slide1 l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
with Ephedrine PowerPoint Presentation
Download Presentation
with Ephedrine

Loading in 2 Seconds...

play fullscreen
1 / 68

with Ephedrine - PowerPoint PPT Presentation


  • 1072 Views
  • Uploaded on

TIVA TIVAE Total IntraVenous Anesthesia Total IntraVenous Awareness Total IntraVenous Anesthesia with Ephedrine Steven L. Shafer, MD Professor of Anesthesia, Stanford University Adjunct Professor of Biopharmaceutical Science, UCSF Staff Anesthesiologist, Palo Alto VA Health Care System

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'with Ephedrine' - Gabriel


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

TIVA

TIVAE

Total IntraVenous Anesthesia

Total IntraVenous Awareness

Total IntraVenous Anesthesia

with Ephedrine

Steven L. Shafer, MD

Professor of Anesthesia, Stanford University

Adjunct Professor of Biopharmaceutical Science, UCSF

Staff Anesthesiologist, Palo Alto VA Health Care System

what is tiva in 2005
What is TIVA in 2005?
  • Pure:
    • Propofol @ 50-75 mg/kg/min
    • Remifentanil @ 0.1-0.3 mg/kg/min
  • Cheating:
    • Propofol @ 20-75 mg/kg/min
    • Remifentanil @ 0.01-0.3 mg/kg/min
    • 70% Nitrous Oxide
more complex pk model multi compartment
More complex PK Model:Multi-compartment

100

Rapid

10

Concentration

Intermediate

Slow

1

0

120

240

360

480

600

Minutes since bolus injection

opioid pharmacokinetics
Opioid Pharmacokinetics

100

10

Percent of peak plasma opioid concentration

fentanyl

1

sufentanil

alfentanil

0.1

360

480

600

240

0

120

Minutes since bolus injection

context sensitive half time
Context-Sensitive Half-Time

120

fentanyl

90

alfentanil

Minutes required

60

sufentanil

30

0

240

360

480

600

0

120

Minutes since beginning of infusion

Hughes MA, Glass PS, Jacobs JR. Anesthesiology. 1992 76:334-41.

awake eeg
Awake EEG

Gregg K, Varvel JR, Shafer SL. J Pharmacokinet Biopharm 20, 611-635, 1992

profound opioid eeg effect
Profound Opioid EEG Effect

Gregg K, Varvel JR, Shafer SL. J Pharmacokinet Biopharm 20, 611-635, 1992

eeg time course with fentanyl
EEG Time Course with Fentanyl

Scott J, Ponganis KV, Stanski DR. Anesthesiology 62:234-241, 1985

eeg time course with alfentanil
EEG Time Course with Alfentanil

Scott J, Ponganis KV, Stanski DR. Anesthesiology 62:234-241, 1985

remifentanil vs other opioids
Remifentanil vs. other opioids

100

remifentanil

80

state

-

60

alfentanil

effect site opioid concentration

Percent of steady

40

sufentanil

20

fentanyl

0

0

10

20

30

40

50

60

Minutes since beginning of continuous infusion

Shafer SL, ASA Refresher Course, Chapter 19, 1996

remifentanil vs other opioids20
Remifentanil vs. other opioids

100

10

Percent of peak plasma opioid concentration

fentanyl

1

sufentanil

alfentanil

remifentanil

0.1

360

480

600

240

0

120

Minutes since bolus injection

remifentanil vs other opioids21
Remifentanil vs. other opioids

100

sufentanil

80

fentanyl

60

Percent of peak effect site opioid concentration

40

alfentanil

20

remifentanil

0

4

6

8

10

0

2

Minutes since bolus injection

50 effect site decrement curves
50% effect sitedecrement curves

Minutes required

Minutes since beginning of infusion

Shafer SL, ASA Refresher Course, Chapter 19, 1996

80 effect site decrement curves
80% effect sitedecrement curves

Minutes required

Minutes since beginning of infusion

Shafer SL, ASA Refresher Course, Chapter 19, 1996

propofol alfentanil interaction
Propofol/Alfentanil Interaction

400

  • Adapted from Vuyk et al, Anesthesiology 83:8-22, 1995
  • Characterizes the concentrations for
      • intubation
      • maintenance
      • on emergence
  • Concentrations are 50% response level

Intubation

300

Maintenance

200

Alfentanil Concentration (ng/ml)

Emergence

100

0

0

2

4

6

8

10

Propofol Concentration (mg/ml)

propofol remifentanil tiva
Propofol/Remifentanil TIVA
  • Remifentanil:
      • 0.25 mg/kg/min
  • Propofol:
      • 80 mg/kg/min
  • Requires controlled ventilation

Shafer SL, ASA Refresher Course, Chapter 19, 1996

  • Little tolerance for interruption of remifentanil or propofol infusion
slide31

10 Minute Infusion

Alfentanil

Fentanyl

Remifentanil

Sufentanil

slide32

60 Minute Infusion

Alfentanil

Fentanyl

Remifentanil

Sufentanil

slide33

600 Minute Infusion

Alfentanil

Fentanyl

Remifentanil

Sufentanil

slide34

Hierarchical Model of Drug Interaction

Opioids,N2O

Hypnotics

Conscious,Responsive

Cortex

AmbientStimuli

Unconscious,Unresponsive

SystemicOpioids

Pain projection

Midbrain,

Thalamus

N2O

Severe

to cortex

None

Spinal

Local

Opioids

Anesthetics

Pain projection

Severe

to midbrain

Peripheral nerves,

Spinal cord

None

Inspired by:

Glass PS.. Anesthesiology. 1998 88:5-6.

Pain

slide35

Hierarchical Model of Drug Interaction

AmbientStimuli

Afferent

Stimuli

Pain projection

to cortex

Pain

Pain

propofol remifentanil interaction surface bis
Propofol-RemifentanilInteraction Surface: BIS

Bouillon et al, Anesthesiology 2004

propofol remifentanil interaction surface bis39
Propofol-RemifentanilInteraction Surface: BIS

Bouillon et al, Anesthesiology 2004

my two cases
My two cases

1. Treat light anesthesia, then pontificate.

2. Don’t turn off your anesthetic for extended periods.

the aspect data base
The ASPECT Data Base
  • Patient trials (movement):
          • Thiopental
          • Propofol
          • Fentanyl/Alfentanil/Sufentanil
          • Isoflurane
          • Nitrous Oxide
  • Volunteer trials (recall, sedation, eyelash):
          • Propofol
          • Isoflurane
          • Alfentanil
          • Midazolam
predictors of movement
Predictors of Movement

Measure

Pk

0.74

Blood propofol

0.76

Effect-site propofol

Bispectral Index

0.86

Relative delta power

0.79

Relative beta power

0.83

95% SEF (Hz)

0.81

Median Frequency (Hz)

0.8

Leslie et al, Anesthesiology 84:52-63, 1996

slide48

Sedation, BIS, and Propofol

Glass et al, Anesthesiology 86:836-847, 1997

slide50

Conscious/Unconscious Prediction (Pk)

Target

Measured

Agent (n)

BIS

Concentration

Concentration

Propofol (399)

0.976 ± 0.006*

0.936 ± 0.010

0.937 ± 0.013

Isoflurane (70)

0.959 ± 0.021

0.965 ± 0.015

0.967 ± 0.016

Midazolam (50)

0.885 ± 0.047

0.859 ± 0.045

0.886 ± 0.048

Significantly different from Pk value for Target Concentration (p < 0.001),

and Measured concentration (p < 0.01)

Glass et al, Anesthesiology 86:836-847, 1997

p k for aai bis and predicted propofol concentrations when combined with remifentanil
PK for AAI, BIS, and Predicted Propofol Concentrations(when combined with remifentanil)

Struys et al, Anesthesiology 99:802-812

bottom line on awareness
Bottom line on awareness
  • Give enough drug.
  • Don’t completely paralyze patients unless absolutely necessary.
  • Look for changes in heart rate.
  • Respond to light anesthesia with a bolus of propofol.
  • BIS contains valuable additional information
  • Did I mention you need to give enough drug?
top 10 reasons to do tiva
Top 10 reasons to do TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
  • Patients like waking up from TIVA
isoflurane hyperalgesia
Isoflurane Hyperalgesia

Pamela Flood, preliminary data

propofol vs isoflurane
Propofol vs. Isoflurane

Pamela Flood, preliminary data

what is the role of n 2 o
What is the role of N2O?
  • Excellent analgesic in sub-MAC doses
  • MAC is around 110%.
      • MACasleep tends to be about 60% of MAC.
      • MACasleep for N2O is 68-73%
        • Well tolerated by most patients.
        • At N2O concentrations of 70%, there may be no need for additional drugs to ensure lack of awareness.
  • Has the fastest elimination of any hypnotic agent used in anesthesia.
      • If you want your patients to wake up quickly, keep them within N2O of being awake!
key concept
Key Concept
  • If you want your patients to wake up quickly, keep them within N2O of being awake!
setting up your pump
Setting up your pump
  • Check out your infusion pump as thoroughly as you check out your anesthesia machine.
      • Is your drug dilution correct?
      • Is the syringe and plunger properly held in the clamp?
      • Are your infusion units correct?
      • Is the weight correct (for calculator pumps)?
      • Has the dead space been taken out of the line?
      • Have the batteries been checked?
  • Think of the check out as though you were going to infuse sodium nitroprusside.
setting up drug infusions
Setting up drug infusions
  • Always infuse drug as close to the catheter as possible.
      • Typical IV tubing contains 5-8 mls of dead space between injection ports and catheter.
easy propofol remifentanil
Easy Propofol - Remifentanil
  • Add 1 mg of remifentanil to your 50 cc propofol syringe
  • Remifentanil concentration will be 20 mg/ml
  • Approach gives a bit less remi than you might otherwise use.
  • Use with 70% N2O, or increase propofol dose to 100-120 mg/kg/min
remifentanil maintenance infusion rates
Remifentanil Maintenance Infusion Rates
  • 1.0 mg/kg/min
      • Profound analgesia
  • 0.5 mg/kg/min
      • Paralysis required
  • 0.25 mg/kg/min
      • Ventilation required
      • > 50% MAC reduction
  • 0.1 mg/kg/min
      • May be satisfactoryfor spontaneous ventilation
steve s tiva approach
Steve’s TIVA Approach
  • Unremarkable IV induction
    • Propofol, fentanyl, relaxant
  • After induction, just run 66-70% nitrous oxide. Don’t start propofol/remi until BP recovers.
  • Remifentanil
    • Start @ 0.1 mg/kg/min
    • Maintain @ 0.05-0.3 mg/kg/min
  • Propofol
    • Start @ 40 mg/kg/min
    • Maintain @ 25-76 mg/kg/min
  • Either monitor BIS, or don’t fully paralyze
transition to postoperative analgesia
Transition to postoperative analgesia
  • Local Anesthesia
  • Methadone 5-10 mg
      • 45-60 minutes before the end of anesthesia
  • Morphine 5-10 mg
      • 15-30 minutes before the end of anesthesia
  • Fentanyl 50-100 mg
      • 5-10 minutes before the end of anesthesia