2014/7/8 ICU
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1 2014/7/8 ICU
2 Autoregula5on
3 MAP 60mmHgが人の脳還流圧の Autoregula5onの下限 犬の腎臓 動静脈 尿管にカニュレーションして圧と流量を測定 Am J Physiol 1971; 220:
4 Pv=2mmHg Pv=10mmHg Pv=20mmHg 還流圧 PA- PV 腎静脈圧/尿管圧が 上がると腎動脈圧が 維持されていても 腎還流量は低下する Am J Physiol 1971; 220:
5 Autoregula5on 120mmHg BMJ 1973; 1: angiotensin amide, trimetaphan camsylate
6 autoregula5on 24 CPP CBF A: B: J. Appl Physiol 2007; 102: 72-78
7 ICM 2001; 27: ICU 8 PaCO2 CBF NCR Hb TCD, NIRS autoregula5on NCR Hb autoregula5on!?
8 Newtonian Fluid Viscosity Resistance R l/r 4 Poiseuille s law of resistance Resistance r flow Resistance
9 血圧の変化に対して最も鋭敏に 還流量が変化するのは腎臓 J App Physiol 1986; 61: 犬にニトロプルシドを投与してめいっぱい血管を拡張させ autoregula5onを効かなくした状態を模倣 血圧と還流量の関係を プロット 単位組織(g)あたりの血管床面積が最も大きいのは腎臓 心臓 腎臓
10 autoregula5on MAP!?
11 ICM 2012; 38: % CI MAP Vasomotor Tone
12 ProCESS
13 Methods n US 31 n SIRS 2 fluid challenge SBP 90 mmhg> or or 4mmol /L Web- based program 3 protocol- based EGDT vs. protocol- based standard therapy vs. usual care
14 Ø Oximetric port CV を使用 Ø CVP Ø MAP MAP>90 Ø ScvO2 Ht 30%, Ø Ø ScvO2
15 Ø CV Ø,, SpO2 Ø SBP Baseline SBP 10% SBP>100 Ø A- line Ø MAP<65, lactate >4mmol/L,,, Ø Hb <7.5
16 Results 1 P protocol- based vs. usual care 1 60
17 Results Ø 6 で MAP >65 mmhg standard protocol 83.1%, 84.1%, 77.2% P= hr Ø standard protocol
18 Results RRT protocol- based standard therapy
19 Standard therapy fluid overload MAP RRT MAP CO
20 ICM 2005; 31: mixed ICU 3 Sep5c shock 111 retrospec5ve MAP MAP 65 mmhg 60,70,75mmHg 30 MAP 65mmHg
21 NE CI DO2
22 Sep5c shock Head Trauma NE MAP SVR Cre CHEST 2004; 126:
23 CVP/GEDV, Pmsf, Rv NE doses Guytonian approach in controlling cardiac output Decreasing NE in sep5c shock pa5ents Decreases Pmsf and Rv Decreases cardiac preload (CVP/ GEDV) NE=α1- adrenergic s5mula5on increases the stress against the vessel walls Increases intravascular pressure Increases stressed blood volume and decreases unstressed blood volume
24 Venous Return Guyton s explana5on on CO P ms : upstream P RA : downstream At steady state, CO=VR Bayliss WM, Starling EH. Observa5ons on venous pressures and their rela5onship to capilary pressures. J Physiol 1894; 16:
25 What makes up Pms? Stressed volume Unstressed volume Adapted from: Funk, D. J., Jacobsohn, E., & Kumar, A. (2013). The role of venous return in cri5cal illness and shock- part I: physiology. Cri5cal care medicine, 41(1),
26 Clinical U5lity of the VR curve (2) Effects of norepinephrine and VR curve Methods 16 sep5c shock pa5ents Respiratory hold maneuver (Insp. & Exp.) CO: PiCCO2 Pcv: right internal jugular vein Reference: anterior axillary line and 5cm below the sternal angle Pvent: proximal of endotracheal tube Persichini R et al. Effects of norepinephrine on mean systemic pressure and venous return in human sep5c shock. Crit Care Med 2009;
27 Methods to determine P msf Mechanical Ven5la5on: A/C VCV Baseline Measurements: map, CVP, CI, GEDV, Con5nuous Measurements: map, CVP, Paw, SV, CI Pvent plateau: 5, 30cmH 2 O (Insp & Exp) BEFORE and AFTER norepinephrine decreases
28 1/Slope=Rv High dose NE: 6.2 ( ) Low dose NE: 5.0 ( ) p=0.01 Pmsf
29
30 Pro/Con
31
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33
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35
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40 SEPSISPAM
41 Methods ml/kg or right- heart catheteriza5on, pulse- pressure measurement, stroke- volume measurement, or echocardiography or 6
42 Methods Low MAP group MAP mmhg MAP >70 mmhg 0.05 μg/kg/min >75 mmhg 0.1μg/Kg/min High MAP group MAP mmhg MAP >85 mmhg 0.05 μg/kg/min >95 mmhg 0.1μg/Kg/min 5
43 Results 5 MAP Low- target group MAP High- target group. Low- target group MAP (65-70)
44 High- target group Day1 Low- Target group 0.45μg/kg/min High, Low- target group % %
45 % vs. 36.6%, HR 1.07 (95%CI ), P= RRT High- Target Group interac5on P= % vs. 31.7%, OR 0.64 (95%CI ), P=0.46
46 Adverse event Af High- target low- target
47 SEPSISPAM 65mmHg Af 80mmHg MAP Autoregula5on RRT
48
49 permissive hypotension THE PREVENTIVE TREATMENT OF WOUND SHOCK JAMA 1918; 70: Injec5on of a fluid that will increase blood pressure has dangers in itself. If the pressure is raised before the surgeon is ready to check any bleeding that may take place, blood that is sorely needed may be lost.
50 !? NEJM 1994; 331:
51 limita5on etc Dunham CM et al. Resuscita5on 1991; 21: 207 Turner J et al. Health Technology Assessment 2000; 4:1 Dula DJ et al. Emergency Care 2002; 6:417 Duuon RP et al. J Trauma 2002; 52: 1141 RCT
52 P V
53 65mmHg
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11) Kumar, R., et al.: Lancet, 1 : 90, 1973. 12) Baek, S. M., et al.: Ann. Surg., 177: 253, 1973. 13) Beak, S. M., et al.: Ann. Surg., 178 : 605, 1978. 14) Beak, S. M., et al.: Surgery, 77: 632, 1975.
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