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1A02
S
Objectives
S
Benefits of TIVA
S Anti-emetic benefits
S No Malignant Hyperthermia
S
TIVA anaesthesia requirements:
S
3 Compartment Model
S
• Drug injected into Central compartment V1
• Initial volume of distribution
• Comparable to ‘plasma’
• Redistribution into second compartment (V2)
• “vessel-rich” or “fast”
• Redistribution into third compartment (V3)
• “vessel-poor” or “slow”
• Governed by rate constant / concentration
gradient
• Exponential process
• Elimination
• Fixed rate
Achieving a constant plasma
level
3 mcg/ml
But:
S “open-loop” systems
S If user wishes to decrease the level then the pump will stop
and allow the level to fall before restarting
Plasma vs Effect site
Targeting
S
S The clinical effect of Propofol is related to brain
concentration = effect site
Nomenclature of TCI:
Cp = Plasma concentration
S
Evidence for Manual vs. TCI
S 1759 patients
S
2 available models for Propofol TCI in adults:
S Marsh
S Schnider
Marsh Model
S Published in 1991
S Published in 1998
V2 32.4 L 24.0 L
S
1. Time To Peak Effect
S Schnider does
Weight
Marsh model
But….
Servin formula:
S
Minto model
S 3 compartment model
S
Preventing awareness
1. Infusion pumps
S Maintained
S Appropriate alarms
S Deliver the drug how you want to deliver it
S You are competent and trained in their use
2. Drugs
S Correct drug in correct concentration in correct pump
S Appropriate model and dosing selected
Preventing awareness
S
Improving TCI
2. Multi-drug models
Summary
1. TIVA rocks
2. Effect-site targeting rocks
3. Use Schnider for effect-site targeting
4. Use Marsh for plasma targeting
5. IBW + ‘a bit’ for Marsh model
6. TBW for Schnider and Minto models
7. Use BIS……