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1 - PK For Dummies
1 - PK For Dummies
1 - PK For Dummies
for Dummies 6
Johan Ræder
As anaesthesiologists, our drugs and their pharmacology are effective in the central nervous system. Lipid solubility
among our most important tools. Compared with most other creates two problems; the drugs are also distributed very
physicians, we use high doses of very efficient and potent extensively into all other cells and tissues, and they will
drugs with strong and actually intoxicating effects, for a very not readily be excreted through the kidneys.
defined period of time. General anaesthesia may be said to Fortunately, the brain and spinal cord is very well per-
be a “state of controlled drug intoxication”, and for that fused so they will have access to a large number of drug
reason the proper and thorough knowledge of pharmacology molecules initially after a bolus dose or start of high-dose
of the relatively few drugs we use is crucial. infusion, before other tissues “steal” a large number of drug
In this chapter I will limit the discussion to general molecules (Fig. 6.2). Then, the infusion has to be adjusted on
anaesthetic drugs (analgesics and hypnotics) given an appropriate level to compensate for the ongoing loss of
intravenously. drug into tissues which are abundant in volume and not
relevant for any anaesthetic effect, but some side effects.
The speed and amount of drug diffusion into different organs
is dependent upon blood flow to the organ, plasma concen-
General Aspects
tration, concentration gradient between blood and tissue and
drug solubility in the tissues.
Basically the relation between a given dose and the observed
The infusion has to compensate for both these
effect may be split into two (Fig. 6.1):
mechanisms. The lipid-soluble IV drugs need to be
transformed into water-soluble inactive metabolites, which
1. Relation between dose and plasma level
subsequently are excreted renally (Fig. 6.3).
(pharmacokinetics)
Whereas a lot of molecules have been tested and work for
2. Relation between plasma level and effect(s)
general anaesthesia, the present selection of common drugs
(pharmacodynamics)
have been through an almost evolutionary process with
selection of the best drugs with some beneficial features in
While we as clinical anaesthesiologists primarily are
common: they have low toxicity, low potential of anaphy-
interested in the dose–effect relationship, it is still very useful
lactic reactions, high speed of metabolism, inactive
to know the laws who dictate the plasma concentration.
metabolites and metabolism by 1.order mechanism which
Better understanding of plasma concentration will help us
ensure a constant fraction being metabolized all the time (see
in hitting the desired effect level more precisely.
later). In contrast to zero-order metabolisms (a constant
As the mechanisms and target cells of strong hypnotic,
amount per time), the first-order mechanism will protect
analgesic and anti-nociceptive drugs are inside the central
somewhat against unlimited accumulation with overdose.
nervous system, the anaesthetic drugs have to be lipid solu-
This is because with 1.order metabolism, potential accumu-
ble in order to penetrate the blood–brain barrier and be
lation of drug in plasma will also result in more drug
molecules getting metabolized. By constant continuous dos-
J. Ræder, MD, PhD (*)
ing, the elimination will eventually (after three to five times
Department of Anaesthesiology—Ullevaal, Oslo University the elimination half-life) increase until being equal to the
Hospital and University of Oslo, Faculty of Medicine, supply of drugs per time, and the plasma will reach a stable
Kirkeveien, Oslo 0424, Norway ceiling level.
e-mail: johan.rader@medisin.uio.no
For most drugs, metabolism takes place in the liver. With very rapidly and extensively. There is also work in
a liver flow of 1.5 l per min in an adult, this will also be the progress of having propofol-like or benzodiazepine drugs
maximum potential clearance of a liver-metabolized drug. constructed this way in order to ensure an ultra-rapid
Clearance is defined as the amount of blood which is fully metabolism.
cleaned of drug per time unit. With the neuromuscular blocking agents and reversal
For some drugs, such as propofol, there is an extrahe- agents, there is no need to have lipid soluble drugs, because
patic metabolism (enzymes in lung, gut, etc.); thus, the the effect site is on surface of the muscular membrane and
clearance may be somewhat higher than liver blood flow. accessible to water-soluble drugs. Although some of these
The even more efficient way of ensuring a rapid drug also have a partly degradation in the liver, they do not diffuse
elimination is to construct drugs which are eliminated by so readily through membranes and into cells, thus their
enzymes being widespread in the body, and thus a more distribution volumes are lower.
extensive and liver-independent degradation. This is the
case with remifentanil, being degraded by tissue esterases
A Good Model
their volumes and weight and blood flow received). Then for measurements in all relevant tissues, and we do not actually
each specific drug, we may add the solubility of the drug in need all this information in order to tell us the two major
the different organs and the diffusion speed of drug into or issues of interest: what is the concentration of drug in
out of the organ and then construct a very accurate picture on plasma? What is the anticipated effect in the target organs
how and where all drug molecules given IV will distribute at of brain and spinal cord?
any given time in the total body. Thus, we will do well by simplifying this model of ten
Such an attempt of modelling is done. However, in order organs into a construct of three compartments as we do in
to construct such a model, we will need a vast amount of Fig. 6.4.
102 J. Ræder
This model is more practical for dosing and calculation, 0.1 g salt per litre, we know that the volume of the
both in terms of measuring what we need for constructing the container is 100 l. This is in parallel with IV drugs: if
model and using mathematical methods in calculating rele- we measure a level of X in plasma and know the dose
vant information for our patients. The mathematical con- given (Y ), we can calculate the distribution volume of the
struct of V1 may be (although very roughly!) regarded as drug by the formula: Distribution volume ¼ Dose given/
analogue to plasma þ the extracellular fluid and some tissue Plasma concentration. This is in direct parallel with IV
very close to blood vessels, whereas V2 may be the medium- drugs: if we measure a level of X in plasma and know the
perfused parts of the body (such as muscular tissue) and V3 dose given (Y ), we can calculate the distribution volume
the poorly perfused tissue, including fat and bone tissue. of the drug by the formula: Distribution volume ¼ Dose
But in order to use such a model, we need some basic given/Plasma concentration.
terms and definitions. However, in order to do more easy calculations, we
Some pharmacokinetic terms, as defined by an everyday want to have same concentrations in all three
project:
The everyday project:
• The author will fill the sink with herbal salt in water for an
adequate footbath, then empty the sink, then have some
lunch and then (see the TCI model discussion) change to
jeans! (Fig. 6.5).
Fig. 6.7 (a–c) This is how a semi-anatomical model of compartments water), although the free fraction for diffusion equlibrium is the same
of total 70 l (a) in a 70 kg person may look like in terms of propofol in all compartments. In part (b) the two compartments, V2 and V3, are
concentrations (X-2X and 6X at steady state after a 12–24 h period of “stretched” in order to “dilute” the propofol to the same concentrations
infusion). The higher concentration in V2 and V3 are due to the fact (part (c)) as V1 has in part (a)
that much more drug binds in the tissue than V1 (which is mostly
compartments; thus, we “stretch” the V2 to twice the size, The rate of emptying will have to do with how much
i.e. to 32 l, and V3 to six times the size (Fig. 6.7c), i.e. 202 l, water we need to empty (i.e. the distribution volume, the
in order to have concentration of X everywhere (Fig. 6.7a). higher the volume—the more to empty) and the size of
Thus, we conclude that the total distribution volume the outlet (Fig. 6.8). The bigger the outlet, the higher rate
of propofol at steady state in this model is 250 l in a of emptying. The speed of emptying through the outlet is
70 kg man, or 3.6 l per kg. If we extrapolate to a 60 kg called the clearance and should be measured in some
woman, this will be 3.6 $ 60 ¼ 216 l. amount (e.g. litres) per unit of time (e.g. min).
3. Then we need to know how to empty the footbath when 4. But we also need to know if the speed of water (ml/min)
we are finished. through the outlet is a constant amount irrespectively of
104 J. Ræder
???
how much water there is in the sink or if there is some b. You feel you like to taste a bite of everything on the
association of higher speed with higher amount. For that, table, that is, ten bites for ten dishes and three bites
we may look at the lunch table example: for three dishes. You will eat the same fraction of the
Let’s say there are two ways of eating from a lunch table table always, but the amount will be very different.
(Fig. 6.9): This is the way the liver eats propofol; the liver will eat
a. You take the same amount of food or calories, the same fraction whether the blood concentration is
whether the table is huge with lots of dishes or high or low (Fig. 6.10). This is the 1.order way of
small with just two to three dishes to choose from. eating, which means it will take the same time to
This is 0-order way of eating and is the way the liver half empty the blood, irrespectively of the starting
eats alcohol, about 0.15 units per hour, whether you concentration.
have 4 units or 0.5 units per litre in your blood. It Actually, the drugs we use in modern anaesthesia have a
takes much more time to half empty the blood when 1.order elimination, because 0.order elimination drugs
you have 4 units at start. are hard to dose, as they may accumulate to very high
6 Basic Pharmacology: Kinetics and Dynamics for Dummies 105
concentrations with dosing errors. With an infusion of a amount of blood fully cleared, that is, for fentanyl 0.75 l
1.order drug, the elimination (i.e. amount) will increase per minute.
as the plasma concentration increase, until the amount Now, we have built a model for steady-state situation
eliminated is as high as the dose given per time unit, thus with distribution volume at steady state and clearance
reaching an upper plateau or safe upper limit for plasma (Fig. 6.11). In this model the time to half the concentration
concentration after about three to five times the half-life when the dosing (or infusion) stops is given by the relation:
of elimination. T½ ¼ k $ VD/clearance. Also in this situation the dosing is
5. But even though we have established our drug as a 1. very simple if we want to keep a steady plasma concentra-
order elimination drug, we need to know how big is the tion; we simply replace the amount cleared every time unit;
fraction eliminated every time or time unit. For the lunch in our example of propofol of 4 mg/l blood concentration,
example: do we take 1 bite of every dish or 2 bites? For we need to give 6 mg every minute. In this situation we do
the liver, which receives an “offer” of 1.5 l of blood every not actually need the three-compartment model; it is enough
minute in the adult: how much does the liver eat from this to know the clearance.
offer? For propofol it is very simple and fortunate: the But very few anaesthetics last for 12–24 h, which is what
liver eats everything, that is, with a propofol concentra- we need to create a steady state. Thus we need to know more
tion of 4 mg/l blood, the liver eats 6 mg propofol every on two important situations:
minute (4 mg/l $ 1.5 l per min). We may say that the
liver clearance is 100 % of the flow, that is, 1.5 l is fully a. How much drug do we need in the start?
cleared every minute. If the liver instead is offered fenta- b. How much drug do we need in the phase after start and
nyl, it only eats about 50 %, that is, for 1.5 l liver flow until steady state is reached?
during a minute, there is only a 50 % clearance. Instead
of saying “50 % clearance of 1.5 l”, we instead divide the
liver flow into volume of blood fully cleared and volume How Much Drug Do We Need in the Start?
not cleared at all. For fentanyl: 1.5 l 50 % cleared will be
the same as 0.75 l not cleared þ0.75 l fully cleared. We In the very start, we do not need to pay much attention to
will for simplicity always do this in our model, talk about elimination or distribution to slowly perfused tissues in V2
106 J. Ræder
are age, fat or lean (relation between weight and height), The context-sensitive elimination time.
gender, changes in the liver or kidney function, etc. This is the time taken to achieve a predefined reduction of
plasma concentration from the stop of dosing. The reduction
is a net result of elimination (clearance) þ distribution from
What About Stopping Dosing Before Steady plasma to nonequilibrated tissue. The term is usually used in
State Is Reached? conjunction with constant dosing (fixed dose per time unit)
and looking for a reduction of 50 %, i.e. the context-sensitive
One very important concept for the practical anaesthetist is half-time.
to know what happens with the pharmacokinetics when we In Fig. 6.13, we have simulated the situation after 1 h of
stop dosing before reaching steady state. stable propofol infusion, compared with 6 h infusion. If we
This concept is stop the infusion after 1 h, there is a large gradient of diffusion
108 J. Ræder
into V3, “helping” us to half the concentration fairly quick, With high dosing for, e.g. coronary surgery, it may be
compared with the situation after 6 h, where the gradient is appropriate to look for 80 % reduction for the concentrations
lower. In both situations the diffusion into V3 adds to the before breathing and verbal contact are achieved.
contribution from the clearance, which is running all the time. Figure 6.14 shows the context elimination half-life for
A 50 % reduction is usually the easiest to estimate and propofol and some relevant opioids (see later for individual
also fairly relevant for intermediate dosing of IV hypnotics drug description).
for sleep and analgesics for stress response attenuation. With Pharmacodynamics of intravenous drugs:
50 % reduction in such doses, you may expect the patient to Pharmacodynamics has to do with both
wake up (50 % reduction in hypnotic agent) and breathe
spontaneously (50 % reduction in opioid). a. Timing of effect onset/offset
Still, the context-sensitive concept may be used for any b. Strength of effect
kind of dosing schedule and endpoints of 20, 80 % or any c. Type of effect
other degree of reduction may be applied.
With a carefully titrated and down-adjusted general
anaesthetic combination for closing the wound at end of Timing
surgery, it may sometimes be relevant to check for only
further 20 % reduction of analgesic or hypnotic drugs in Basically a drug has to pass some steps from being in plasma
order to have the patient breathing or awake, respectively. into exerting effect (Fig. 6.15):
90
Alfentanil
60
Propofol
Sufentanil
30
Remifentanil
0
0 120 240 360 480 600
• Diffusion out of blood vessel (through blood–brain The time to peak effect after a bolus dose is the result
barrier) of both the effect delay per se and the effects on
• Diffusion in extracellular fluid plasma-to-brain gradient in dynamic change due to distribu-
• Surface of effect or cell tion of drug out of plasma. With infusion only, the time to
• Binding to a receptor or cell surface or structure inside peak effect will be prolonged, but this is due to the slow
cell increase in plasma concentration more than delay from
• Biologic effect plasma to effect site (Fig. 6.17).
KeOs and time to peak effect are given for some drugs in
The biologic effect may be fast, such as opening an ion Table 6.1.
channel, more slowly such as activating protein synthesis Knowing the time to peak effect after bolus is useful in
(e.g. NSAIDS) or even more slowly such as activating DNA three important contexts:
and protein synthesis (e.g. corticosteroids). As the drugs
differ both in their biological effect mechanism and how 1. Go for the maximum effect when the trauma is maximal,
fast they get from plasma to the effect site, there is a differ- such as during intubation or start of surgery.
ence in time to onset. This difference may be expressed by a 2. Titrate a drug until proper level. Titration is to give a dose
constant, keO, a high constant means a rapid onset, or short and wait for full effect. If the full effect is insufficient, a
T½ keO which is the time taken for 50 % equilibration new dose is given and then wait for effect and so on. With
from plasma to effect site. Both these terms are theoretical a short time to peak effect, the process of titration goes
constructs based on assumption on stable plasma faster.
concentrations. In the three-compartment model, we may 3. Anticipate risk of side effects. For instance, with a slow-
add an effect compartment, embedded in V1 (since the acting drug such as morphine, the event of respiratory
CNS is very well perfused), as shown in Fig. 6.16. depression will evolve slowly, patients being gradually
drowsy and then reduce the respiratory frequency before
eventual apnoea by the time of the peak effect after
15–20 min. With alfentanil the maximal effect comes
much more rapidly may be with a sudden apnoea 2 min
after a bolus. Thus, with a slow-acting drug you have to
watch longer in order to feel safe, and titration is slower.
A positive aspect will be that you have more time to
observe problems emerging and have some more time to
call for help and find appropriate drugs and equipment
needed. The negative effect of slow action is that
you have to wait and observe the patient for longer in
order to be sure to not miss the time of maximum side
effect.
Strength of Effect
Fig. 6.17 Infusion is like rapidly Infusion ( = repeated small bolus doses)
repeated, with same interval,
small, identical bolus doses over 8 1000
time. Time to peak effect is
determined more by the slow rise 7 Propofol 6 mg/kg/t in 20 min 900
in plasma, than delay in plasma-
effect-site equilibration 800
6
700
5
Concentration (mg/ml)
4 500
400
3
300
2 plasma
200
1
effect 100
0 0
0 10 20 30
Table 6.1 Delay (min) from drug being in plasma until effect plasma concentration and only compensate for variability
Time to maximal
in sensitivity.
effect between plasma In order to go from EC50 to EC95 (effective concentra-
T½ for and effect site (T½keO) tion for effect in 95 % of patients), the dose needs to be
equilibration after a bolus dose increased by 40–50 %; from ED50 to ED95 increase by
Barbiturates (thiopenthone) 1.2 1.0–2.0 60–80 %. The interindividual variability in EC (and thus
Propofol 2.6 1.5–3.5 ED) is generally larger for opioids than for hypnotic agents,
Midazolam 5.6 5–7 and we must be prepared for quite some variability in clini-
Diazepam 2 1–3
cal need of opioids compared to other drugs, even in an
Opioids
otherwise normal patient. The range may be up to fivefold,
Remifentanil 1.2 1–2
i.e. the patient with minimal opioid need will require
Alfentanil 1.1 1.5–3
one-fifth of the dose in a patient with maximal need for the
Fentanyl 5.8 4–5
Morphine ? 10–20
same standardized stimulus.
NSAID ? 15–30
Corticosteroid ? 60–120
The table shows in the middle column the half-life of equilibration from Type of Effect: Side Effect
plasma to effect site for some relevant drugs (means that good data are
not available), whereas the right column shows the time to maximal The intravenous anaesthetic drugs also have side effects; the
effect after a single bolus dose. The figures in both columns are average most important and frequent are circulatory and respiratory
estimates from different sources and may vary considerably, whereas
the ranking of speed between different drugs are better established effects. These different effects come from different organs
and effector cells, and each effect has a specific time-effect
profile and delay (keO), which is different to the basic
The strength of effect may be expressed in an intravenous effects of general anaesthesia: hypnosis and anti-
analogue of MAC, the ED50 or EC50. Effective dose, nociception.
ED50, is the dose needed in order to have the effect
(e.g. sleep, no movement on incision) in 50 % of patients;
the effective concentration, EC50, is the plasma concentra- Respiratory Effects
tion needed.
The variability in ED will always be larger than The opioids cause a dose-dependent reduction in respiration
variability in EC, because a dose may result in a variety of frequency, ending in apnoea. When the patients get drowsy
plasma concentrations. With EC we anticipate a given and the respiratory rate is below 8–10 per minute, it may be a
6 Basic Pharmacology: Kinetics and Dynamics for Dummies 111
warning of apnoea potentially emerging. Inability to main- Opioids, on the other hand, may provide excellent abolish-
tain free airway may be absent or present. ment of pain reaction when the dose is high enough but is not
The ventilatory depression, being CNS driven, usually reliable as hypnotics. Although most patients will be asleep
follows the analgesic and sedative effect fairly closely. most of the time on a high-dose opioid, some may be fully
Respiratory depression may be counteracted by stimulation, awake in an unpredictable manner for periods. Thus, general
verbal or (more efficient) tactile and even painful. In a worst anaesthesia with intravenous drugs only, total intravenous
case, these effects may always be reversed by naloxone, anaesthesia (TIVA), is usually achieved with a combination
which will also reverse the analgesia abruptly if not titrated of opioid and hypnotic, most often propofol.
very carefully. Opioids will reduce the dose need of propofol for sleep by
The respiratory depression with hypnotics is usually 20–50 % at fairly low doses, such as alfentanil 1–2 mg in an
regarded as less than with opioids, but it is difficult to sort adult, or remifentanil plasma level of 2.5–5.0 ng/ml. Increas-
out equipotency of these two drug classes, as the anaesthetic ing the opioid dose does not add much to further dose
effects are quite different. Respiratory depression with reduction of propofol for being asleep.
hypnotics is clinically evident as inability to maintain free Thus a minimum dose of propofol at 3–4 mg/kg/h for
airway and shallow tidal volumes, whereas the ventilator maintenance or target of 1.5–1.8 μg/ml (Marsh model, see
frequency may be normal or low. Propofol will always result below) should be used for sleep, irrespectively if the opioid
in apnoea with high doses, whereas the benzodiazepines are dose is high or low.
safer in terms of very high dose needed for respiratory arrest. Propofol will reduce the need of opioids for anti-
Also, with the benzodiazepines, full reversal is possible with nociception in a dose-related manner, anything from 10 to
flumazenil. 20 % reduction with a low sleeping dose (6 mg/kg/h or
target 3 μg/ml) to almost 90–100 % if the dose is five to
six times higher (target of 15–20 μg/ml).
Circulatory Effects The practical approach will depend on the type of opioid
in use as demonstrated by Vuyk and colleagues in
The circulatory effects will be a mixture of drug effects in their important work on EC50 and EC95 values for propofol
the CNS and peripheral effects directly in the heart and þ opioid combination in open abdominal surgery
vessel walls (vasodilatation), as well as the physiological (Table 6.2 [3]).
effect of going to sleep with subsequent reduction in sym- The major point with opioid þ propofol combination is
pathetic nerve tone. A drop in blood pressure and heart rate to use a high dose of the drug with shorter context-sensitive
during general anaesthetic induction is almost always seen elimination half-life. With alfentanil or remifentanil that
(except with ketamine), unless the surgery or other stimu- means to have a low and stable concentration of propofol
lation starts concomitantly. Although elective patients also to ensure sleep and then “play” with opioid adjustments in
are slightly hypovolaemic (from fasting), they usually tol- medium to high dose according to strength of nociceptive
erate well a short-lasting drop in syst BP down to the 70–90 stimulation. This is also logical, because the variable stimu-
range, as organ flow is well maintained, and oxygen con- lus during surgery is pain and nociception, whereas the need
sumption low when being asleep. Kazama and co-workers of being asleep is stable.
have shown that the maximal drop in blood pressure is With short-lasting use of fentanyl (or low doses;
delayed for 2–3 min when compared to maximal hypnotic i.e. 0.1–0.2 mg for a less than 30 min procedure, or less
effect of propofol in the average adult. In the elderly, the than 0.1 mg/h) the same strategy, i.e. low-dose propofol for
delay after sleep is 5–6 min, and the drop is larger, probably sleep, may be used. However, if the use of fentanyl is more
due to stiffer myocardium and vessel walls in the extensive, then a more rapid recovery will result by increas-
elderly [2]. ing the propofol dose with up to 100 % and subsequently
reducing the dose of fentanyl.
As to respiratory depression, opioids are more potent than
Intravenous Drug Interactions: Opioids propofol, but the combination is synergistic.
and Hypnotics
given by syringe, infusion or computer; the cells react upon the computer will give the bolus dose and the infusion and
the number of drug molecules present at the effect sites. automatically adjust rate after 10 and 20 min without any
Still, with a TCI system, you may ensure a rapid onset, a more actions from the anaesthetists. If the anaesthetist tells
stable effect when needed, a rapid offset or reduction in the computer to go “up”, the computer will deliver the small
effect and less work with dosing and calculations. bolus and adjust the infusion rate. If the anaesthetist tells the
computer to go “down”, the computer pump will stop for
some minutes and then start the infusion at the lower level.
The Logic of TCI By programming this “Recipe X” into the computerized
pump, we have made a simple TCI plasma system. If we run
With a manual scheme for giving propofol, you may get to a this programme in a series of patients and do measurements
good result in ensuring rapid and stable sleep in an adult by on stable propofol plasma concentrations 15 min after start
the following recipe: start with bolus 1.5 mg/kg together of the programme, we may find that the average plasma
with an infusion of 10 mg/kg/h for 10 min, then adjust concentration is about 3 μg/ml (Fig. 6.18b). Thus, we have
infusion to 8 mg/kg/h for another 10 min; then adjust to programmed our pump to deliver a plasma target concen-
6 mg/kg/h which is maintained for the rest of the case. If tration of 3 μg/ml. If we test the plasma levels 15 min after
this seems to be too much, then adjust the infusion down by doing the “up” and “down” adjustments, we may find a
2 mg/kg/min or if this seems to be too low dose, give another concentration of 4 and 2 μg/ml, respectively. Thus, we
bolus of 0.5 mg/kg and adjust the infusion up with 2 mg/kg/ have made a programme for how the pump should work
h. Stop infusion by the end of the case (Fig. 6.18a). when we want to increase the target to four or reduce the
This recipe is based on the weight of the patient and then target to two. By testing different ways of dosing, measuring
simple calculations on bolus dose and pump rates. If we call plasma concentrations (in patients or volunteers) and fit into
this recipe for “Recipe X”, we may programme a mathematical algorithms, we can make a programme for
computerized pump to do this automatically. We programme how to dose for any given target in any patient; the only
the computer with patient weight and push the start button: thing we need to tell the computer in the OR is the weight of
6 Basic Pharmacology: Kinetics and Dynamics for Dummies 113
1000 10 1000
a 10 b
Bolus 2 mg/kg Bolus 1 mg/kg
9 10 mg/kg/h->8->6 900 9 900
8 mg/kg/h
4 mg/kg/h
7 700 7 700
Concentration mg/ml
3 300 3 300
Effect
2 200 2 200
Pump
Pump Rate Rate
1 100 1 100
0 0 0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 0 10 20 30 40 50 60
1000
c 10 d10 1000
9 900 9
Effect-Site 900
Target Control Infusion-
7 700 7 700
Plasma
Concentration mg/ml
Concentration mg/ml
Infusion Rate(ml/hr)
6 600 6 600
5 500 5 500
Target
4 Plasma 400 4 400
3 300 3 300
Effect
2 200 2 200
Pump Effect
Rate Pump Speed
1 100 1 100
0 0 0 0
0 10 20 30 40 50 60 0 10 20 30 40 50 60
Fig. 6.18 (a) Plasma concentration (red) and relative strength of with a plasma target of 5.5 μg/min during induction, in order to get a
hypnotic effect (green) for a manual propofol regime of start bolus, more rapid effect (green curve); now patient will probably be asleep at
then infusion adjusted at 10 and 20 min. Also shown is an increase in 2–3 min. (d) Effect-site TCI for propofol. The pump is programmed to
dosing at 30 min and decrease at 75 min (Marsh kinetic/dynamic deliver an effect level corresponding to 3, then 5, then 3 again. Note the
model, Tivatrainer®). (b) Plasma target control infusion, TCI (pump differences from Fig. 4.11 and plasma TCI: by start and increasing
rate are black columns) for target 3, then 5, then back to 3 again. Note dose, there will be a plasma “overshoot” created by a more vigorous
that the pump gives a short-lasting bolus infusion at start and increasing bolus infusion, then stopping for proper equilibration with the effect
the dose and stops temporarily by decreasing. Also note that the pump site. By decreasing effect level, the pump will stop and allow the
adjust far more frequently (¼more accurately) than a manual regimen plasma concentration to go below the new target, then giving a small
(as in Fig. 6.9). Also note the delay in effect, patient probably not being bolus to “catch up” with the effect curve and keep stable at new level
asleep until 5–7 min. (c) Same as in Fig. 4.11b, except for “cheating”
the patient and the target we will like to have. This is the A limitation with the Marsh algorithm was that only
concept of the original Marsh plasma target control infusion weight was adjusted; there was no adjustment for the age
algorithm, which was widely used with propofol-prefilled of the patient and no adjustment for obese or slim body
syringes for pumps programmed with the Diprifusor® soft- composition, only total weight. These limitations have
ware (www.eurosiva.org). When testing with blood samples, been addressed in some of the other models, such as
the Marsh algorithm gave quite different plasma levels in Schnider, Schuttler, Paedfusor, etc., where some of these
different patients (þ/&30–50 % around target) and also covariates has been added to the weight for adjustment of
tended to give somewhat higher plasma levels than the dosing.
preset target [4]. Still it was still very useful and gained A major limitation with all models of plasma target and
high popularity in clinical everyday practice. It provided a the plasma target concept is that they do not take into
stable level, and the clinicians soon learnt what a relevant account the delay in drug equilibration between plasma
proper starting target in their patients should be and how to and CNS. As the anaesthetic drug effect is not in plasma,
easily adjust up or down according to clinical needs. but in the brain, we should rather like to have a computer
114 J. Ræder
pump who could deliver a preset concentration into effect whether we need to adjust the dosing. This is in parallel with
sites in the CNS. We then have to expand our plasma TCI buying jeans; they are made from testing in a group of test
system into an effect-site TCI system. people in order to fit. Thus, even though we know our mea-
The logic by such an expansion may be: sure of waist and length, the jeans may still not fit perfectly.
We observe that with a plasma target of three, most of our Also, it may be that in two persons with the same waist and
patients will go to sleep, but due to delay in propofol diffu- length, one jean model may be best in one whereas another
sion from plasma to CNS, this will take about 5–10 min, model may work best in the other. Thus, it may not be realistic
even though the plasma concentration is stable at 3 after 30 s. to hope for one model to fit all, either with jeans or TCI, as
In order to speed up, we may “cheat” with the plasma target they are models made from an average of test persons. Still,
and tell the pump to start at target of 6 (Fig. 6.18b). It will some models may work better in most situations than others,
still take 5–10 min to reach this target in the brain, but after and this do not have to do with the number of persons tested,
30 s the plasma concentration is 6 and we have a much but rather if they are representative. For instance, most of the
higher speed (gradient) of diffusion of drug into CNS than common TCI modes have not been tested for the extreme
with a target of 3. By 2–3 min with a plasma target of 6, we obese or the extreme elderly or young; thus, we cannot expect
have a CNS concentration of about 3 and then the patient them to work well in these situations.
goes to sleep. At this point we do not need to “cheat”
anymore; actually we will overdose the CNS continuously;
thus, we reduce the plasma target (pump stopping, then Plasma Models Versus Effect-Site Models
starting lower) to 3. By doing this up-down “cheating”
with the plasma target, we have actually created an effective The first question is whether to use a plasma TCI or an effect
algorithm of giving an effect-site (CNS) concentration of -siteTCI. The general logical rule will be to use the effect-
3. Next time we can programme the computer to do this site mode, as this is more close to drug physiology including
automatically by one button push, asking for an effect-site the clinical effect. Still, one may do quite well with plasma
target of 3 to be delivered. The algorithms for effect-site TCI TCI, and it should be kept in mind that the difference in
are basically doing plasma overshoot at start or by increasing dosing between plasma TCI and effect-site TCI is only
targets and prolonged stop and plasma underscore when we present during 10–15 min after each change (or start) in
want to reduce the target (Fig. 6.18c). dosing; during stable conditions they deliver the same.
A problem with the effect-site modelling is that the delay Using plasma TCI one should remember to do some
of effect is quite variable between individuals, and also target overshoot by the start and eventually when a rapid
somewhat dependent upon rate of bolus/dosing, high versus increase in effect is wanted. Using effect-site TCI one should
low dose, state of circulation, etc. Also, the delay is hard to remember that a higher bolus dose is given every time the
measure exactly and the relation may be both to arterial and dose is increased, and this may exert a stronger effect on
venous drug concentration, which will differ during change respiration and haemodynamics. This stronger effect could
in dosing. Still, the effect-site modelling gets closer to the be compensated by titrating the effect target in increments
clinical needs and is proven to be very useful in clinical work. when needed for the fragile patient.
Exactly the same ways of making plasma TCI and effect-
site TCI have been used with remifentanil, and also for other
opioids, such as alfentanil, fentanil and sufentanil. Remifentanil
sensitivity in the elderly is about twice that seen in the • Kataria/Paedfusor: All models above do not compensate if
younger. The drug sensitivity is not built into the models, the patient being is a child. Children have a higher V1 and a
only the drug concentrations. higher clearance in relation to weight than adults. Both
these children models will compensate for these features,
resulting in a higher and more appropriate dose for a given
Propofol target, both for start and maintenance in children.
Paedfusor has an age dynamic change in clearance which
With propofol there have been a number of groups who have is more precise for all children, whereas the kataria has a
made TCI models based on their measurements of plasma fixed rate for clearance which may result in overdose in
and effect delay in their series of patients or volunteers. Such children above 5-10 years of age.
measurements are not exact, and the results will also differ
between individuals. For this reason, it is no surprise that Addendum
different authors have come to different models. The basic Interactions with inhalational agents
differences between models are in their estimation of the size Dynamic interactions with intravenous agents:
of V1 and the delay of effect. Basically, if a model conclude Whereas the clinical effect and dose level in a population
that V1 is large, then the initial dosing (in mg/kg) should be of intravenous drugs often is measured in plasma
large, and if the delay is long (low keO, long T½ keO), the concentrations, e.g. EC50 which is the concentration
initial dose (overshoot) in effect-site modus should be large. needed to get 50 % of patients asleep, the corresponding
Still, these differences are basically evident in the first 15 min effect of inhalational agents are usually measured with
of a case, after that the models will behave fairly similarly. stable end-tidal concentrations. The minimum alveolar
Also, it should be noted that some models compensate for concentration (MAC) is defined as the concentration
weight/height ratio and/or age, whereas others only compen- (i.e. dose level) needed to get 50 % of unconscious
sate for total weight. The common models do not compen- patients not moving when subjected to strong nociceptive
sate for differences in propofol sensitivity as may be or painful stimuli. Typically this will be 6 % for
decreased in children and slightly in females. For more desflurane and 2 % for sevoflurane in an average adult.
detailed discussion on models, one is referred to However, the inhalational agents are also potent sleeping
Chap. XX, but some rough statements could be made. agents, and the hypnotic effect is evident at doses about
one-third of those needed to lay still upon pain. Thus, a
• Marsh plasma TCI [5]: Generally delivers somewhat term called MACsleep is defined as the stable end-tidal
more than predicted, especially in the start (high V1). concentration needed to get 50 % of non-stimulated
• Marsh effect—old: This model has a long delay in effect patients to sleep. Typically MACsleep is 2 % and 0.7 %
and will tend to overdose initially, compared with for desflurane and sevoflurane, respectively.
measurements in patients. The intravenous opioids and hypnotics will interact
• Marsh effect—new [6]: This model has a short delay in with inhalational agents, but somewhat differently
effect, which will compensate somewhat for the according to class of IV drug and type of effect. The
overdosing done for the plasma part of the algorithm. clinical interactions are logical; if you combine inhala-
Still it is a clinical impression that the delay is too short tional agent with a hypnotic, the combination is additive
in this model, and a 25-50% overshoot in target for or supra-additive in terms of hypnotic effect. Still, the
1–2 min during the start of a case will work better in adding of an IV hypnotic does not add much to the anti-
terms of getting asleep within 2–3 min. nociceptive or analgesic effect of the gas. On the other
• Schnider plasma: The Schnider model [7] is actually not hand, if you add an opioid analgesic on top of the inhala-
developed for plasma modus and will (low V1) underdose tional agent, the combination is additive or supra-additive
the patients initially. If used, the start target should be in anti-nociceptive effect, whereas the opioid do not add
50–100 % higher than with the Marsh model in order to much to the pure hypnotic effect [8–10]. However, for
have the same dose (mg/kg) delivered. induction general anesthesia and deep unconsciousness
• Schnider effect: This has an intermediate delay in effect, for intubation or surgery, we need a combined anti-
which will compensate somewhat for the underdosing in nociceptive and hypnotic effect for which the opioid-
plasma. It also compensate somewhat for thin/fat patients hypnotic combination is supra-additive.
and elderly. Still, the target levels need to be a little higher The hypnotic potency measure, MACsleep, may be linearly
than those for Marsh models. In the very obese, the for- and additively reduced by adding the hypnotic propofol or
mula for weight correction will be very wrong, and the midazolam. With midazolam 0.1 mg/kg IV, MACsleep for a
model should not be used above 100–120 kg total weight. potent inhalational agent will be reduced by about 50 %,
similarly with a propofol plasma level of 1.5 μg/ml.
116 J. Ræder
1. The hypnotic potency measure, MACsleep, is reduced only 2. Hoymork SC, Raeder J. Why do women wake up faster than men
by 10–20 % after a dose of fentanyl of 0.2 mg in the adult from propofol anaesthesia? Br J Anaesth. 2005;95:627–33.
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infusion of 0.3 μg/kg/min. Whereas some patients may be propofol-opioid concentrations that assure adequate anesthesia and
fully asleep on a high opioid dose alone, the individual a rapid return of consciousness. Anesthesiology. 1997;87:1549–62.
variation is huge; thus, an average reduction in MACsleep 4. Hoymork SC, Raeder J, Grimsmo B, Steen PA. Bispectral index,
predicted and measured drug levels of target-controlled infusions of
of 50 % by adding opioid demands a very high dose of remifentanil and propofol during laparoscopic cholecystectomy and
opioid (fentanyl 0.6 mg or other opioid in equipotent emergence. Acta Anaesthesiol Scand. 2000;44:1138–44.
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6. Vereecke HE, Vasquez PM, Jensen EW, et al. New composite
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thesiology. 2005;103:500–7.
0.1 mg/kg bolus or propofol plasma level of 1.5 ng/ml. 7. Minto CF, Schnider TW, Gregg KM, et al. Using the time of
Still, the effect of further increased hypnotics IV is infra- maximum effect site concentration to combine pharmacokinetics
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