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BIS EVALUATION IN TCI
ANESTHESIA BY PROPOFOL
Nguyễn Văn Chinh, MD, PhDProf. Nguyễn Văn Chừng, MD, PhD
INTRODUCTION
New situation: Science Equipments and techniques Advances in medical technology…
New techniques:TCI: Target Controlled InfusionBIS: Bispectral Index
INTRODUCTION
TARGET CONTROLLED INFUSION
Time
Time
Plasma Concentration (Cp)
TCI
1968
1981
1997
Now
BET: Bolus Elimination Transfer
DipprifusorSchwilden
FRANCE
KrugerThiemer
Many Hospital
TCI HISTORY
TARGET CONTROLLED INFUSION
TARGET CONTROLLED INFUSION
Cp
(Ce)
Dose
TARGET CONTROLLED INFUSION
(Ce)
Drugs Fomula Population Data file
Midazolam Zomorodi Adult Weight, Age, height
Propofol Marsch
Schnider
Katarian
Adult, Children
26 – 81 years of age
3 – 11 years of age
Weight, Age
Weight, Age, height
WeightSufentanil Gepts
Minto
Adult
20 – 85 years of age
Weight
Weight, Age, height
TARGET CONTROLLED INFUSION
Target of Propofol (Diprivan)Loss of consciousness: Cp: 1,9 – 7,7 mcg/ml
Ce: 1,1 – 4,7 mcg/ml
Loss of pain response: Cp: 3 – 6,8 mcg/ml
Maintenance: Cp: 2,5 – 6,8 mcg/ml
Cp: 4 – 7 mcg/ml
Awareness: Ce: 1,1 – 1,3 mcg/ml
TARGET CONTROLLED INFUSION
BIS TECHNOLOGY
1987-1997
1998
2003
Now
FDA
FDAMonitorA 2000
BIS BIS TechnologyTechnology
Research
ManyHospital
BIS HISTORY
BIS TECHNOLOGY
0
20
40
60
80
100
BIS 50
BIS ValueChỉ số
BIS TrendBiểu đồ lưu
EEG WaveformĐiện não đồ dạng sóng
EMG (electromyogram)Điện cơ đồ
SQI (signal quality index)Chỉ số chất lượng tín hiệu
SR (suppression ratio)Tỉ lệ ngừng phát xung
SQI 90
SQI
EMG 40
EMG
SR 0
BIS Display Information
Incidence of Inappropriate SedationIncidence of Inappropriate Sedation
Over-sedation/ Quá liều
On Target/ Đủ liều
Under-sedation/ Chưa đủ liều
54%
15.4%
30.6%
Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110.
Olson D et al. NTI Proceedings. 2003; CS82:196.
10%20%
70%
Kaplan L. and Bailey H. Kaplan L. and Bailey H. 20002000
Olson D. et al.Olson D. et al.20032003
EEG Response to Anesthetics EEG Response to Anesthetics
Donald R. Stanski and Steven L. Shafer, Miller’s Anesthesia, ed. Ronald D. Miller (Philadelphia: Elsevier Inc., 2005), p. 1253.
15
MANAGING HYPNOTIC LEVEL
AWAKE/AWAKE/T NHỈT NHỈ
FLAT LINE EEG/FLAT LINE EEG/EEG hi n th ph ngể ị ẳEEG hi n th ph ngể ị ẳ
High risk of awareness
Deep AnesthesiaLonger Recovery
100
70
60
0
Optimal Depth of
Unconsciousness
Đ sâu gây mê t i uộ ố ư 45
Sedation
BIS-Guided Agent
Titration/BIS hướng dẫn điều chỉnh thuốc mê
Assumes Adequate Analgesia in Technique
OBJECTIVES
This study is performed to evaluate a change of Bispectral Index (BIS) in target controlled infusion (TCI) anesthesia.
METHODS
Prospective study on 54 patients From July 2011 to July 2013. All of them have undergone general anesthesia.
Pulse, blood presure, resspiratory rate and health status of the patients were monitored right before and after anesthesia.
Close careful monitoring during and after the operation must be applied in order to detect and manage in time complications.
METHODS
Premedication: Midazolam 0,04mg/kg + Fentanyl 2-3mcg/kgInduction:
O2: 3-5 minutes
Propofol (Diprivan) TCI: Cp: 6 mcg/ mlRocuronium: 0,3-0,6 mg/kgPLMA or Intubation: Ce: 3,5 – 4mcg/ml.Maintenance:Cp: 2-3mcg/ ml after PLMA or Intubation. Ventilation, Fentanyl and Rocuronium.
RESULTS AND DISCUSSION
ÑAËC ÑIEÅM CHUNG
Features Mean
Age 47,21 ± 5,52
Weight (kg) 53,17 ± 8,63
Height (cm) 151,06 ± 12,13
N 54
ADD DISEASE
Features n (%)
Circulation 5 (9,25)
Respiration 2 (3,70)
Diabetes 4 (7,41)
Other Disease 3 (5,56)
RESULTS AND DISCUSSION
Loss of consciousness time:
Loss of consciousness at Cp: 1,42 ± 0,27 mcg/ml, BIS: 63,66 ± 5,53.
Cp (mcg/ml)
BIS Time (s)
This Research 1,42 ± 0,27 63,66 ± 5,53 82,14 ± 10,42
Macquaire, Absalom vaø Struys.
1,4 – 1,9 68,37 ± 8,22 90 - 110
RESULTS AND DISCUSSION
Induction:
TCI had lower induction doses
Induction doses of Kenny: Cp: 8 mcg/ml
Propofol (mg/kg)
BIS
This Research 1,47 ± 0,06 44,11 ± 2,63
Macquaire 1,41 ± 0,09 40 – 60
Struys 1,31 ± 0,11 40 – 60
RESULTS AND DISCUSSION
Maintenance:
Nghieân cöùu
Cp (mcg/ml) Giaù trò BIS
This Research 3 40 – 60
Irwin 3,82 45
Ngai Liu 3,8 40 – 60
Struys 5,4 40 – 60
RESULTS AND DISCUSSION
Maintenance: BIS monitoring values helped guide anesthetic dosing. Decreasing the risk of awareness and recognizing Lehman: smooth maintenance by TCIRussel and Struys: Less hemodynamic changes and
smooth maintenance by TCI.Bonnin: Easy titration during TCI anaesthesia.
RESULTS AND DISCUSSION
RESULTS AND DISCUSSION
Following awareness with recall, 33–69% of the patients suffer from late psychological symptoms, incl. Post Traumatic Stress Disorder (PTSD)
Samuelsson et al., Anesthesiology. 2007 Jan;106(1):26-32.
Hemodynamic changes in anesthesia:
Less hemodynamic changes in anesthesia.Kazama: more hemodynamic changes in elderly patients.Tackley: less hemodynamic changes in anesthesia.
RESULTS AND DISCUSSION
Awareness stage :This Research: short recovery times, decreasing the
risk of awareness and recall.
Leslie: haven’t recall during anaesthesia at Cp level loss of consciousness.
Sandin: about 0,16% recall during anaesthesia.
Vermon: Decreasing the risk of awareness and recall at BIS 40 – 60.
RESULTS AND DISCUSSION
Clinical judgment should always be used when interpreting BIS in conjunction with other available clinical signs.
Reliance on the BIS alone for intraoperative anesthetic management is not recommended.
BIS values should be interpreted cautiously in patients:
With known neurological disorders
Taking psychoactive medications
In children below the age of one
RESULTS AND DISCUSSION
CONCLUSIONS
Propofol target controlled infusion is safe and effective.
Quick loss of consciousness.
Lower induction doses, smooth inductions.
Less hemodynamic changes in anesthesia.
Short recovery times, improve patient recovery.
Reduce the risk of awareness with recall during anaesthesia.
Thanks!