Target Controlled Infusion (TCI) - Stellenwert und klinische Perspektiven

Zusammenfassung.

Die Entwicklung der intravenösen Anästhesie wurde in jüngster Zeit maßgeblich durch die Technik der Target Controlled Infusion (TCI) beeinflußt, die darüber hinaus noch weitere klinisch interessante Anwendungsmöglichkeiten in der perioperativen Medizin bietet. Die Markteinführung des „Diprifusor^TM” als erstes kommerziell verfügbares TCI System für Propofol kann als Meilenstein einer erfolgreichen Forschungstätigkeit während der letzten Dekade gelten, welche die pharmakokinetischen Grundlagen der Computer unterstützten intravenösen Anästhesie begründete. Gegenwärtig befinden wir uns in einer Phase, in der TCI Technologie nicht mehr nur forschenden Spezialisten und Enthusiasten vorbehalten ist, sondern vielmehr anfängt, ein Teil der klinischen Routine zu werden. Die vorliegende Übersicht beschreibt die pharmakokinetischen Grundlagen der TCI Entwicklung, vorläufige klinische Erfahrungen, und diskutiert technische Aspekte hinsichtlich Pumpen- und Modellgenauigkeit und mögliche Anwendungsprobleme in der Praxis. Darüber hinaus werden neue Konzepte der patienten-kontrollierten Applikation von Sedativa und Analgetika auf der Basis von TCI vorgestellt.

The technique of target controlled infusion (TCI) has influenced the development of intravenous anaesthesia substantially and opens the possibility of many new and exciting applications in peri-operative anaesthetic care. The launch of „Diprifusor^TM” as the first commercially available TCI system for propofol was the cornerstone of a successful research period within the last decade, which evaluated the pharmacokinetic foundations of computer assisted intravenous drug delivery. We are now in a period where TCI technology is becoming a part of routine anaesthesia technique for the practitioner rather than a research tool for specialists and enthusiasts. This review gives an update on the rational pharmacokinetic basis of TCI development, the preliminary clinical experience with the new technique, the performance and accuracy of TCI devices and potential technical pitfalls in clinical routine. Besides clinical application in anaesthesia with „Diprifusor®” TCI, target controlled systems are expected to play a significant role as research tools in the evaluation of drug interactions in anaesthesia and in the development of novel control techniques for the administration of sedative and analgesic drugs in the peri-operative period.

Schlüsselwörter:

Intravenöse Anästhesie - Propofol - Alfentanil - Remifentanil - Computer - Target Controlled Infusion

Key words:

Anaesthesia, intravenous - Anaesthetics, intravenous, propofol - Analgesics, alfentanil, remifentanil - Computer, target controlled infusion

Literatur

• 1 Bergman N. Early intravenous anesthesia: an eyewitness account.  Anesthesiology. 1990;  72 185-186
• 2 Smith I, White P F, Nathanson M, Gouldson R. An update on its clinical use.  Anesthesiology. 1994;  81 1005-1043
• 3 Schraag S, Georgieff M. Intravenöse Anästhesie-aktuelle Aspekte.  Anästhesiol Intensivmed Notfallmed Schmerzther. 1995;  30 469-478
• 4 Kruger-Thiemer E. Continuous intravenous infusion and multicompartmental accumulation.  Eur J Pharmacol. 1968;  4 317-324
• 5 Glass P S, Glen J B, Kenny G N, Schüttler J, Schafer S. Nomenclature for computer-assisted infusion devices.  Anesthesiology. 1997;  86 1430-1431
• 6 Kapila A, Glass P S, Jacobs J R, Muir K T, Hermann D J, Shiraishi M, Howell S, Smith R L. Measured context-sensitive half-times of remifentanil and alfentanil.  Anesthesiology. 1995;  83 968-975
• 7 Schwilden H. A general method for calculating the dosage scheme in linear pharmacokinetics.  Eur J Clin Pharmacol. 1981;  20 379-386
• 8 Roberts F L, Dixon J, Lewis G T, Tackley R M, Prys R C. Induction and maintenance of propofol anaesthesia. A manual infusion scheme.  Anaesthesia. 1988;  43 14-17
• 9 Gepts E. Pharmacokinetic concepts for TCI anaesthesia.  Anaesthesia. 1998;  53 4-12
• 10 Jacobs J R. Agorithm for optimal linear model-based control with application to pharmacokinetic model-driven drug delivery.  IEEE Trans Biomed Eng. 1990;  37 107-109
• 11 Shafer S L, Gregg K M. Algorithms to rapidly achieve with a computer-controlled infusion pump.  J Pharmacokinet Biopharm. 1992;  20 147-169
• 12 Varvel J R, Donoho D L, Shafer S L. Measuring the predictive performance of computer-controlled infusion pumps.  J Pharmacokinet Biopharm. 1992;  20 63-94
• 13 Alvis J M, Reves J G, Govier A V. Computer assisted continuous infusion of fentanyl during cardiac anesthesia: comparison with a manual method.  Anesthesiology. 1985;  63 41-49
• 14 Schüttler J, Kloos S, Schwilden H, Stoeckel H. Total intravenous anaesthesia with propofol and alfentanil by computer-assisted infusion.  Anaesthesia. 1988;  43 2-7
• 15 White M, Kenny G N. Intravenous propofol anaesthesia using a computerised infusion system.  Anaesthesia. 1990;  45 204-209
• 16 Shafer S L, Varvel J R, Aziz N, Scott J C. Pharmacokinetics of fentanyl administered by computer-controlled infusion pump.  Anesthesiology. 1990;  73 1091-1102
• 17 Tackley R M, Lewis G T, Prys R C, Boaden R W, Dixon J, Harvey J T. Computer controlled infusion of propofol.  Br J Anaesth. 1989;  62 46-53
• 18 Marsh B, White M, Morton N, Kenny G N. Pharmacokinetic model driven infusion of propofol in children.  Br J Anaesth. 1991;  67 41-48
• 19 Dyck J B, Shafer S L. Effects of age on propofol pharmacokinetics.  Sem Anesth. 1992;  11 2-4
• 20 Coetze J F, Glen J B, Wium C A, Boshoff P. Pharmacokinetic model selection for target controlled infusion of propofol.  Anesthesiology. 1995;  82 1328-1345
• 21 Swinhoe C F, Peacock J E, Glen J B, Reilly C S. Evaluation of the predictive performance of a „Diprifusor” TCI system.  Anaesthesia. 1998;  53 61-67
• 22 Davidson J A, Macleod A D, Howie J C, White M, Kenny G N. Effective concentration 50 for propofol with and without 67 % nitrous oxide.  Acta Anaesthesiol Scand. 1993;  37 458-464
• 23 Gray J M, Kenny G N. Development of the technology for „Diprifusor” TCI system.  Anaesthesia. 1998;  53 22-27
• 24 Albrecht S, Hering W, Schüttler J, Schwilden H. Neue intravenöse Anästhetika. Remifentanil, S(+)-Ketamin und Target Controlled Infusion.  Anaesthesist. 1996;  45 1129-1141
• 25 Taylor I, White M, Kenny G N. Assessment of the value and pattern of use of a target controlled propofol infusion system.  Int J Clin Monit Comput. 1993;  10 175-180
• 26 Russell D, Wilkes M P, Hunter S C, Glen J B, Hutton P, Kenny G N. Manual compared with target-controlled infusion of propofol.  Br J Anaesth. 1995;  75 562-566
• 27 Engbers F. Practical use of „Diprifusor” systems.  Anaesthesia. 1998;  53 28-34
• 28 Servin F S. TCI compared with manually controlled infusion of propofol: a multicentre study.  Anaesthesia. 1998;  53 82-86
• 29 Chaudhri S, White M, Kenny G N. Induction of anaesthesia with propofol using a target-controlled infusion system.  Anaesthesia. 1992;  47 551-553
• 30 Tzabar Y, Brydon C, Gillies G W. Induction of anaesthesia with midazolam and a target-controlled propofol infusion.  Anaesthesia. 1996;  51 536-538
• 31 Servin F S, Marchand M F, Desmonts J M. Influence of analgesic supplementation on the target propofol concentrations for anaesthesia with „Diprifusor” TCI.  Anaesthesia. 1998;  53 72-76
• 32 Schreiber M N, Schraag S, Flaschar F, Marx T, Kenny G NC, Georgieff M. Effektive Konzentration (EC 50) von Propofol während Lachgas- vs. Xenon-Anästhesie.  Anästhesiol Intensivmed Notfallmed Schmerzther. 1998;  33 S210
• 33 Vuyk J, Lim T, Engbers F H, Burm A G, Vletter A A, Bovill J G. The pharmacodynamic interaction of propofol and alfentanil during lower abdominal surgery in women.  Anesthesiology. 1995;  83 8-22
• 34 Vuyk J, Engbers F H, Burm A L, Vletter A A, Griever G E, Olofsen E, Bovill J G. Pharmacodynamic interaction between propofol and alfentanil when given for induction of anesthesia.  Anesthesiology. 1996;  84 288-299
• 35 Kazama T, Ikeda K, Morita K. Reduction of fentanyl of teh Cp50 values of propofol and hemodynamic responses to various noxius stimuli.  Anesthesiology. 1997;  87 213-227
• 36 Vuyk J. Pharmacokinetic and pharmacodynamic interactions between opioids and propofol.  J Clin Anaesth. 1997;  9 23-26S
• 37 Vuyk J, Mertens M J, Olofsen E, Burm A G, Bovill J G. Propofol anesthesia and rational opioid selection: determination of optimal EC50-EC95 propofol-opioid concentrations that assure adequate anesthesia and a rapid return of consciousness.  Anesthesiology. 1997;  87 1549-1562
• 38 Jackson J. Siphoning from a syringe pump: a cause of sudden overdose.  Anaesth Intensive Care. 1983;  11 244-245
• 39 Kataria B K, Ved S A, Nicodemus H F, Hoy G R, Lea D, Dubois M Y, Mandema J W, Shafer S L. The pharmacokinetics of propofol in children using three different data analysis approachis.  Anesthesiology. 1994;  80 104-122
• 40 Westmoreland C L, Sebel P S, Gropper A. Fentanyl or alfentanil decreases the minimum alveolar anesthetic concentration of isoflurane in surgical patients.  Anesth Analg. 1994;  78 23-28
• 41 Crankshaw D P, Morgan D J, Beemer G H, Karasawa F. Preprogrammed infusion of alfentanil to constant arterial plasma concentration.  Anesth Analg. 1993;  76 556-561
• 42 Schraag S, Mohl U, Hirsch M, Stolberg E, Georgieff M. Recovery from opioid anesthesia: the clinical implication of context-sensitive half-times.  Anesth Analg. 1998;  86 184-190
• 43 Schüttler J, Albrecht S, Breivik H, Osnes S, Prys R C, Holder K, Chauvin M, Viby M J, Mogensen T, Gustafson I, Lof L, Noronha D, Kirkham A J. A comparison of remifentanil and alfentanil in patients undergoing major abdominal surgery.  Anaesthesia. 1997;  52 307-317
• 44 Egan T D, Minto C F, Hermann D J, Barr J, Muir K T, Shafer S L. Remifentanil versus alfentanil: comparative pharmacokinetics and pharmacodynamics in healthy adult male volunteers.  Anesthesiology. 1996;  84 821-833
• 45 Davies F W, White M, Kenny G N. Postoperative analgesia using a computerised infusion of alfentanil following aortic bifurcation graft surgery.  Int J Clin Monit Comput. 1992;  9 207-212
• 46 Irwin M G, Jones R D, Visram A R, Kenny G N. Patient-controlled alfentanil. Target-controlled infusion for postoperative analgesia.  Anaesthesia. 1996;  51 427-430
• 47 Checketts M R, Gilhooly C J, Kenny G N. Patient-maintained analgesia with target-controlled alfentanil infusion after cardiac surgery: a comparison with morphine PCA.  Br J Anaesth. 1998;  80 748-751
• 48 Van den Nieuwenhuyzen M, Engbers F H, Burm A G, Vletter A A, Van K J, Bovill J G. Computer-controlled infusion of alfentanil versus patient-controlled administration of morphine for postoperative analgesia: a double-blind randomized trial.  Anesth Analg. 1995;  81 671-679
• 49 Van den Nieuwenhuyzen M, Engbers F H, Burm A G, Vletter A A, Van K J, Bovill J G. Target-controlled infusion of alfentanil for postoperative analgesia: a feasibility study and pahrmacodynamic evaluation in the early postoperative period.  Br J Anaesth. 1997;  78 17-23
• 50 Schraag S, Kenny G N, Mohl U, Georgieff M. Patient-maintained remifentanil target-controlled infusion for the transition to early postoperative analgesia.  Br J Anaesth. 1998;  81 365-368
• 51 Irwin M G, Thompson N, Kenny G N. Patient-maintained propofol sedation. Assessment of a target-controlled infusion system.  Anaesthesia. 1997;  52 525-530
• 52 Murdoch J AC, Kenny G N. Patient-maintained propofol sedation as premedication in day-case surgery: assessment of a target-controlled system.  Br J Anaesth. 1999;  82 429-431
• 53 Mortier E, Struys M, De S T, Versichelen L, Rolly G. Closed-loop controlled administration of propofol using bispectral analysis.  Anaesthesia. 1998;  53 749-754
• 54 Kenny G N, McFadzean W, Mantzaridis H, Fisher A C. Propofol requirements during closed-loop anesthesia.  Anesthesiology. 1993;  79 A329
• 55 Stockmanns G, Nahm W, Thornton C, Shannon C, Konecny E, Kochs E. Wavelet analysis of middle latency auditory evoked potentials during repetitive propofol sedation.  Anesthesiology. 1997;  87 A465
• 56 Jensen E W, Nebot A, Caminal P, Henneberg S W. Identification of causal relations between haemodynamic variables, auditory evoked potentials and isoflurane by means of fuzzy logic.  Br J Anaesth. 1999;  82 25-32
• 57 Suttner S, Boldt J, Schmidt C, Piper S, Kumle B. Cost analysis of target-controllted infusion-based anesthesia compared with standard anesthesia regimens.  Anesth Analg. 1999;  88 77-82