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ITIVA Lecture

The document provides guidelines for using target controlled infusion (TCI) of propofol and remifentanil for anesthesia, including recommended effect site concentrations for induction, maintenance of different surgical procedures, and emergence from anesthesia. It also discusses using BIS monitoring to guide propofol dosing and adjusting remifentanil to control hemodynamics and provide adequate analgesia. Clinical cases are presented as examples of applying these TCI guidelines for a brain MRI and laparoscopic cholecystectomy.

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pavel.ermolaev
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86 views16 pages

ITIVA Lecture

The document provides guidelines for using target controlled infusion (TCI) of propofol and remifentanil for anesthesia, including recommended effect site concentrations for induction, maintenance of different surgical procedures, and emergence from anesthesia. It also discusses using BIS monitoring to guide propofol dosing and adjusting remifentanil to control hemodynamics and provide adequate analgesia. Clinical cases are presented as examples of applying these TCI guidelines for a brain MRI and laparoscopic cholecystectomy.

Uploaded by

pavel.ermolaev
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Assistant for manual TCI

David Eduardo Ramírez


Anesthesiologist
Stress

Theoretical concentrations
for an adequate anesthesia

incision
Intubation

Apprehension
Surgical silence end of Sx
Time
TRICOMPARTIMENTAL MODELS
TRICOMPARTIMENTAL MODELS

DOSIS
Efecto
keo

k12 k13
V2 V1 V3
k21 k31

k10
Effect site: Hysteresis

Scott JC et al. Anesthesiology 1985;62:234-241


TCI
(Target controlled
infusion)
• Better hemodynamic stability
Less hypotension
Less bradycardia
• Fewer apnea episodes during sedation
• Reduced remifentanil consumption
Lower plasma concentration
High plasma concentrations are associated with
hyperalgesia
Example: Respiratory depression

Diederik J.F. Nieuwenhuijs. Response Surface Modeling of Remifentanil–Propofol Interaction on Cardiorespiratory Control and
Bispectral Index. Anesthesiology 2 2003, Vol.98, 312-322
Remifentanil 0.15 mcg/kg/min

Minuto Concentración (ng/ml)


- 1 0.4
- 2 1
- 5 2.2
- 10 3
- 30 3.8
Perfusors
Induction

Propofol ES Remifentanil ES NMB


Schnider: 4-6 mcg/ml LMA - OT 4 – 7 ng/ml 2 ED95
Eleveld: 2 – 3 mcg/ml Sedation: 0 – 1 ng/ml
Sedation 0 / 1 - 1.5
Maintenance ng/ml
Sx silence 2-3 ng/ml
Propofol ES Remifentanil ES
• Hypnosis -> 2.5 - 3 mcg/ml Soft tissue 3-4 ng/ml
2 – 6 ng/ml
• Sedation -> 1.5 – 2.5 mcg/ml Analgesia Abdomen 4-5 ng/ml
Laparoscopy 5-6 ng/ml
Thorax 6-7 ng/ml
BIS 40-60 TAS mmHg HR x Min
c

c
< 40 > 60 > 20% Basal < 20% Basal > 20% Basal < 40 bpm
Settings

↓ES 0.2 – 0.5 Check IV line ↑remifentanil ↓remifentanil ↑remifentanil ↓remifentanil


mcg/ml Optimize analgesia! 1-2 ng/ml 1-2 ng/ml 1-2 ng/ml 1-2 ng/ml
Imminent Awakening
NO YES • Crystalloid infusion
• Vasopressor Atropine
c

0.01mg/kg
↑ES 0.5 mcg/ml 50 mg bolus OR ↑ES mcg/ml
Schnider 3 / Eleveld 1

Emergence Remifentanil ES 2 – 3 ng/ml


Propofol ES mcg/ml Reversal NMB /
Schnider: 1 -1.5 3-5 min before end Sx TOF
Eleveld: 1.5 – 2 until extubation
For last skin sutures • Better hemodynamic, < Bucking
http://tinyurl.com/
TCIbasico
Clinical case
• Adult
• 66 year old
• Male
• Weight: 70 kg
• Height: 163 cm

• BRAIN MRI

• PROPOFOL TCI
Clinical case
• Adult
• 30 year old
• Male
• Weight: 77 kg
• Height: 168 cm

• Sx: laparoscopic cholecystectomy

• TIVA: PROPOFOL/REMIFENTANIL – CISATRACURIUM BOLUSES


david@itiva.co

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