日本臨床麻酔学会 vol.37

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1 219 日本臨床麻酔学会第 35 回大会シンポジウム日臨麻会誌 Vol.37 No.2, , 2017 Goal-Directed Therapy( 目標指向型輸液療法 ) の実践 ~ 国内外の実例を交えて ~ ERAS 時代の目標指向型輸液療法 (Goal-Directed Therapy) *1 松崎孝 *2 森松博史 [ 要旨 ] 周術期の輸液管理は重要で, 脱水と輸液過剰は術後合併症の点で有害である. 侵襲の伴う開腹手術における長時間の絶食はエビデンスが乏しい. 術中の維持輸液は術前の体重を維持する目的 ( ゼロバランスの維持 ) で施行すべきである. 周術期に 1 回拍出量を指標にした目標指向型の輸液管理は, 合併症を有するハイリスクの患者群で術後合併症や病院滞在日数を軽減させる可能性があるが, 前向き研究では否定的である. 可能ならできるだけ術後早期に点滴は中止して, 経口摂取を再開するべきである. 問題がなければ周術期の乏尿は経過観察すべきである. キーワード : 目標指向型輸液管理, 術後回復力の強化, ゼロバランス, 許容される乏尿はじめに Enhanced Recovery After Surgery ERAS ERAS goal-directed therapy GDT 1 2 表 ERAS GDT OPTIMISE POE- MAS GDT 30 7, 8 GDT ERAS

2 220 Vol.37 No.2/Mar 表 1 GDT に関するメタ解析およびシステマティックレビューのまとめ著者年度文献数サマリー Bundgaard Nielsen et al. 1) GDT は, 入院日数や PONV, 術後合併症を減少し, 消化管回復時間も早める Giglio et al. 2) Hamilton et al. 3) 消化器手術における GDT と適切な酸素化は, 周術期の臓器低灌流による消化器合併症のリスクを減少 GDT でハイリスク患者の術後死亡率が減少し ( オッズ比 0.48,95% CI ) 術後合併症も減少 Dalfino et al. 4) 輸液管理だけでなく変力作用薬を使用する GDT により術後急性腎不全を減少 Prowle et al. 5) GDT は術後の創感染, 肺炎, 尿路感染症を減少 Arulkumaran et al. 6) GDT は急性肺水腫と心筋梗塞の増加に関与しないが, 酸素運搬 Index 最適化の GDT は心血管合併症を減少 mL Ⅰ 術前輸液管理 Ⅱ 術中輸液管理 ASA kg 1. 維持輸液 3 10mL/kg/ 13

3 kg mL/kg/ 輸液負荷 Frank-Starling GDT central venous pressure CVP CVP CVP 20 GDT 1 Stroke Volume Index 10 Stroke Volume Variation SVV Pulse Pressure Variation PPV 13 R-R 1 8mg/kg 21

4 222 Vol.37 No.2/Mar ) 3. GDT が推奨されるべき対象 GDT mL L 80 Ⅲ 術後輸液管理 GDT L Ⅳ 最近の GDT に関する前向き多施設臨床研究の結果 1. POEMAS study 7) Pestaña ICU 24 GDT MAP 65 CI 2.5 GDT GDT 5.6 vs p OPTIMISE study 8) Pearse GDT n LiDCOrapid SV n 366 CVP 30 GDT vs. 6.5 GDT GDT Ⅴ 乏尿に関して GDT Kheterpal 65, mL/kg/ 24 23

5 ERAS 26 Permissive 参考文献 1) Bundgaard-Nielsen M, Holte K, Secher NH, et al.: Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 51: , ) Giglio MT, Marucci M, Testini M, et al.:goal-directed haemodynamic therapy and gastrointestinal complications in major surgery:a meta-analysis of randomized controlled trials. Br J Anaesth 103: , ) Hamilton MA, Cecconi M, Rhodes A:A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 112: , ) Dalfino L, Giglio MT, Puntillo F, et al.:haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care 15:R154, ) Prowle JR, Chua HR, Bagshaw SM, et al.:clinical review: Volume of fluid resuscitation and the incidence of acute kidney injury - a systematic review. Crit Care 16:230, ) Arulkumaran N, Corredor C, Hamilton MA, et al.: Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Br J Anaesth 112: , ) Pestaña D, Espinosa E, Eden A, et al.:perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery:a prospective, randomized, multicenter, pragmatic trial:poemas Study(PeriOperative goaldirected therapy in Major Abdominal Surgery). Anesth Analg 119: , ) Pearse RM, Harrison DA, MacDonald N, et al.:effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery:a randomized clinical trial and systematic review. JAMA 311: , ) Lobo DN, Bostock KA, Neal KR, et. al.:effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection:a randomised controlled trial. Lancet 359: , )Brady M, Kinn S, Stuart P:Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003;(4):CD )Lobo DN, Hendry PO, Rodrigues G, et al.:gastric emptying of three liquid oral preoperative metabolic preconditioning regimens measured by magnetic resonance imaging in healthy adult volunteers:a randomised double-blind, crossover study. Clin Nutr 28: , )Srinivasa S, Taylor MH, Singh PP, et al.:randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy. Br J Surg 100:66-74, )Jacob M, Chappell D, Rehm M:The third space - fact or fiction? Best Pract Res Clin Anaesthesiol 23: , )Becker BF, Chappell D, Jacob M:Endothelial glycocalyx and coronary vascular permeability: the fringe benefit. Basic Res Cardiol 105: , )Chappell D, Jacob M, Hofmann-Kiefer K, et al.:a rational approach to perioperative fluid management. Anesthesiology 109: , )Marjanovic G, Villain C, Juettner E, et al.:impact of different crystalloid volume regimes on intestinal anastomotic stability. Ann Surg 249: , )Cecconi M, Parsons AK, Rhodes A:What is a fluid challenge? Curr Opin Crit Care 17: , )Marik PE, Lemson J:Fluid responsiveness: an evolution of our understanding. Br J Anaesth 112: , )Hamilton-Davies C, Mythen MG, Salmon JB, et al.: Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry. Intensive Care Med 23: , )Marik PE, Baram M, Vahid B:Does central venous

6 224 Vol.37 No.2/Mar pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 134: , )Perel A, Habicher M, Sander M:Bench-to-bedside review: functional hemodynamics during surgery - should it be used for all high-risk cases? Crit Care 17:203, )Mythen MG, Swart M, Acheson N, et al.:perioperative fluid management:consensus statement from the enhanced recovery partnership. Perioper Med (Lond)1:2, )Varadhan KK, Lobo DN:A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc 69: , )Kheterpal S, Tremper KK, Englesbe MJ, et al.:predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology 107: , )Ewaldsson CA, Hahn RG:Kinetics and extravascular retention of acetated ringer s solution during isoflurane or propofol anesthesia for thyroid surgery. Anesthesiology 103: , )Prowle JR, Echeverri JE, Ligabo EV, et al.:fluid balance and acute kidney injury. Nat Rev Nephrol 6: , 2010 Goal-Directed Therapy of Perioperative Fluid Management within Enhanced Recovery after Surgery Takashi MATSUSAKI, Hiroshi MORIMATSU Department of Anesthesiology and Resuscitology, Okayama University Hospital Appropriate perioperative fluid management, especially in Goal-Directed Therapy(GDT), plays an important role in Enhanced Recovery after Surgery(ERAS). Some systematic reviews have suggested that perioperative GDT decreases postoperative complications such as infection, respiratory and bowel function and hospital stay, but recent multi-center randomized controlled studies arrived at different conclusions. The overall goal of perioperative GDT is to maintain central euvolemia and avoid excess salt and water during not only the intraoperative phase but also the pre- and post-operative ones. For low risk patients, zero-balance should be recommended, while for high-risk patients undergoing high-risk surgery, individualized GDT should be considered based on surgical and patient risk factors. Without other problems, detrimental postoperative fluid overload would not be justified and permissive oliguria could be tolerated. Key Words : Goal-Directed Therapy(GDT), Enhanced Recovery after Surgery(ERAS), Zero-balance, Permissive oliguria The Journal of Japan Society for Clinical Anesthesia Vol.37 No.2, 2017

長崎Edwards

長崎Edwards BMJ 1997; 315: 909-15 Esophageal Doppler FTc > 0.35 Protocol (1997) Esophageal Doppler GDT Anesthesiology 2002; 97: 820-6 Major surgery Esophageal Doppler FTc >0.35 GDT PONV LOSGDT5 vs 7 6% hetastarchgoal