日本臨床麻酔学会 vol.31

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1 81 81 日本臨床麻酔学会第 29 回大会シンポジウム日臨麻会誌 Vol.31 No.1, 81 90, 2011 循環モニター : 非侵襲的モニターは侵襲的モニターを超えられるか? フロートラックシステムの有用性の検討福田 * 功 [ 要旨 ] フロートラックシステムは FloTrac t m sensor と Vigileo t m monitor からなるキャリブレーションを必要としない連続的動脈圧心拍出量モニター (arterial pressure-based cardiac output: APCO) である. この精度は Version 3.02 では間欠的熱希釈式心拍出量 (intermittent cardiac output:ico) 測定値と高い相関を示した. またこのモニターは付加価値として1 回拍出量変動 (stroke volume variation:svv) が測定できるが, このSVVは輸液反応性の指標としては有用であると考えられた. しかし APCO と SVV では輸液過剰の指標とはならないため,APCO と SVV で循環血液量を適正化し, その後中心静脈圧 (central venous pressure:cvp) や肺動脈閉塞圧 (pulmonary artery occlusion pressure:paop) をモニタリングしながら輸液量をコントロールする方法が望ましいと考えられた. またフロートラックシステムは中心静脈血酸素飽和度 (ScvO 2 ) もしくは混合静脈血酸素飽和度 (SvO 2 ) が測定できる. これらを前述した APCO,SVV や CVP,PAOP などと併せて用いることにより最適な酸素需給バランスを保つことが可能であると考えられた. キーワード : フロートラックシステム, 連続的動脈圧心拍出量モニター, 相関関係,1 回拍出量変動, 輸液反応性緒言 pulmonary artery catheter PAC 1 4 cardiac output CO Edwards Lifesciences Irvine FloTrac TM sensor Vigileo TM monitor arterial pressure-based cardiac output APCO 図 1 CO APCO calibration APCO

フロートラックセンサー / ビジレオモニターとモニター画面 stroke volume SV

5 CO SV pulse pressure variation PPV systolic

2 82 Vol.31 No.1/Jan 図 1 フロートラックシステム図 2 連続的動脈圧心拍出量測定システム : フロートラックセンサー / ビジレオモニターとモニター画面 stroke volume SV 1 stroke volume variation SVV central venous pressure CVP SVR 図 2 ScvO 2 APCO 図 1 individualized goal-directed fluid management 5 CO SV pulse pressure variation PPV systolic pressure variation SPV SVV CVP pulmonary artery occlusion pressure PAOP 5, 6 20 SV SVV

3 83 83 図 3 全症例での ICO と APCO との相関係数と Bland-Altman plot(n=80) Ver y=0.31x+2.8 r=0.51 Bias Precision 1.51 Ver y=0.40x+2.5 r=0.56 Bias Precision 1.36 Ver y=0.56x+1.8 r=0.75 Bias Precision 1.06 ICO intermittent cardiac output APCO arterial pressurebased cardiac output APCO SVV APCO PAC intermittent cardiac output ICO SVV CVP PAOP Ⅰ 対象, 方法と結果 ASA PS APCO 80 BD -A TM 22G 30mm 22G 30mm PAC Edwards Lifesciences 774HF75 Vigilance TM ICO CO 5% 10ml 5 PAC ICO APCO APCO Ver Ver Ver hyperdynamic state Linear regression Bland-Altman

4 84 Vol.31 No.1/Jan 図 4 Hyperdynamic 時の ICO と APCO との相関係数と Bland-Altman plot(n=19:10 On-Pump CABG and 9 hyperdynamic patients) Ver y=0.15x+3.7 r=0.42 Bias Precision 2.06 Ver y=0.20x+3.6 r=0.39 Bias Precision 2.15 Ver y=0.43x+2.3 r=0.73 Bias Precision 1.57 ICO intermittent cardiac output APCO arterial pressurebased cardiac output Ver r=0.51 Bias Precision 1.51 Ver r=0.56 Bias Precision 1.36 Ver r=0.75 Bias Precision 1.06 図 3 図 5 Hyperdynamic Ver r=0.42 Bias 0.30 Precision 2.06 Ver r=0.39 Bias 0.11 Precision 2.15 Ver r=0.73 Bias 0.14 Precision 1.57 図 4 Hyperdynamic Ver r=0.63 Bias 0.22 Precision 1.09 Ver r=0.71 Bias 0.16 Precision 1.00 Ver r=0.78 Bias 0.22 Precision 0.87 図 5 2. SVV 16 PAC 774HF75 BD - A TM 22G 30mm FloTrac TM /Vigileo TM monitor 8 10ml/kg volume control mode / CO 5% 10ml 5 volume expansion VE Hes 500ml 30 blood volume BV DDG analyzer Dye Densitogram Analyzer DDG-2001 VE APCO SVV DDG-CO

5 85 85 図 5 Hyperdynamic にならなかった症例 (n=61) Ver y=0.51x+1.9 r=0.63 Bias Precision 1.09 Ver y=0.57x+1.8 r=0.71 Bias Precision 1.00 Ver y=0.65x+1.3 r=0.78 Bias Precision 0.87 ICO intermittent cardiac output APCO arterial pressurebased cardiac output BV ICO CVP PAOP PAC Wilcoxon ICO DDG-CO APCO Bland-Altman CVP PAOP SVV receiver operating characteristic curve ROC DDG-CO ICO r=0.85 Bias Precision 1.17 図 6 BV SVV BV SVV 図 6 BV SVV ROC r=0.64 Area=0.93 BV ICO ROC r=0.41 Area=0.65 図 7 BV CVP ROC r=0.25 Area=0.55 図 8 BV PAOP ROC r=0.37 Area=0.79 図 8 Ⅱ 考察図 1 FloTrac TM sensor Vigileo TM monitor CO SV SVR SVV 図 2 図 3 APCO Ver r=0.53 Bias APCO 8 Version up 図 3 Ver PAC 図 3 図 9 dicrotic

6 86 Vol.31 No.1/Jan 図 6 ICO と DDG-CO の相関関係と Bland-Altman plot ( 上図 ),BV と SVV の時間的経過 ( 下図 ) y=1.00x+0.28 r=0.85 p < Bias Precision 1.17 p < 0.01 vs ctr p < 0.05 vs ctr ICO intermittent cardiac output DDG-CO DDG analyzer Dye Densitogram Analyzer cardiac output DDG BV blood volume SVV stroke volume variation 1 Ctr VE volume expansion notch 2 Ver Ver X t s t d A s a A s b A s c A s d Ver dicrotic notch t s t d A s a A s b A s c A s d APCO dicrotic notch 9 図 7 循環血液量 BV と SVV との相関関係と ROC 曲線下面積 ( 上図 ),BV と ICO との相関関係 ( 下図 ) y=-0.07x+5.29 r=0.64 p < Area 0.93 p < y=-0.54x+2.67 r=0.41 p < Area 0.65 p < 0.05 BV blood volume ICO intermittent cardiac output CVP PAC PAOP pulmonary capillary wedge pressure PCWP Frank-Starling 10 CVP PAOP static variables BV 5, 11, 12 SVV dynamic variables

7 87 87 PAOP SVV 図 8 APCO SVV SvO 2 16, 17 SvO 2 Presep ScvO 2 18 APCO IABP 19 1 SV 1 Ver CO SVV SVV 図 8 BV と CVP との関係 ( 上図 ),BV と PAOP との関係 ( 下図 ) y=-0.08x+3.86 r=0.25 p < Area 0.55 p < 0.05 y=-0.17x+2.92 r=0.37 p < Area 0.79 p < , 11, 13 SVV Ver Ver CABG SVV 14 Ver Ver SVV PiCCOplus TM SVV 9.6% 10% 15 APCO Ver dicrotic notch Version APCO SVV HES 500ml DDG SVV 図 6 図 7 CVP 1 20, 21 1 SVV SVV SVV SV 10 SVV SVV BV CVP PAOP SVV CO SV CVP PAOP 22 SVV CVP PAOP 結語

8 88 Vol.31 No.1/Jan 図 9 Ver. 1.03,Ver と Ver の動脈波形認識の違い Individualized goal-directed fluid management CO SVV APCO SV SVV CVP PAOP ScvO 2 SvO 2 参考文献 1) Sandham JD, Hull RD, Brant RF, et al.:a randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 348:5-14, ) Domino KB, Bowdle TA, Posner KL, et al.:injuries and liability related to central vascular catheters:a closed claims analysis. Anesthesiology 100: , ) Boyd KD, Thomas SJ, Gold J, et al.:a prospective study of complications of pulmonary artery catheterizations in 500 consecutive patients. Chest 84:245-

9 , ) Squara P, Bennett D, Perret C:Pulmonary artery catheter:does the problem lie in the users? Chest 121: , ) Bundgaard-Nielsen M, Holte K, Secher NH, et al.: Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 51: , ) Parry-Jones AJD, Pittman JAL:Arterial pressure and stroke volume variability as measurements for cardiovascular optimization. Int J Intensive Care 10: 67-72, ) Mayer J, Boldt J, Schöllhorn T, et al.:semi-invasive monitoring of cardiac output by a new device using arterial pressure waveform analysis:a comparison with intermittent pulmonary artery thermodilution in patients undergoing cardiac surgery. Br J Anaesth 98: , ) de Waal EE, Kalkman CJ, Rex S, et al.:validation of a new arterial pulse contour-based cardiac output device. Crit Care Med 35: , ) Pratt B, Roteliuk L, Hatib F, et al.:calculating arterial pressure-based cardiac output using a novel measurement and analysis method. Biomed Instrum Technol 41: , )Biais M, Nouette-Gaulain K, Cottenceau V, et al.:uncalibrated pulse contour-derived stroke volume variation predicts fluid responsiveness in mechanically ventilated patients undergoing liver transplantation. Br J Anaesth 101: , )Osman D, Ridel C, Ray P, et al.:cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 35:64-68, ) 松谷厚子, 長谷川隆一, 星邦彦ほか : ダイデンジトグラムアナライザーと連続心拍出量計から得られる循環諸量の関係.ICU と CCU 25: , )Michard F:Changes in arterial pressure during mechanical ventilation. Anesthesiology 103: , )Hofer CK, Senn A, Weibel L, et al.:assessment of stroke volume variation for prediction of fluid responsiveness using the modified FloTrac TM and PiCCOplus TM system. Crit Care 12:R82, )de Waal EE, Rex S, Kruitwagen CL, et al.:stroke volume variation obtained with FloTrac/Vigileo fails to predict fluid responsiveness in coronary artery bypass graft patients. Br J Anaesth 100: , ) 小山薫 : 混合静脈血酸素飽和度と中心静脈血酸素飽和度. 臨麻 33: , )Reinhart K, Bloos F:The value of venous oximetry. Curr Opin Crit Care 11: , )Reinhart K, Kuhn HJ, Hartog C, et al.:continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill. Intensive Care Med 30: , )Michard F, Teboul JL:Predicting fluid responsiveness in ICU patients:a critical analysis of the evidence. Chest 121: , )De Backer D, Heenen S, Piagnerelli M, et al.:pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med 31: , )Reuter DA, Bayerlein J, Goepfert MS, et al.:influence of tidal volume on left ventricular stroke volume variation measured by pulse contour analysis in mechanically ventilated patients. Intensive Care Med 29: , )Powell-Tuck J, Gosling P, Lobo DN, et al.:british Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients(GIFTASUP). NHS Evidence.

10 90 Vol.31 No.1/Jan Clinical Usefulness of the FloTrac System Efficacy of Arterial Pressure-Based Cardiac Output and Stroke Volume Variations Isao FUKUDA Department of Anesthesiology, National Hospital Organization Tokyo National Hospital The FloTrac system is composed of the FloTrac TM sensor and Vigileo monitor TM (Edwards Lifesciences, Irvine, CA). The FloTrac system uses arterial pressure-based cardiac output:apco, which is based on the relationship between pulse pressure and stroke volume. This principle, as well as recent advances in signal processing, has led to the development of a novel system that can continuously measure cardiac output from an arterial pressure waveform that does not require an external calibration reference method. The latest FloTrac system software(ver. 3.02)shows the highest degree of precision compared to PAC values. Modification of the software, such as assessing differences in systolic/diastolic area and time ratios based on the dicrotic location analysis, has resulted in improved accuracy in measuring cardiac output. SVV calculated by the FloTrac system is a useful predictor of increased CO in response to volume expansion(ve), and the FloTrac system is able to track changes in CO induced by VE. The FloTrac system is considered to be useful as a monitoring device in clinical practice. In conclusion, our findings suggest that dynamic indices, such as stroke volume variation(svv), are able to adequately predict the individual response to fluid loading, and can reliably predict fluid responsiveness compared to routinely used static variables of cardiac preload, such as filling pressures(central venous pressure, CVP, and pulmonary artery occlusion pressure, PAOP)in fluid optimization. Key Words : FloTrac system, APCO, Precision, SVV, Fluid responsiveness The Journal of Japan Society for Clinical Anesthesia Vol.31 No.1, 2011

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<95DB8C9288E397C389C88A E696E6462> 2011 Vol.60 No.2 p.138 147 Performance of the Japanese long-term care benefit: An International comparison based on OECD health data Mie MORIKAWA[1] Takako TSUTSUI[2] [1]National Institute of Public Health,