Inhalation Kinetics Models Grand Rounds Technology Block 2005.
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Transcript of Inhalation Kinetics Models Grand Rounds Technology Block 2005.
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Inhalation Kinetics Models
Grand RoundsTechnology Block
2005
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Inhalation Anesthesia Kinetics - A model-based approach
ala
Inhaled Drug Kinetics and their Applications at BWH
BWH Anesthesia Technology Block, 2005
© Copyright 2005, James H Philip, all rights reserved.
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ready
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Inhalation Anesthesia Kinetics - A model-based approach
ala
Inhaled Drug Kinetics and their Applications at BWH
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Inhalation Anesthesia Kinetics - A model-based approach
James H. Philip, M.E.(E.), M.D.
Anesthesiologist andDirector of Technology Assessment,
Brigham and Women's HospitalAssociate Professor of Anaesthesia,
Harvard Medical SchoolMedical Liaison, Partners Biomedical Engineering
Everything profitable I ever invented is owned by Brigham and Woman’s Hospital(Edwards Vigilance CCO, Baxter InfusOR Pump, Cardinal-IVAC-Alaris Signature Pump
Perkin-Elmer Life Watch™ CO2 Monitor
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Inhalation Anesthesia Kinetics - A model-based approach
James H. Philip, M.E.(E.), M.D.
Anesthesiologist andDirector of Technology Assessment,
Brigham and Women's HospitalAssociate Professor of Anaesthesia,
Harvard Medical SchoolMedical Liaison, Partners Biomedical Engineering
I have performed funded research on Sevoflurane, Desflurane, Isoflurane
I am a frequent speaker for Baxter and occasional speaker for Abbott
I have a financial interest in Gas Man® and Med Man Simulations, Inc. - I make no profitASA Booth 413
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Models for
Inhalant and
IntravenousDrugs
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IV and Inhalant Differences
PharmacologicalReceptor-directed
No (known) receptor
PhysiologicalEffect-directed
Multifaceted
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IV and Inhalant Kinetic Differences
Different Models
Different Authors
Different Speakers
Different Units of Measure
Different weeks at BWHShafer last week, me this week
Same Group of Clinical Users
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IV ModelEntry via a vein
Distribute to central volume of distribution
Sample arterial concentration after 5 min
Model and estimate and control effect site
Model ignores cardiac output
Measure concentration in art. or ven. blood
Measurements are difficult and uncommon
Tissue and blood concentrations are not equal
Dosing is sometimes confusing
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Inhalant ModelEntry via Lungs
Cardiac output affects blood level
Tension ( AKA Partial Pressure)measures gas, blood, and tissue levels
We ignore concentrations whenever possible
Blood/Gas Solubility Dominates kinetics
Expired (Exp) tension is measured commonly
Exp tension estimates blood tension now
Tissue and blood tensions become equal w time
VRG (brain) lags blood by 2-3 minutes ()
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Major difference between Inhalant and IV
Inhalant measure is tension or partial pressureMaximum tension anywhere is vaporizer settingMaximum tension in alveolar gas is inspired tensionMaximum tension in brain is alveolar tension
IV measure is plasma concentrationNo maximum
A small Central Compartment results in high concentrationActual Volume and Concentration are difficult to computeTrial dosage is based on body weight, possibly to some powerWt 0.75
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Inhaled Kinetic Model Compartments and Paths
VenousBlood
ArterialBlood
LungsBreathingCircuit
VaporizerTissues( Brain)
Compartmentsand
Paths
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Inhaled Kinetic Model Conductance move drug from place to place
.
VenousBlood
ArterialBlood
LungsBreathingCircuit
VaporizerTissues( Brain)
FGF = Fresh Gas Flow
VA = Alveolar Ventilation
CO = Cardiac Output
Compartmentsand
Paths
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Inhaled Kinetic ModelMeasurements confirm model and control care
.
VenousBlood
ArterialBlood
LungsBreathingCircuit
VaporizerTissues( Brain)
FGF = Fresh Gas Flow
VA = Alveolar Ventilation
CO = Cardiac Output
Exhaled GasInhaled Gas Anesthetic DepthSetting
Compartmentsand
Paths
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The Model - Gas Man® Picture
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The Model - Compartments and Flows
VaporizerBreathingCircuit Lungs
Blood
------Tissues------BrainVRG
Mus FatVenousBlood
FGFFreshGasFlow
Alv(Lung)Vent
CardiacOutput
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The Model - Return Flows
BreathingCircuit Lungs Venous
Blood
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The Model - From Vaporizer to Brain !
Vaporizer
Brain(VRG)
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Measurements we make
BreathingCircuit Lungs
Vaporizer
Setting Inspired Expired
BrainEEG,
BIS, PSI?HR,BP
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Time, Uptake, and Delivered Liters and $
Questions on Model ?
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Gas Man® Model and Math are correct.
Thus, we can use them.
• (A) Wash-in 360 minutes = 6 hr
15 minutes
• (B) Wash-out
after breathing 1 MAC for 1 hr.
• (C) Wash-out after breathing
1 MAC for 2 h.
• (D) Wash-out after breathing
1 MAC for 4 h.
• (E) Washout after breathing
1 MAC for 12 h.
• Bouillon T, Shafer S. Editorial – Hot air or full steam ahead? An empirical pharmacokinetic model of potent inhaled agents. Brit J. Anaes. 84:429-431 2000.
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In a multi- Compartment System
Intelligent drug administrationcan achieve the desired effect
Intelligence, here, meansKnow drug kinetics
Movement of drug through compartments Know drug dynamics
Dose-response relationship at effect site
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IV Drug Administration to achieve and maintain constant effect One compartment with no loss
Bolus Actually would last forever !
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Bolus fills a sealed compartment
Experiment
V
VolatileLiquid Agent
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Bolus fills a sealed compartment
Experiment
V
VolatileLiquid Agent
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Bolus fills a sealed compartment
Experiment
V
VolatileLiquid Agent
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Gas Man example
Bolus into breathing circuit
No removal (FGF = 0, VA = 0)
Removal via alveolar ventilation (VA)
Gas Man Result
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IV Drug Administration to achieve and maintain constant effect One compartment with no loss
Bolus One compartment real system (w clearance)
Bolus + constant infusionTwo compartment system
Bolus + constant + exponential decreaseThree Compartment system
Bolus + constant + 2 exponential decreaseComplicated mathematics
Open Loop Control based on “population-based parameters”By hand or by Computer
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IV Drug Administration to achieve and maintain constant effect
Closed-loop controlBased on some measurement
CV EffectsEstimate from EEGOther
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Step response causes the curve we are familiar with
Initial rise
Plateau
Knee
Tail
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Step response for many agents
from Ether to Xenon
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Step response for many agents
from Ether to XenonOctober 16, 1846
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Agents with a new spin
MatLab Simulation of
Creation and rotation of
Continuous distribution of Lambda and Alveolar Tension curve with Plateau
Mandel JE, Philip JH. New Approaches to Visualization of Phenomena in Inhalational Pharmacokinetics. Society for Technology in Anesthesia (STA). Tucson AZ, January 1998.
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Agents with a new spin
Mandel JE, Philip JH. New Approaches to Visualization of Phenomena in Inhalational Pharmacokinetics. Society for Technology in Anesthesia (STA). Tucson AZ, January 1998.
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Agents with a new spin
Mandel JE, Philip JH. New Approaches to Visualization of Phenomena in Inhalational Pharmacokinetics. Society for Technology in Anesthesia (STA). Tucson AZ, January 1998.
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Up and Down Bolus are both possiblewith Inhaled Drugs
Up Bolus - Induces anesthesia quickly
Typical 50 seconds
Well tolerated by adults without premedication
Fast from high inspired concentration
Fast from one or more deep breaths
Up Bolus deepens existing anesthesia quickly
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Special advantages of inhalation route
Breathed in via lungs
100% of cardiac output interacts
Still distributed, like IV Drugs
Breathed out via lungs100% of cardiac output allows high clearance
Low Blood/Gas Solubility creates high clearance
End-expired level ≈ Alveolar ≈ Blood
Brain + CV follow blood with ≈ 3 minute delay
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End-expired agent monitor
Agent Monitor monitorsEnd-tidal agent
Cardiovascular Monitor monitors HR, BP,...
Models predict and help to interpretAlveolar, Blood, Brain, Other tissuesGas Man® is my model
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Inhalants are fast in achieving control
“An inhalation bolus of sevoflurane seems to be more effective than an IV remifentanil bolus during maintenance, with more effective control of hemodynamic responses to surgical stress.”
Matute E, Alsina E, Roses R, Blanc G, Perez-Hernandez C, Gilsanz F. An inhalation bolus of sevoflurane versus an intravenous bolus of remifentanil for controlling hemodynamic responses to surgical stress during major surgery: a prospective randomized trial.Anesth Analg 2002 May;94(5):1217-22
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Bolus up
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Bolus down, then up
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Show Gas Man® Results
Adjust DEL for 1 MAC, Overlay FGF
8 -> 4 -> 2 -> 1 LPM
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Low Flow
• Reduces Cost
• Reduces Control
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Bolus Techniques
• Bolus UpIV DrugsInhaled Drugs
• Bolus DownInhaled Drugs only
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Agent Monitors Show and Teach
• Inhalation anesthesia kinetics
• How to better administer anesthetics
• How to predict the result of anesthetic administration
• Graphic Trends facilitate this understanding.
• They show the time course of anesthesia
• This is more important than static numerals
• Gas Man® first
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Single Breath Induction
• Bolus up followed by bolus down
• Fast induction
• Avoid overdose once airway is secured
• Agent Monitor and Gas Man® graphs show this
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Gas Man® showsSingle Breath Induction
Gas Man® Simulation
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Show Gas Man ® Results
Gas Man® showsSingle Breath Induction
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AgentMonitor Graph
E
I
I
E
I
E
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AgentMonitor Graph
GasMan®
Graph
E
I
E
I
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AgentMonitor Graph
GasMan®
Graph
Superimpose
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These Trend Graphsshow all variables:
Bolus up and down
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Wake Up
!
Enough of going to sleep
It’s now time to
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Gas Man® showsEmergence Time
Gas Man Simulation
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Show Gas Man® Results
Gas Man® showsEmergence Time
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Gas Man® OverlaysCompare
Emergence withIso, Sevo, Des
ALV
VRG
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Gas Man® OverlaysCompare
Emergence withIso, Sevo, Des
ALV
VRG
Awake0.33 MACIn Brain
7 10 30Des Sevo Iso
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At lower value, time difference is greater
.33.20
3 min
14 min
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Residents show emergence times on Ambulatory Anesthesia Rotation
Gas Man Homework
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Gas Man Comparison - September
1 MAC brain Iso, Sevo, Des for 1.5 hours
Use the same FGF, VA and CO for all drugs
Start with higher flows for the first few minutes
Perform a Wake up comparison
Measure time for VRG to reach 0.33 MAC
Measure time for VRG to reach 0.2 MAC
Here, Gas Man simulations are inserted into PowerPoint
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Time Zero
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Af ter
1.5
hrs
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Af ter
1.5
hrs
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At
0.33
MAC
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At
0.33
MAC
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Overlay of three wake ups 0.33 MAC
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Overlay of three wake ups 0.33 MAC
0.33 MAC
05’ 26” 07’ 42” 10’ 55”Time to 0.33 MAC
0.33
0.20 MAC
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Each
at
0.2MAC
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Each
at
0.2MAC
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Overlay at 0.2 MAC
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Overlay at 0.2 MAC
0.20 0.20 MAC
07’ 25” 11’ 26”17’ 45” Time to 0.20 MAC
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Overlay at 0.2 MAC
0.20 MAC0.200.33 MAC0.33
07’ 25” 11’ 26”17’ 45” Time to 0.20 MAC
05’ 26” 07’ 42” 10’ 55”Time to 0.33 MAC
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These simulations are similar to
Eger EI, Shafer SL. Context-Sensitive Decrement Times for Inhaled Anesthetics. Anesth Analg 2005 101: 688-696 (Tutorial).
Except, Our residents used Gas Man® on their own
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• Eger EI, Shafer SL. Tutorial: Context-Sensitive Decrement Times
• for Inhaled Anesthetics. Anesth Analg 2005 101: 688-696
Eger published this, Sept 200580%80% 88%88%
90%90% 92%92%
95%95%
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Journal Club week before this lecture
Eger EI, Shafer SL. Context-Sensitive Decrement Times for Inhaled Anesthetics. Anesth Analg 2005 101: 688-696 (Tutorial).
Authors used Gas® Man to infer much about inhalation anesthesia and different drugs
David Goodman Compared Emergence afterIsoflurane 1 hr
Sevoflurane 4 hrDesflurane 4 hr
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Cases 4 hrs Sevo, Des, 1 hr Iso
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Observe wake up
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Wake up from Iso 1 hr is inferior to Sevo or Des for 4 hrs.Wake up from 4 hr Des is superior to 4 hr Sevo.
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• Eger EI, Shafer SL. Tutorial: Context-Sensitive Decrement Times
• for Inhaled Anesthetics. Anesth Analg 2005 101: 688-696
Eger published this, Sept 200580%80% 88%88%
90%90% 92%92%
95%95%
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Thank you
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Your Questions, please
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My Questions
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Return in 5 minutes for Clinical Conference
What our Gas Monitors teach us
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Importance of Solubility
•Blood •Brain
•Muscle
• Fat
Show Gas Man® Results
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Switching Agents is confusing
More
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GasMan® in Neumann MA et al. Anesthesiology 1998;88:914-21.
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November 1-2 Visiting Professor
• Dwayne Westenskow PhD
• Anesthesia Inventor extraordinaire
• QUESTIONS
• DISCUSSION NOV 1 WITH HIM“Technology Club”Insight into his inventionDiscussion about your ideasMight you attend - Raise hands
• My home or Hospital Raise hand for my home