn 1.5-2.0 g/ml 2 g/ml

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wake up time = time from 42 g/ml = X min X min to end of operation Stop or Cet 0.01 g/ml Observe Propofol Cet & clinical, BIS

Usually wake up < 1.5-2.0 g/ml later than wake up time Reverse MR extubation

Rescue dose for unexpected event !!

Check TCI advantage : post op.

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Not inhibit HPV IOP

non-ideal environment emesis

Clear headed recovery

ICP CMR Do not prescribe prophylaxis for PONV

Date of Birth Orientation Emergence delirium

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TCI advantages & clinical application

One lung ventilation

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X-rays ER Military Developing country

Open eye injury

IOP

Not inhibit HPV

non-ideal environment

emesis
Clear headed recovery without delirium ICP CBFCMR

Day case surgery Neuro exam

neurosurgery

Laporoscopic Sx. Obstetrics GI surgery Eye, ENT Hx of PONV

TCI for neuroanesthesia

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Goal : Not only an adequate anesthetic condition (amnesia/sedation, analgesia, immobility & hemodynamic stability) ..BUT..
1. optimal operating conditions 2. neurological protection 3. rapid emergence from anesthesia for neurological examination

Goal I : optimal neurosurgical condition

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Low CBF

Adequate

CPP

ICP

Optimal operating condition

minimal brain bulk

CMR O2

specific effects of IV. & inhalations

Drug ketamine nitrous oxide halothane enflurane isoflurane desflurane sevoflurane thiopental etomidate propofol CBF
Increase increase increase increase increase increase increase decrease decrease decrease

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CMR
increase increase decrease decrease decrease decrease decrease decrease decrease decrease

TCI for neuroanesthesia

Volatile anesthetics have been shown to affect cerebral autoregulation and intracranial pressure which can make the surgery more difficult and dangerous, increasing the risk of .ischemic cerebral insults

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: Neurosurgery 61[ONS suppl 2] : ONS369-ONS378,2007

the reduction in cerebral blood flow with in cerebral vascular resistance and CMRO2 seems to make TIVA ..the more advantages anesthesia technique .. for patients with increased ICP
: :Todd MM et al: Anesthesiology 78:1005-1020,1993

Goal II : cerebral protection

O2 demand O2 supply Avoid ischemia

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Non pharmacologic technique

Pharmacologic technique

Non-pharmacologic technique
Hemodilution Hct 30-34 % euvolemia

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Good venous return Upright head

Avoid Hypoxia, Hypercarbia PaCO2 28-32 mmHg

Brain protection
Mild hypothermia 1c CMRO2 7% 32-35 c protection not recommend Avoid hyperthermia Glusoce control < 150 mg/dl > 60 mg/dl

Avoid hypotension MAP > 70 mmHg SAP > 90 mmHg CPP = MAP-ICP = 60-70

Pharmacologic technique

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Prevent apotosis IV. Agent Thiopental Propofol Local anesthetics But not Ketamine
GABA,NMDA

Inhalation Isoflurane Sevorane Desflurane But not halothane, N2O

Ca ++,Na+ influx

free radical

Block ischemic cascade

Goal III : rapid emergence for neuroexam.

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slow

fast

faster

fastest

Se

r flu Iso ane

Clear headness

Pr o po fol

De

dysphoria

v of a lur ne

ran sflu e
?

Ratchaburis experience
Induction : TCI Propofol Cet 2-3 6-8 g/ml 2-3 g/ml Air:O2, Fentanyl, Midazolam, Muscle relaxants Maintenance : TCI Propofol Cet 4-6 g/ml (Cet 6.2 g/ml burst suppression) End point :

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BP

BIS

ICP

systemic hypotension is a major contributor to poor outcome avoid SBP < 90 mmHg level II*

40 - 50

brain relaxation & surgical access

* www.braintrauma.org

Most common pitfalls

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Delayed awakening

Movement

Hypotension

Not deep enough

Unfamiliar

delayed muscle relaxant Supplement Neuromuscular monitoring

Hypovolemia

Unsecured iv. access

BIS,CSI

Fluid status evaluation

Always checked !!

Other problems
Bradycardia agitation BIS diff. from clinical

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Awareness

Unfamiliar long dead space Inadequate analgesics BIS,CSI

On -block

judgement

precaution
Not recommend for TCI-propofol Not recommend for TCI-propofol

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No available model placental transfer Drug metabolite

Age <15

BW>150

C/S

Liver impairment

Propofol-related infusion syndrome

High dose infusion >5 mg/kg/hr for > 48 hrs

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Abrupt onset of profound bradycardia, metabolic acidosis , lipemic plasma,

symptoms

renal failure, fatty liver, rhabdomyolysis or myoglobinuria Risk factors : poor oxygen delivery, sepsis serious cerebral injury

Monitor : acidosis, K+, renal function

Take home message :

TCI

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Simple. to operate Continuous process from induction through to maintenance Easy to titrate the level of anesthesia Good control of depth of anesthesia Improved control of cardiovascular and respiratory parameters

Try it !!

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