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
01 TABLE OF CONTENTS Members of the expert panel 02 03 04 05 06 07 08 Maintenance of anaesthesia 09 of total 10 11 12 Members of the specialty expert panel 13 14 15 16 TCI in MAC 17 Bibliography 18 Appendix 1: TIVA checklist 19 Appendix 2: Remifentanil 20 21 2013 College of Anaesthesiologists, Academy of Medicine of Malaysia
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:
03 INTRODUCTION 1 2 Propofol
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
03 INTRODUCTION A target controlled infusion allows the anaesthesiologist to match the Prep. Haemostasis Ind. Incision Closing Dressing Target conc (µg/ml) 6 4 2 0 0 20 40 60 80 100 120 Time (min) overshoot of plasma conc. Target conc (µg/ml) 8 6 4 2 Plasma conc. 0 0 30 60 90 120 Time (min)
04 APPROPRIATE INDICATIONS FOR TOTAL INTRAVENOUS ANAESTHESIA especially useful in: monitoring, such as spine surgery thoracoscopic surgery
05 PRINCIPLES OF TOTAL INTRAVENOUS ANAESTHESIA knowledge will ensure correct dosage that leads to smooth This hypnosis and analgesia pressure is persistently low
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
06 GENERAL CONSIDERATIONS elderly. monitors are mandatory.
07 GENERAL PRINCIPLES OF OPERATION
07 GENERAL PRINCIPLES OF OPERATION
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
09 MAINTENANCE OF ANAESTHESIA Table 3. Drug Target controlled infusion Constant rate infusion bolus dose Propofol Remifentanil Alfentanil
10 ALGORITHM FOR THE PRACTICAL MANAGEMENT OF TOTAL INTRAVENOUS ANAESTHESIA 1
10 ALGORITHM FOR THE PRACTICAL MANAGEMENT OF TOTAL INTRAVENOUS ANAESTHESIA Note: Note: should be gradually decreased to and then maintained
10 ALGORITHM FOR THE PRACTICAL MANAGEMENT OF TOTAL INTRAVENOUS ANAESTHESIA BIS IBISanhh, IBISan, BP YES Movement and NO Cnn nn Figure 1.
11 ALTERNATIVE TOTAL INTRAVENOUS ANAESTHESIA REGIMEN rates as detailed in Table 2 & Table 3: remifentanil or alfentanil:
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
12 TREATING POST-OPERATIVE PAIN AFTER REMIFENTANIL/ ALFENTANIL
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:
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
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
15 TIVA IN THE ELDERLY PATIENT (see Table 4 Remifentanil:the monitoring during TIVA in elderly
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
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 13 14 15 Marsh model, which inputs TBW
15 TIVA IN THE ELDERLY PATIENT and height) according
16 TIVA IN THE ASA III PATIENT Marsh model, which inputs TBW and height) the BIS
16 TIVA IN THE ASA III PATIENT followed Balance the need to reduce CVS depression with that of
17 TCI IN MAC 17,18 and IVI for anaesthesia 19 21 distress is due to pain 22 TCI deep excellent model for propofol
17 TCI IN MAC model for remifentanil
17 TCI IN MAC May be used as a sole agent in the following dosage:
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
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
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
19 APPENDIX 1: TIVA CHECKLIST Schnider or Marsh Model (Age, Weight, remifentanil
19 APPENDIX 1: TIVA CHECKLIST
20 APPENDIX 2: REMIFENTANIL or ephedrine (c) decreased by decreasing infusion or administering a neuromuscular blocker
20 APPENDIX 2: REMIFENTANIL general anaesthesia
21 APPENDIX 3: TARGET CONCENTRATIONS AND DRUG DOSAGES Drug above before intub. if BP above above above
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
College of Anaesthesiologists, Academy of Medicine of Malaysia This pocket reference is made possible by an unrestricted educaonal grant from AbbVie Sdn Bhd.