Download PDF
Anästhesiol Intensivmed Notfallmed Schmerzther 2000; 35(1): 12-20
DOI: 10.1055/s-2000-10845
ÜBERSICHT
Georg Thieme Verlag Stuttgart · New York

Target Controlled Infusion (TCI) - Stellenwert und klinische Perspektiven

Target Controlled Infusion (TCI) - Status and Clinical Perspectives.S. Schrag, J. Flaschar, M. Georgieff
  • Universitätsklinik für Anästhesiologie der Universität Ulm (Geschäftsführender Direktor: Prof. Dr. Michael Georgieff)
Further Information

Publication History

Publication Date:
31 December 2000 (online)

Also available at
    Permissions and Reprints

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 „DiprifusorTM” 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 „DiprifusorTM” 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
    PubMedGoogle Scholar
  • 2 Smith I, White P F, Nathanson M, Gouldson R. An update on its clinical use.  Anesthesiology. 1994;  81 1005-1043
    CrossrefPubMedGoogle Scholar
  • 3 Schraag S, Georgieff M. Intravenöse Anästhesie-aktuelle Aspekte.  Anästhesiol Intensivmed Notfallmed Schmerzther. 1995;  30 469-478
    PubMedGoogle Scholar
  • 4 Kruger-Thiemer E. Continuous intravenous infusion and multicompartmental accumulation.  Eur J Pharmacol. 1968;  4 317-324
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 7 Schwilden H. A general method for calculating the dosage scheme in linear pharmacokinetics.  Eur J Clin Pharmacol. 1981;  20 379-386
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 9 Gepts E. Pharmacokinetic concepts for TCI anaesthesia.  Anaesthesia. 1998;  53 4-12
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 11 Shafer S L, Gregg K M. Algorithms to rapidly achieve with a computer-controlled infusion pump.  J Pharmacokinet Biopharm. 1992;  20 147-169
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 15 White M, Kenny G N. Intravenous propofol anaesthesia using a computerised infusion system.  Anaesthesia. 1990;  45 204-209
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 19 Dyck J B, Shafer S L. Effects of age on propofol pharmacokinetics.  Sem Anesth. 1992;  11 2-4
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 23 Gray J M, Kenny G N. Development of the technology for „Diprifusor” TCI system.  Anaesthesia. 1998;  53 22-27
    PubMedGoogle Scholar
  • 24 Albrecht S, Hering W, Schüttler J, Schwilden H. Neue intravenöse Anästhetika. Remifentanil, S(+)-Ketamin und Target Controlled Infusion.  Anaesthesist. 1996;  45 1129-1141
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 27 Engbers F. Practical use of „Diprifusor” systems.  Anaesthesia. 1998;  53 28-34
    PubMedGoogle Scholar
  • 28 Servin F S. TCI compared with manually controlled infusion of propofol: a multicentre study.  Anaesthesia. 1998;  53 82-86
    PubMedGoogle Scholar
  • 29 Chaudhri S, White M, Kenny G N. Induction of anaesthesia with propofol using a target-controlled infusion system.  Anaesthesia. 1992;  47 551-553
    PubMedGoogle Scholar
  • 30 Tzabar Y, Brydon C, Gillies G W. Induction of anaesthesia with midazolam and a target-controlled propofol infusion.  Anaesthesia. 1996;  51 536-538
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 36 Vuyk J. Pharmacokinetic and pharmacodynamic interactions between opioids and propofol.  J Clin Anaesth. 1997;  9 23-26S
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 38 Jackson J. Siphoning from a syringe pump: a cause of sudden overdose.  Anaesth Intensive Care. 1983;  11 244-245
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 54 Kenny G N, McFadzean W, Mantzaridis H, Fisher A C. Propofol requirements during closed-loop anesthesia.  Anesthesiology. 1993;  79 A329
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar

Dr. Stefan Schraag

Universitätsklinik für Anästhesiologie

Universitätsklinikum Ulm

Steinhövelstraße 9

D-89075 Ulm

Email: stefanschraag@compuserve.com

      >