Total. Intravenous. ANAESTHESIA using target contro. Elderly. MAC Critica ill. Obese. Col Acad. College of Anaesthesiologists,

Transcription

1 Total Intravenous ANAESTHESIA using target contro controlled infusion A pocket p reference Elderly MAC Critically Critica ill O Obese College of Anaesthesiologists, Col Acad Academy of Medicine of Malaysia

2 01 TABLE OF CONTENTS Members of the expert panel Maintenance of anaesthesia 09 of total Members of the specialty expert panel TCI in MAC 17 Bibliography 18 Appendix 1: TIVA checklist 19 Appendix 2: Remifentanil College of Anaesthesiologists, Academy of Medicine of Malaysia

3 02 MEMBERS OF THE EXPERT PANEL Professor Dr Lim Thiam Aun (Chair) Dr Azizi Ahmad Consultant Anaesthesiologist, Lam Wah Ee Hospital, Penang Dr Lim Wee Leong Hospital Sungai Buloh, Selangor Dr Hari Krishnan Consultant Anaesthesiologist, Sime Darby Medical Centre Ara Damansara, Subang Jaya, Selangor Professor Dato Dr Wang Chew Yin Dr Thiagarajan Praba Dr Khoo Teik Hooi Consultant Anaesthesiologist, Hospital Pulau Pinang, Penang Dr Wan Mohd Nazaruddin Wan Hassan Dr Mohd Rohisham bin Zainal Abidin Consultant Anaesthesiologist, Putra Specialist Hospital, Malacca Disclaimer:

4 03 INTRODUCTION 1 2 Propofol

5 03 INTRODUCTION 3 Remifentanil 3 It has been established as the drug of choice for at steady state (V ss 1,3 Sufentanil 3 Alfentanil V ss, 3

6 03 INTRODUCTION A target controlled infusion allows the anaesthesiologist to match the Prep. Haemostasis Ind. Incision Closing Dressing Target conc (µg/ml) Time (min) overshoot of plasma conc. Target conc (µg/ml) Plasma conc Time (min)

7 04 APPROPRIATE INDICATIONS FOR TOTAL INTRAVENOUS ANAESTHESIA especially useful in: monitoring, such as spine surgery thoracoscopic surgery

8 05 PRINCIPLES OF TOTAL INTRAVENOUS ANAESTHESIA knowledge will ensure correct dosage that leads to smooth This hypnosis and analgesia pressure is persistently low

9 06 GENERAL CONSIDERATIONS This includes weight, age, height and gender Table 1. anaesthesia using target controlled infusions Drug Target Propofol Remifentanil 5. Drug dosage should always be adjusted according to

10 06 GENERAL CONSIDERATIONS elderly. monitors are mandatory.

11 07 GENERAL PRINCIPLES OF OPERATION

12 07 GENERAL PRINCIPLES OF OPERATION

13 08 INDUCTION OF ANAESTHESIA Table 2. Drug Target controlled infusion Constant rate infusion Single bolus dose Comments Propofol Remifentanil A Alfentanil Fentanyl Single bolus dose at induction is followed by remifentanil TCI, remifentanil constant for

14 09 MAINTENANCE OF ANAESTHESIA Table 3. Drug Target controlled infusion Constant rate infusion bolus dose Propofol Remifentanil Alfentanil

15 10 ALGORITHM FOR THE PRACTICAL MANAGEMENT OF TOTAL INTRAVENOUS ANAESTHESIA 1

16 10 ALGORITHM FOR THE PRACTICAL MANAGEMENT OF TOTAL INTRAVENOUS ANAESTHESIA Note: Note: should be gradually decreased to and then maintained

17 10 ALGORITHM FOR THE PRACTICAL MANAGEMENT OF TOTAL INTRAVENOUS ANAESTHESIA BIS IBISanhh, IBISan, BP YES Movement and NO Cnn nn Figure 1.

18 11 ALTERNATIVE TOTAL INTRAVENOUS ANAESTHESIA REGIMEN rates as detailed in Table 2 & Table 3: remifentanil or alfentanil:

19 11 ALTERNATIVE TOTAL INTRAVENOUS ANAESTHESIA REGIMEN BIS BP YES Movement and or NO C Figure 2. Dosage adjustment during maintenance of anaesthesia with constant rate infusion of remifentanil

20 12 TREATING POST-OPERATIVE PAIN AFTER REMIFENTANIL/ ALFENTANIL

21 13 MEMBERS OF THE SPECIALTY EXPERT PANEL Professor Dr Lim Thiam Aun (Chair) Dr Muhammad Maaya Dr Lim Teng Chow Consultant Anaesthesiologist, Hospital Melaka, Malacca Dr Azizi Ahmad Consultant Anaesthesiologist, Lam Wah Ee Hospital, Penang Dr Wan Mohd Nazaruddin Wan Hassan Consultant Anaesthesiologist, Putra Specialist Hospital, Melaka Dr Lim Wee Leong Hospital Sungai Buloh, Selangor Dr Thiagarajan Praba Disclaimer:

22 14 TIVA IN THE OBESE PATIENT 4 anaesthesia factory set defaults in the TCI pump: for 5 peripheral compartment is expected to increase with an increase Remifentanil

23 14 TIVA IN THE OBESE PATIENT (TBW) to the TCI pump and allow the selected model to calculate the infusion rates for the be during TIVA in model for propofol Marsh model, which inputs TBW and height) 7

24 15 TIVA IN THE ELDERLY PATIENT (see Table 4 Remifentanil:the monitoring during TIVA in elderly

25 15 TIVA IN THE ELDERLY PATIENT Table 4. more suitable as it has surgery, especially those carrying the ApoE4 8,9 Circulatory Psychomotor There is only a minor def 12

26 15 TIVA IN THE ELDERLY PATIENT to the TCI pump and allow the selected model to calculate the infusion rates for the desired target work and Marsh model, which inputs TBW

27 15 TIVA IN THE ELDERLY PATIENT and height) according

28 16 TIVA IN THE ASA III PATIENT Marsh model, which inputs TBW and height) the BIS

29 16 TIVA IN THE ASA III PATIENT followed Balance the need to reduce CVS depression with that of

30 17 TCI IN MAC 17,18 and IVI for anaesthesia distress is due to pain 22 TCI deep excellent model for propofol

31 17 TCI IN MAC model for remifentanil

32 17 TCI IN MAC May be used as a sole agent in the following dosage:

33 18 BIBLIOGRAPHY Anaesthesia & Intensive Care Medicine Base Primea and Injectomat et al Asia Pac J Clin Nutr guesswork? Eur J Anaesthesiol J Clin Anesth Current Anaesthesia & et al

34 18 BIBLIOGRAPHY et al Anesthesiology Drugs Aging Curr Opin Anaesthesiol et al Br J Anaesth et al PLoS One et al and elderly Br J Anaesth Chan MT, Cheng BC, Lee TM, et al J Neurosurg Anesthesiol

35 18 BIBLIOGRAPHY et al. Hospital stay and mortality are Anesthesiology et al Anesthesiology Anesth Analg et alminerva Anestesiol et al Korean J Anesthesiol J Clin Anesth et al. Korean J Anesthesiol

36 19 APPENDIX 1: TIVA CHECKLIST Schnider or Marsh Model (Age, Weight, remifentanil

37 19 APPENDIX 1: TIVA CHECKLIST

38 20 APPENDIX 2: REMIFENTANIL or ephedrine (c) decreased by decreasing infusion or administering a neuromuscular blocker

39 20 APPENDIX 2: REMIFENTANIL general anaesthesia

40 21 APPENDIX 3: TARGET CONCENTRATIONS AND DRUG DOSAGES Drug above before intub. if BP above above above

41 21 APPENDIX 3: TARGET CONCENTRATIONS AND DRUG DOSAGES Drug Propofol Constant infusion: non-obese Constant infusion: not above Remifentanil Constant infusion: non-obese Constant infusion: above Alfentanil TCI : not Constant infusion: non-obese non-obese above

42 College of Anaesthesiologists, Academy of Medicine of Malaysia This pocket reference is made possible by an unrestricted educaonal grant from AbbVie Sdn Bhd.