Total Intravenous Anesthesia: from Pharmaceutics to Pharmacokinetics
Keywords:
Intravenous anesthesia, remifentanyl, propofol, infusion pump, nomograms
Abstract
Introduction. The availability of medications such as remifentanyl and propofol has made anesthesiologists feel the need to understand the basics of total intravenous anesthesia (TIVA). In fact. beyond knowing how to develop a pharmacokinetic model, it is essential to differentiate among the pharmaceutical, pharmacokinetic and pharmacodynamic approach for administering a particular drug.
Objective. To review the basic concepts the modern anesthesiologist needs for the pharmacokinetic administration of the drugs used for intravenous anesthesia.
Methodology. A search of the indexed literature was done to identify educational and illustrative articles about total intravenous anesthesia concepts and pharmacokinetics. The most relevant articles were selected for this review and it was supplemented with anesthesia textbooks in the guearea of pharmacokinetics and total intravenous anesthesia.
Results. 51 articles and 5 chapters from textbooks on anesthesia were selected. Regardless of the instruments used or how accurate they may be, what is really important is knowing that we have the tools available and based on the estimated plasma levels, we can adjust the anesthesia to the different stages of the surgical procedure; in the case of remifentanyl, it can be adjusted to the specific conditions such as the age of the patient.
The point is that the anesthesiologist has to evolve keeping pace with the increasingly more predictable drugs now available and with the possibility of achieving a safer, more predictable and costeffective anesthesia with greater control both by the experienced professional and the trainee.
References
1. Campbell L, Engbers FH, Kenny GNC. Total intravenous anesthesia. Anesthesia. 2001;3(3):109-19.
2. Kerdel F. El diario de William Harvey. 2008 Jul 12 citado 2009 Nov 3. En: Bitácora médica blog Internet. Kerdel F. Disponible en: http://bitacoramedica.com/weblog/?p=427.
3. Halford FJ. A critique of intravenous anesthesia in war surgery. Anesthesiology. 1943;4(1):67-9.
4. Kay B, Stephenson DK. ICI 35868 (Diprivan): a new intravenous anesthetic. A comparison with Althesin. Anaesthesia. 1980;35(12):1182-7.
5. Glass PS, Hardman D, Kamiyama Y, Quill TJ, Marton G, Donn KH, et al. Preliminary pharmacokinetics and pharmacodynamics of an ultra-short-acting opioid: remifentanil (GI87084B). Anesth Analg. 1993;77(5):1031-40.
6. Schwilden H. A general method for calculating the dosage scheme in linear pharmacokinetics. Eur J Clin Pharmacol. 1981;20(5):379-86.
7. Voss LJ, Ludbrook G, Grant C, Upton R, Sleigh JW. A comparison of pharmacokinetic/pharmacodynamic versus mass-balance measurement of brain concentrations of intravenous anesthetics in sheep. Anesth Analg. 2007;104(6):1440-6.
8. Eyres R. Update on TIVA. Paediatr Anaesth. 2004;14(5):374-9.
9. Grahame-Smith DG. How will knowledge of the human genome affect drug therapy? Br J Clin Pharmacol. 1999;47(1):7-10.
10. Pennant J, White P. The laryngeal mask airway. Its uses in anesthesiology. Anesthesiology. 1993;79(1):144-63.
11. White PF. Use of continuous infusion versus intermittent bolus administration of fentanyl or ketamine during outpatient anesthesia. Anesthesiology. 1983;59(4):294-300.
12. Ausems ME, Vuyk J, Hug CC Jr, Stanski DR. Comparison of a computer-assisted infusion versus intermittent bolus administration of alfentanil as a supplement to nitrous oxide for lower abdominal surgery. Anesthesiology. 1988;68(6):851-61.
13. Pang KS, Weiss M, Macheras P. Advanced pharmacokinetic models based on organ clearance, circulatory, and fractal concepts. AAPS J. 2007;9(2):E268- 83.
14. Upton RN. The two-compartment recirculatory pharmacokinetic model an--introduction to recirculatory pharmacokinetic concepts. Br J Anaesth. 2004;92(4):475-84.
15. Carrasco MS. Aspectos farmacológicos de la anestesia intravenosa. Rev Venez Anestesiol. 2002;7(2):90- 7.
16. Aguilera L. Conceptos básicos de farmacocinética farmacodinámia en TIVA Internet. Grupo de Anestesia Total Intravenosa; 2008. 2008 Jun 1 citado 2009 Nov 3; Disponible en: http://www.tivabcn.org/ponencias.html.
17. Wagner Jon G. Farmacocinética clínica. Barcelona: Reverté; 1983. p. 146-8.
18. Galeazzi RL, Benet LZ, Sheiner LB. Relationship between the pharmacokinetics and pharmacodynamics of procainamide. Clin Pharmacol Ther. 1976;20(3):278-89.
19. Muñoz JH. Anestesia basada en analgesia. Rev Mex Anest. 2007;30(Suppl 1):S180-4.
20. Gupta D, Henthorn T. Pharmacologic principles. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M, Stock MC (editors). Clinical anesthesia. 6th Ed. Philadelphia: Lippincott; 2009. p. 137-64.
21. Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanyl. II. Model application. Anesthesiology. 1997;86(1):24-33.
22. Minto CF, Schnider TW, Gregg KM, Henthorn TK, Shafer SL. Using the time of maximum effect site concentration to combine pharmacokinetics and pharmacodynamics. Anesthesiology. 2003;99(2):324-33.
23. Sepúlveda P. Actualizaciones en modelación, drogas y tecnologías complementarias. La anestesia intravenosa II. Santiago de Chile: Sociedad de Anestesiología de Chile, Clínica Alemana de Santiago, Universidad del Desarrollo; 2006. p. 209-15.
24. Coetzee JF, Glen JB, Wium CA, Boshoff L. Pharmacokinetic model selection for target controlled infusions of propofol. Assessment of three parameter sets. Anesthesiology. 1995;82(6):1328-45.
25. Glen JB. The development of 'Diprifusor': a TCI system for propofol. Anesthesia. 1998;53 Suppl 1:13-21.
26. Marsh B, White M, Morton N, Kenny GN. Pharmacokinetic model driven infusion of propofol in children. Br J Anaesth. 1991;67(1):41-8.
27. Schnider TW, Minto CF, Shafer SL, Gambus PL, Andresen C, Goodale DB, et al. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999;90(6):1502-16.
28. Schnider TW, Minto CF, Gambus PL, Andresen C, Goodale DB, Shafer SL, et al. The influence of method of administration and covariates on the pharmacokinetics of propofol in adult volunteers. Anesthesiology. 1998;88(5):1170-82.
29. White P, Eng M. Intravenous anesthetics. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M, Stock MC (editors). Clinical anesthesia. 6th Ed. Philadelphia: Lippincott; 2009: 444-64.
30. Barakat AR, Sutcliffe N, Schwab M. Effect site concentration during propofol TCI sedation: a comparison of sedation score with two pharmacokinetic models. Anaesthesia. 2007;62(7):661-6.
31. Schnider T, Minto C. Pharmacokinetic models of propofol for TCI. Anesthesia. 2008;63(2):206.
32. Absalom AR, Mani V, De Smet T, Struys MM. Pharmacokinetic models for propofol--defining and illuminating the devil in the detail. Br J Anaesth. 2009;103(1):26-37.
33. Minto CF, Schnider TW, Egan TD, Youngs E, Lemmens HJ, Gambus PL, et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology. 1997;86(1):10-23.
34. Shafer SL, Varvel JR, Aziz N, Scott JC. Pharmacokinetics of fentanyl administered by computer-controlled infusion pump. Anesthesiology. 1990;73(6):1091- 102.
35. Shibutani K, Inchiosa MA, Sawada K, Bairamian M. Accuracy of pharmacokinetic models for predicting plasma fentanyl concentrations in lean and obese surgical patients: derivation of dosing weight ("pharmacokinetics mass"). Anesthesiology. 2004;101(3):603- 13.
36. Shafer SL, Varvel JR. Pharmacokinetics, pharmacodynamics, and rational opioid selection. Anesthesiology. 1991;74(1):53-63.
37. Harris RS, Lazar O, Johansen JW, Sebel PS. Interaction of propofol and sevoflurane on loss of consciousness and movement to skin incision during general anesthesia. Anesthesiology. 2006;104(6):1170-5.
38. Mertens MJ, Olofsen E, Engbers FH, Burm AG, Bovill JG, Vuyk J. Propofol reduces perioperative remifentanil requirements in a synergistic manner: response surface modeling of perioperative remifentanil-propofol interactions. Anesthesiology. 2003;99(2):347-59.
39. Marcou TA, Marque S, Mazoit JX, Benhamou D. The median effective dose of tramadol and morphine for postoperative patients: a study of interactions. Anesth Analg. 2005;100(2):469-74.
40. Vuyk J, Mertens MJ, Olofsen E, Burm AG, Bovill JG. 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(6):1549-62.
41. Roberts FL, Dixon J, Lewis GTR, Tackley RM, Prys- Roberts C. Induction and maintenance of propofol anaesthesia. A manual infusion scheme. Anesthesia. 1988;43 Suppl:14-7.
42. Servin FS. TCI compared with manually controlled infusion of propofol: a multicentre study. Anaesthesia. 1998;53(Suppl 1):82-6.
43. Russell D, Wilkes MP, Hunter SC, Glen JB, Hutton P, Kenny GN. Manual compared with target-controlled infusion of propofol. Br J Anesth. 1995;75(5):562-6.
44. Engbers FH. Target controlled infusion in practice. Eur J Anesthesiol Suppl. 1995;12(10):88-90.
45. Moerman AT, Herregods LL, De Vos MM, Mortier EP, Struys MM. Manual versus target-controlled infusion remifentanil administration in spontaneously breathing patients. Anesth Analg. 2009;108(3):828-34.
46. O'Hare RA, Mirakhur RK. Intravenous anesthesia: Manual or target controlled infusion systems. Anesthesiology. 1999;91:A345.
47. Breslin DS, Mirakhur RK, Reid JE, Kyle A. Manual versus target-controlled infusions of propofol. Anaesthesia. 2004;59(11):1059-63.
48. Tafur LA, Serna AM, Lema E. Fentanilo PK/PD, un medicamento vigente. Rev Col Anest. 2010;38(1):68- 83.
49. Tafur LA, Gómez JM, Parra LE. Validación de nomogramas de remifentanil y propofol para la administración de anestesia total endovenosa. Rev Colomb Anestesiol. 2009;37(1):21-8.
50. Gómez JM, Tafur LA, Quintero I, Figueroa S, Serna A. Gutiérrez A. Infusión manual única de remifentanil y propofol para anestesia en cirugía laparoscópica ginecológica: serie de casos. Rev Esp Anestesiol Reanim. 2010;57(4):71-8.
51. Ithnin F, Lim Y, Shah M, Shen L, Sia AT. Tracheal intubating conditions using propofol and remifentanil target-controlled infusion: a comparison of remifentanil EC50 for Glidescope and Macintosh. Eur J Anaesthesiol. 2009;26(3):223-8.
52. Milne SE, Troy A, Irwin MG, Kenny GN. Relationship between bispectral index, auditory evoked potential index and effect-site EC50 for propofol at two clinical end-points. Br J Anaesth. 2003;90(2):127-31.
53. Xu Z, Liu F, Yue Y, Ye T, Zhang B, Zuo M, et al. C50 for propofol-remifentanil target-controlled infusion and bispectral index at loss of consciousness and response to painful stimulus in Chinese patients: a multicenter clinical trial. Anesth Analg. 2009;108(2):478-83.
54. Nunes CS, Ferreira DA, Antunes L, Lobo F, Santos IA, Amorim P. Individual effect-site concentrations of propofol at return of consciousness are related to the concentrations at loss of consciousness and age in neurosurgical patients. J Clin Anesth. 2009;21(1):3- 8.
55. Nunes CS, Ferreira DA, Antunes L, Lobo F, Amorim P. Propofol predicted effect concentrations at loss of consciousness are strongly correlated with predicted concentrations at recovery of consciousness. J Neurosurg Anesthesiol. 2004;16(4):342-3.
56. Tafur LA, Lema E. Aplicación práctica de los nomogramas de remifentanilo y propofol. Rev Col Anest. 2010;37(4):310-20.
2. Kerdel F. El diario de William Harvey. 2008 Jul 12 citado 2009 Nov 3. En: Bitácora médica blog Internet. Kerdel F. Disponible en: http://bitacoramedica.com/weblog/?p=427.
3. Halford FJ. A critique of intravenous anesthesia in war surgery. Anesthesiology. 1943;4(1):67-9.
4. Kay B, Stephenson DK. ICI 35868 (Diprivan): a new intravenous anesthetic. A comparison with Althesin. Anaesthesia. 1980;35(12):1182-7.
5. Glass PS, Hardman D, Kamiyama Y, Quill TJ, Marton G, Donn KH, et al. Preliminary pharmacokinetics and pharmacodynamics of an ultra-short-acting opioid: remifentanil (GI87084B). Anesth Analg. 1993;77(5):1031-40.
6. Schwilden H. A general method for calculating the dosage scheme in linear pharmacokinetics. Eur J Clin Pharmacol. 1981;20(5):379-86.
7. Voss LJ, Ludbrook G, Grant C, Upton R, Sleigh JW. A comparison of pharmacokinetic/pharmacodynamic versus mass-balance measurement of brain concentrations of intravenous anesthetics in sheep. Anesth Analg. 2007;104(6):1440-6.
8. Eyres R. Update on TIVA. Paediatr Anaesth. 2004;14(5):374-9.
9. Grahame-Smith DG. How will knowledge of the human genome affect drug therapy? Br J Clin Pharmacol. 1999;47(1):7-10.
10. Pennant J, White P. The laryngeal mask airway. Its uses in anesthesiology. Anesthesiology. 1993;79(1):144-63.
11. White PF. Use of continuous infusion versus intermittent bolus administration of fentanyl or ketamine during outpatient anesthesia. Anesthesiology. 1983;59(4):294-300.
12. Ausems ME, Vuyk J, Hug CC Jr, Stanski DR. Comparison of a computer-assisted infusion versus intermittent bolus administration of alfentanil as a supplement to nitrous oxide for lower abdominal surgery. Anesthesiology. 1988;68(6):851-61.
13. Pang KS, Weiss M, Macheras P. Advanced pharmacokinetic models based on organ clearance, circulatory, and fractal concepts. AAPS J. 2007;9(2):E268- 83.
14. Upton RN. The two-compartment recirculatory pharmacokinetic model an--introduction to recirculatory pharmacokinetic concepts. Br J Anaesth. 2004;92(4):475-84.
15. Carrasco MS. Aspectos farmacológicos de la anestesia intravenosa. Rev Venez Anestesiol. 2002;7(2):90- 7.
16. Aguilera L. Conceptos básicos de farmacocinética farmacodinámia en TIVA Internet. Grupo de Anestesia Total Intravenosa; 2008. 2008 Jun 1 citado 2009 Nov 3; Disponible en: http://www.tivabcn.org/ponencias.html.
17. Wagner Jon G. Farmacocinética clínica. Barcelona: Reverté; 1983. p. 146-8.
18. Galeazzi RL, Benet LZ, Sheiner LB. Relationship between the pharmacokinetics and pharmacodynamics of procainamide. Clin Pharmacol Ther. 1976;20(3):278-89.
19. Muñoz JH. Anestesia basada en analgesia. Rev Mex Anest. 2007;30(Suppl 1):S180-4.
20. Gupta D, Henthorn T. Pharmacologic principles. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M, Stock MC (editors). Clinical anesthesia. 6th Ed. Philadelphia: Lippincott; 2009. p. 137-64.
21. Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanyl. II. Model application. Anesthesiology. 1997;86(1):24-33.
22. Minto CF, Schnider TW, Gregg KM, Henthorn TK, Shafer SL. Using the time of maximum effect site concentration to combine pharmacokinetics and pharmacodynamics. Anesthesiology. 2003;99(2):324-33.
23. Sepúlveda P. Actualizaciones en modelación, drogas y tecnologías complementarias. La anestesia intravenosa II. Santiago de Chile: Sociedad de Anestesiología de Chile, Clínica Alemana de Santiago, Universidad del Desarrollo; 2006. p. 209-15.
24. Coetzee JF, Glen JB, Wium CA, Boshoff L. Pharmacokinetic model selection for target controlled infusions of propofol. Assessment of three parameter sets. Anesthesiology. 1995;82(6):1328-45.
25. Glen JB. The development of 'Diprifusor': a TCI system for propofol. Anesthesia. 1998;53 Suppl 1:13-21.
26. Marsh B, White M, Morton N, Kenny GN. Pharmacokinetic model driven infusion of propofol in children. Br J Anaesth. 1991;67(1):41-8.
27. Schnider TW, Minto CF, Shafer SL, Gambus PL, Andresen C, Goodale DB, et al. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999;90(6):1502-16.
28. Schnider TW, Minto CF, Gambus PL, Andresen C, Goodale DB, Shafer SL, et al. The influence of method of administration and covariates on the pharmacokinetics of propofol in adult volunteers. Anesthesiology. 1998;88(5):1170-82.
29. White P, Eng M. Intravenous anesthetics. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M, Stock MC (editors). Clinical anesthesia. 6th Ed. Philadelphia: Lippincott; 2009: 444-64.
30. Barakat AR, Sutcliffe N, Schwab M. Effect site concentration during propofol TCI sedation: a comparison of sedation score with two pharmacokinetic models. Anaesthesia. 2007;62(7):661-6.
31. Schnider T, Minto C. Pharmacokinetic models of propofol for TCI. Anesthesia. 2008;63(2):206.
32. Absalom AR, Mani V, De Smet T, Struys MM. Pharmacokinetic models for propofol--defining and illuminating the devil in the detail. Br J Anaesth. 2009;103(1):26-37.
33. Minto CF, Schnider TW, Egan TD, Youngs E, Lemmens HJ, Gambus PL, et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology. 1997;86(1):10-23.
34. Shafer SL, Varvel JR, Aziz N, Scott JC. Pharmacokinetics of fentanyl administered by computer-controlled infusion pump. Anesthesiology. 1990;73(6):1091- 102.
35. Shibutani K, Inchiosa MA, Sawada K, Bairamian M. Accuracy of pharmacokinetic models for predicting plasma fentanyl concentrations in lean and obese surgical patients: derivation of dosing weight ("pharmacokinetics mass"). Anesthesiology. 2004;101(3):603- 13.
36. Shafer SL, Varvel JR. Pharmacokinetics, pharmacodynamics, and rational opioid selection. Anesthesiology. 1991;74(1):53-63.
37. Harris RS, Lazar O, Johansen JW, Sebel PS. Interaction of propofol and sevoflurane on loss of consciousness and movement to skin incision during general anesthesia. Anesthesiology. 2006;104(6):1170-5.
38. Mertens MJ, Olofsen E, Engbers FH, Burm AG, Bovill JG, Vuyk J. Propofol reduces perioperative remifentanil requirements in a synergistic manner: response surface modeling of perioperative remifentanil-propofol interactions. Anesthesiology. 2003;99(2):347-59.
39. Marcou TA, Marque S, Mazoit JX, Benhamou D. The median effective dose of tramadol and morphine for postoperative patients: a study of interactions. Anesth Analg. 2005;100(2):469-74.
40. Vuyk J, Mertens MJ, Olofsen E, Burm AG, Bovill JG. 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(6):1549-62.
41. Roberts FL, Dixon J, Lewis GTR, Tackley RM, Prys- Roberts C. Induction and maintenance of propofol anaesthesia. A manual infusion scheme. Anesthesia. 1988;43 Suppl:14-7.
42. Servin FS. TCI compared with manually controlled infusion of propofol: a multicentre study. Anaesthesia. 1998;53(Suppl 1):82-6.
43. Russell D, Wilkes MP, Hunter SC, Glen JB, Hutton P, Kenny GN. Manual compared with target-controlled infusion of propofol. Br J Anesth. 1995;75(5):562-6.
44. Engbers FH. Target controlled infusion in practice. Eur J Anesthesiol Suppl. 1995;12(10):88-90.
45. Moerman AT, Herregods LL, De Vos MM, Mortier EP, Struys MM. Manual versus target-controlled infusion remifentanil administration in spontaneously breathing patients. Anesth Analg. 2009;108(3):828-34.
46. O'Hare RA, Mirakhur RK. Intravenous anesthesia: Manual or target controlled infusion systems. Anesthesiology. 1999;91:A345.
47. Breslin DS, Mirakhur RK, Reid JE, Kyle A. Manual versus target-controlled infusions of propofol. Anaesthesia. 2004;59(11):1059-63.
48. Tafur LA, Serna AM, Lema E. Fentanilo PK/PD, un medicamento vigente. Rev Col Anest. 2010;38(1):68- 83.
49. Tafur LA, Gómez JM, Parra LE. Validación de nomogramas de remifentanil y propofol para la administración de anestesia total endovenosa. Rev Colomb Anestesiol. 2009;37(1):21-8.
50. Gómez JM, Tafur LA, Quintero I, Figueroa S, Serna A. Gutiérrez A. Infusión manual única de remifentanil y propofol para anestesia en cirugía laparoscópica ginecológica: serie de casos. Rev Esp Anestesiol Reanim. 2010;57(4):71-8.
51. Ithnin F, Lim Y, Shah M, Shen L, Sia AT. Tracheal intubating conditions using propofol and remifentanil target-controlled infusion: a comparison of remifentanil EC50 for Glidescope and Macintosh. Eur J Anaesthesiol. 2009;26(3):223-8.
52. Milne SE, Troy A, Irwin MG, Kenny GN. Relationship between bispectral index, auditory evoked potential index and effect-site EC50 for propofol at two clinical end-points. Br J Anaesth. 2003;90(2):127-31.
53. Xu Z, Liu F, Yue Y, Ye T, Zhang B, Zuo M, et al. C50 for propofol-remifentanil target-controlled infusion and bispectral index at loss of consciousness and response to painful stimulus in Chinese patients: a multicenter clinical trial. Anesth Analg. 2009;108(2):478-83.
54. Nunes CS, Ferreira DA, Antunes L, Lobo F, Santos IA, Amorim P. Individual effect-site concentrations of propofol at return of consciousness are related to the concentrations at loss of consciousness and age in neurosurgical patients. J Clin Anesth. 2009;21(1):3- 8.
55. Nunes CS, Ferreira DA, Antunes L, Lobo F, Amorim P. Propofol predicted effect concentrations at loss of consciousness are strongly correlated with predicted concentrations at recovery of consciousness. J Neurosurg Anesthesiol. 2004;16(4):342-3.
56. Tafur LA, Lema E. Aplicación práctica de los nomogramas de remifentanilo y propofol. Rev Col Anest. 2010;37(4):310-20.
How to Cite
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Tafur LA, Lema E. Total Intravenous Anesthesia: from Pharmaceutics to Pharmacokinetics. Colomb. J. Anesthesiol. [Internet]. 2010 Apr. 1 [cited 2024 Apr. 25];38(2):215-31. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/581
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Tafur LA, Lema E. Total Intravenous Anesthesia: from Pharmaceutics to Pharmacokinetics. Colomb. J. Anesthesiol. [Internet]. 2010 Apr. 1 [cited 2024 Apr. 25];38(2):215-31. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/581
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