日本臨床麻酔学会 vol.34
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1 169 日本臨床麻酔学会第 32 回大会招請講演日臨麻会誌 Vol.34 No.2, , 2014 複雑心奇形の周術期管理 並列循環症例の管理 岩崎達雄金澤伴幸 戸田雄一郎 森松博史 清水一好 森田潔 [ 要旨 ] 先天性心疾患で最もその生理が成人と異なり管理が困難な症例は, 並列循環を伴う単心室症である. これらの患児は, まず第一期姑息術を受けるが, 術後にも並列循環が残存するため周術期管理ではこの並列循環の管理が大切になる. 理想的な並列循環を達成するために動脈血酸素飽和度のみならず体静脈血酸素飽和度をモニタリングして循環動態を正確に把握する. また体静脈血酸素飽和度は患児の予後予測, 目標指向型治療の指標としても有用である. 体 肺血流のバランスをとるために心拍出量, 体 肺血管抵抗を調節するが, 第一期姑息術後では体血管抵抗を調節する方がより効果的で, 積極的な後負荷軽減療法は並列循環を安定させ, 術後合併症を低減する. キーワード : 単心室症, 並列循環,Single ventricular physiology, 体静脈血酸素飽和度モニタリング, 後負荷軽減療法 はじめに parallel circulation Ⅰ Single ventricular physiology pulmonary atresia with intact ventricular septum single ventricular physiology 図 ₈₅₅₈ 2-5-1
2 170 Vol.34 No.2/Mar PAO2 PAO2 lung SpvO2 SaO2 lung SpvO2 ScO2 肺循環 SpaO2 SvO2 体循環 tissue splitting tissue SaO2 SpaO2 mixing SvO2 直列循環 並列循環 図 1 直列循環と並列循環 Pediatric Cardiac Anesthesia, 4th ed. Lake CL, Booker PD, eds. Lippincott-Williams & Wilkins, Philadelphia, 2005, 544 / 表 表 1 並列循環の分類 1. 体循環血流の経路に狭窄がない場合 肺循環血流と体循環血流のバランスが良い (/~1) 経過観察 肺血流が不十分 (/ < 1) 体肺動脈シャント (Blalock Taussig シャント ) 肺血流が過剰 (/ > 1) 肺動脈絞扼術 2. 体循環血流の経路に狭窄がある場合大動脈再建を伴う複雑な手術 (DKS,Norwood) / 1 / 1 Blalock-Taussig shunt BT shunt / 1 pulmonary artery banding PA banding Damus-Kaye-Stansel DKS Norwood
3 171 表 2 肺体血流比の計測および動脈血酸素飽和度との関係 Fick の原理より体循環 VO 2 = (SaO 2 - SvO 2) 肺循環 VO 2= (SpvO 2 - SpaO 2) ( 並列循環では SpaO 2 は SaO 2 と等しい ) SaO 2 - SvO 2 = 式 (1) SpvO 2 - SaO 2 SpvO 2 + SvO 2 SaO 2 = + SpvO 2 + SvO 2 SaO 2 = + SaO 2 = 100 ー 25 式 (2) VO 2 SaO 2 SvO 2 SpvO 2 表 1 Ⅱ モニタリング SpvO / or 1 SaO 2 SvO / Fick 表 2-1 / / SaO 2 表 2-1 SpaO 2 SaO 2 SpaO 2 SaO 2 SpvO SaO 2 SvO / 表 2-2 / 1 SaO 2 75 / 1 SaO 2 75 / 1 SaO 2 75 SaO 2 SpvO SaO 2 75 SpvO 2 / 1 1 SaO 2 SpvO 2 SaO 2 SpvO 2 図 2 / SvO 2
4 172 Vol.34 No.2/Mar 肺体血流比 (/) 静的因子 ( シャントサイズ, 吻合 ) 動的因子 ( 体 肺血管抵抗 ) lung tissue 肺静脈血酸素飽和度 (SpvO2) 体静脈血酸素飽和度 (SvO2) 肺のコンディション 酸素運搬量, 酸素消費量 図 2 並列循環において SaO 2 に影響を与える因子 SpvO 2 X SvO 2 Bradley 2 Norwood 30 SaO 2 SvO 2 30 Tweddell 3 Norwood ICU SvO 2 50 SvO 2 48 SvO 2 SvO 2 50 Ⅲ 体 肺血流の管理 SaO 2 SvO 2 表 3 肺血管抵抗に影響を与える因子 肺血管抵抗増加 肺血管抵抗減少 酸素濃度 低濃度 高濃度 PaCO 2 高 低 ph アシドーシス アルカローシス 気道内圧 高 (PEEP) 低 体血管抵抗 下げる 上げる 薬剤 NO,PGI 2, sildenafil,bosentan 血液粘度 (Ht) 高粘度 ( 高 Ht) 低粘度 ( 低 Ht) SaO 2 SvO 2 表 3 PEEP PaCO 2
5 173 50% 静脈血酸素飽和度 患児 人工呼吸器 加湿器 窒素ガス ガス流量計 ガス分析機 ( 酸素濃度計 ) 80% 動脈血酸素飽和度 図 3 人工呼吸器による低濃度酸素療法 / SvO 2 図 4 ヘッドボックスによる低濃度酸素吸入療法 図 3 図 ml/min SaO 2 80 SvO 2 V/Q 4 / PaCO 2
6 174 Vol.34 No.2/Mar PDE high flow Hoffman 5 POB SaO 2 SvO 2 / De Oliveira 6 POB Norwood POB PA banding BT shunt SVR PVR Ⅳ RV-PA シャントを用いた Norwood 手術 Norwood modified BT shunt MBT Norwood RV-PA Norwood RV-PA Norwood Norwood modified BT shunt / ECMO 7 MBT Norwood modified BT shunt RV- PA shunt RV-PA Norwood 8 MBT Norwood RV-PA Norwood National Institute of Health NIH Pediatric Heart Network RV-PA Norwood 12 9 Stage MBT Norwood 14 RV-PA Norwood MBT Norwood RV-PA Norwood 7, 13 RV-PA Norwood RV-PA shunt MBT Norwood
7 175 Ⅴ 現在の課題 RV- PA Norwood kg 2 intact atrial septum intact atrial septum bilateral PA banding Norwood bidirectional Glenn 参考文献 1) Barnea O, Santamore WP, Rossi A, et al.:estimation of oxygen delivery in newborns with a univentricular circulation. Circulation 98: , ) Bradley SM, Atz AM:Postoperative management:the role of mixed venous oxygen saturation monitoring. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu:22-27, ) Tweddell JS, Ghanayem NS, Mussatto KA, et al.: Mixed venous oxygen saturation monitoring after stage 1 palliation for hypoplastic left heart syndrome. Ann Thorac Surg 84: , ) Lister G, Hellenbrand WE, Kleinman CS, et al.:physiologic effects of increasing hemoglobin concentration in left-to-right shunting in infants with ventricular septal defects. N Engl J Med 306: , ) Hoffman GM, Tweddell JS, Ghanayem NS, et al.:alteration of the critical arteriovenous oxygen saturation relationship by sustained afterload reduction after the Norwood procedure. J Thorac Cardiovasc Surg 127: , ) De Oliveira NC, Ashburn DA, Khalid F, et al.:prevention of early sudden circulatory collapse after the Norwood operation. Circulation 110(Suppl 1):II , ) Ghanayem NS, Jaquiss RD, Cava JR, et al.:right ventricle-to-pulmonary artery conduit versus Blalock-Taussig shunt:a hemodynamic comparison. Ann Thorac Surg 82: , ) Schreiber C, Kasnar-Samprec J, Hörer J, et al.:ringenforced right ventricle-to-pulmonary artery conduit in Norwood stage I reduces proximal conduit stenosis. Ann Thorac Surg 88: , ) Ohye RG, Sleeper LA, Mahony L, et al.:comparison of shunt types in the Norwood procedure for singleventricle lesions. N Engl J Med 362: , )Ghanayem NS, Allen KR, Tabbutt S, et al.:interstage mortality after the Norwood procedure:results of the multicenter single ventricle reconstruction trial. J Thorac Cardiovasc Surg 144: , )Newburger JW, Sleeper LA, Bellinger DC, et al.:early developmental outcome in children with hypoplastic left heart syndrome and related anomalies:the single ventricle reconstruction trial. Circulation 125: , )Frommelt PC, Guey LT, Minich LL, et al.:does initial shunt type for the Norwood procedure affect echocardiographic measures of cardiac size and function during infancy?:the single ventricle reconstruction trial. Circulation 125: , )Naito Y, Aoki M, Watanabe M, et al.:factors affecting systemic oxygen delivery after Norwood procedure with Sano modification. Ann Thorac Surg 89: , 2010
8 176 Vol.34 No.2/Mar Perioperative Management of Children with Complex Congenital Heart Disease: Management of Children with Single Ventricular Physiology Tatsuo IWASAKI, Yuichiro TODA, Kazuyoshi SHIMIZU, Tomoyuki KANAZAWA, Hiroshi MORIMATSU, Kiyoshi MORITA Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences The most difficult congenital heart disease(chd)with the shunt lesion to manage is the single ventricle with parallel circulation(pc). Children undergo some kind of initial palliative surgery to establish unobstructed pulmonary and systemic venous return and unobstructed systemic outflow and limited pulmonary blood flow(pbf)and pulmonary artery pressure. Even after the initial palliative surgery, children still have PC that is difficult to manage, and control of PC is the key issue in the perioperative management of children with complex CHD. To attain the ideal physiology, better evaluation of circulatory status with monitoring not only SaO 2 but also SvO 2 is crucial. SvO 2 is also an excellent indicator of outcome, and Goal-directed therapy with SvO 2 as an indicator of systemic oxygen delivery is associated with excellent, early survival and a low incidence of organ failure in infants after Norwood. Cardiac output, systemic vascular resistance, and pulmonary vascular resistance must be manipulated in order to control /. Manipulation of / by manipulation of SVR may be more effective, especially after initial palliative surgery, and aggressive after load reduction therapy contributes to stable hemodynamic status and improves early outcome. Key Words : Single ventricle, Parallel circulation, Single ventricular physiology, SvO 2 monitoring, After load reduction therapy The Journal of Japan Society for Clinical Anesthesia Vol.34 No.2, 2014
B : Total Cavo-Pulmonary Connection (TCPC) 1) Fontan F, Mounicot FB, Baudet E, Simonneau J, Gordo J, Gouffrant JM : ["Correction" of tricuspid atresia. 2 cases "corrected" using a new surgical technic].
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