ブックタイトル第43回日本集中治療医学会学術集会プログラム・抄録集

概要

第43回日本集中治療医学会学術集会プログラム・抄録集

－364－LS13-1 循環動態モニターの基礎パラメータ日本医科大学多摩永山病院救命救急センター田上 隆　集中治療室に、循環呼吸動態が不安定な患者さん入室してきた。どうやら敗血症性ショックとARDS であるらしい。少ない情報から主治医として、何をどう考え、すぐに何をすべきか？状況証拠から病態を想像し、自己の知識・経験をもとに、最善な初めの一手をうたなくてはならない。ただ、判断する根拠・情報は、しばしば主観的・定性的であることが多く、主治医として葛藤も多い。　集中治療室で、循環不全に対する治療戦略を立てる上で、判断根拠となる情報は、信頼性が高く客観的・定量的であることが望ましい。本セミナーでは、経肺熱希釈法システムから算出される、循環・呼吸のパラメータを紹介し、その妥当性と定量的評価方法を概説する。対象は、経肺熱希釈法について聞いたことの無い方・使用したことが無い方・初めて使用してみようと考えている方である。ランチョンセミナー 13 2月13日（土）　12：20～13：20　第2会場Usefulness of transpulmonary thermodilution systems in ICU patientsLS13-2 Usefulness of transpulmonary thermodilution systems in ICU patientsMedical ICU, Bicetre Hospital, University Paris-South, FranceJean-Louis Teboul　Transpulmonary thermodilution systems provide intermittent measurements of cardiac output（CO）and other variables byapplying the indicator dilution principles with temperature as the indicator. The transpulmonary thermodilution devices are lessinvasive than the pulmonary artery catheter, even if they require insertion of a central venous catheter（for cold bolusinjection）and a thermistor-tipped femoral artery catheter. These devices combine transpulmonary thermodilution and pulsecontour analysis technologies.　The mathematical analysis of the thermodilution curve（blood temperature vs. time）allows calculation of the followingvariables: 1）CO, 2）global end-diastolic volume（GEDV）, a volumetric marker of preload, 3）cardiac function index and globalejection fraction, indicators of cardiac systolic function, 4）extravascular lung water（EVLW）, a measure of lung edema, and 5）pulmonary vascular permeability index（PVPI）, a marker of lung capillary leakage. The measurement of CO by transpulmonarythermodilution is precise provided that three cold boluses are injected. The bolus injection also serves to calibrate the femoralartery pressure waveform analysis that provides real-time calculation of CO by using proprietary algorithms based on therelationship between stroke volume and arterial pressure waveform. Good agreement with thermodilution CO has been reportedin hemodynamically unstable patients.　One major interest of the pulse contour analysis is to track in real-time, the short-term CO changes induced by therapeutictests such as volume challenges. These systems also provide automatic calculation of dynamic indices of fluid responsivenesssuch as pulse pressure variation（PPV）and/or stroke volume variation（SVV）. Using PPV and SVV to predict thehemodynamic response to fluid infusion is based on the concept of marked heart-lung interactions during mechanical ventilationin the case of cardiac preload-dependence and vice-versa. In situations where PPV and SVV are not valid（e.g. spontaneousbreathing activity, arrhythmias, low tidal volume）, monitoring pulse contour CO during volume challenges such passive legraising or end-expiratory occlusion test, can be reliably used to predict fluid responsiveness. The optimal clinical indication oftranspulmonary thermodilution devices is the situations where hemodynamic instability and lung injury coexist. Such systemshelp clinicians to better manage fluid therapy or fluid depletion thanks to the knowledge of PPV, GEDV, EVLW and PVPI.Septic patients with risks of increased permeability pulmonary edema（ARDS）or with cardiac dysfunction are excellentcandidates for the use of transpulmonary thermodilution devices.