IVCを見て輸液を判断してもいいのか？

1 IVC . 2019/08/13. ICU .. ( ). IVC , . ( ). + IVC , .. IVC , ? . , . ( , , ). Orso D, et al. Intensive Care Med. 2018; 5: 1-10. ( , ) . , first-line . Jozwiak M, et al. Ann Transl Med. 2018; 6(18): 352-362.. Ansari , et al. Anaesthesia. 2016; 71: 94-105.. , , .. Monnet X, et al. Ann Intensive Care. 2016; 111. ICU 72 1L/ , 10% .. Wiedemann HP, et al. N Engl J Med. 2006; 354: 2564-2575. 1), 2), 3), AKI4) .. 1)Micek ST, et al. Crit Care. 2013; 17: R246. 2)Murphy CV, et al. Chest. 2009; 136: 102-9. 3)Kirkpatrick AW, et al. Intensive Care Med. 2013; 39: 1190-206. 4)Payen D, et al. Crit Care. 2008; 12: R74.. , . Marik PE, et al. Ann Intensive Care. 2011; 1: 1-9. , 28 . Levy MM, et al. Chest. 2004; 124(suppl): 120S. , .. Lopes MR, et al. Crit Care. 2007; 11: R100. Kalantari K, et al. Kidney International. 2013; 83: 1017-28.. Swan- ganz catheter PAWP CVP.

2 (central venous pressure: CVP). (pulmonary artery wedge pressure: PAWP). : 47%(CVP), 54%(PAWP) . Osman D, et al. Crit Care Med. 2007; 35:64-8.. 1980 , ICU . septic shock + septic cardiomyopathy . Ozier Y, et al. Crit Care Med. 1984; 12(7): 596-9. Predicting fluid responsiveness with echocardiography LV/RV size LVEDP(MV inflow). Doppler . LVOT VTI variation IVC size/IVC diameter variation , . IVC / .. IVC .. -IVC ? - ? .. IVC .. -IVC ? - ? . 1 (SV) (CO) 10 15%.. Cecconi M, et al. Curr Opin Crit Care. 2011; 17: 290-295.. Pierrakos C, et al. Intensive Care Med. 2012; 38: 422-428.. Monnet X, et al. Ann Intensive Care. 2016; 6: 111-21. Frank-Starling Marik-Phillips . ( - ). a: CO , .. ARDS, , *.. b: CO , .. Extravascular lung water(EVLW): . Marik PE, et al. British Journal of Anaesthesia. 2014; 112(4): 617-20. *Lee WL, et al.

3 N Engl J Med. 2010; 363: 689-91.. IVC .. IVC ? ? IVC , . hypovolemia . Comolet R. Abrege Masson. 1984: 36-53. Barbier C. Intensive Care Med. 2004; 30(9): 1740-1746. Barbier C. Intensive Care Med. 2004; 30(9): 1740-1746. IVC (dIVC) , . , 23 ICU (>18 ), . sBP<90mmHg : TV ml/kg, PEEP 4 2 cmH2O, plateau pressure 15 2 cmH2O. 7ml/kg 30 IVC . IVC: dIVC=(IVCmax-IVCmin)/IVCmin Responder; fluid expansion CI 15% Nonresponder; fluid expansion CI<15%.. AUC(dIVC): AUC(CVP): dIVC : >18%. : 90%, : 90%. : , : IVC 10 .. <8ml/kg .. Via G, et al. Intensive Care Med. 2016; 42: 1164-1167. , TR.. , , ECMO, IVCF . Via G, et al. Intensive Care Med. 2016; 42: 1164-1167. , IVC .. Xiang S, et al. Anesth Analg. 2018; 127(5): 1157-1164. Medline, Embase, Cochrane Library, Web of Science database(English). 12 (n=753) 76%. 58%.. sBP<90mmHg .. : TV 8ml/kg, PEEP 5cmH2O.

4 IVC .. TV 8ml/kg, PEEP 5cmH2O. IVC >16% 2%. TV<8ml/kg, PEEP>5cmH2O. IVC >14% 5%. TV 8ml/kg, PEEP 5cmH2O TV<8ml/kg, PEEP>5cmH2O. : (95% CI, ) : (95% CI, ) : (95% CI, ). : (95% CI, ) : (95% CI, ) : (95% CI, ). AUC: (95% CI, ) AUC: (95% CI, ) AUC: (95% CI, ).. Airapetian N, et al. Critical Care. 2015; 19: 400-7. , IVC IVC (cIVC) . 2 ICU, , 59 . (sBP<90mmHg, , ), <20ml/h or , AKI, L/D . TTE baseline VTI, SV, CO, IVC , IVC , PLR2 . , 500ml 15 . IVC: 2cm cIVC=(IVCmax-IVCmin)/IVCmax Responder; fluid expansion CO 10% Nonresponder; fluid expansion CO<10%. 49%. PLR CO . baseline IVCmin; Responders < Nonresponders cIVC; Responders > Nonresponders baseline cIVC>42% (97%), (90%) , (31%) .. Vieillard-Baron A , et al. Intensive Care Med. 2018; 44: 197-203. IVC (IVCEE) . (IAP) . 5 ICU, , 540 (117 IVCEE ) , . (sBP<90mmHg or MAP<65mmHg).

5 (pH< , BE<-5mmol/l), Lac>2mmol/l, ScvO2<70%. TTE baseline IVCEE, VTI, IAP , PLR1 VTI 10% . IVC: 2cm . IAP: 10(7-13) mmHg PEEP: 5(3-7) cmH2O. 15% : 172 (41%). IVCEE.. IAP 12mmHg: 129 (30%) AUC: AUC: AUC: .. Bortolotti P, et al. Ann Intensive Care. 2018; 8: 79-90. + , IVC , IVC (cIVC) . 2 ICU, , 55 (29 : af, 26 : PAC >6/min), sepsis (sBP<90mmHg, baseline >40mmHg ), < 1 , HR>100/min, . TTE baseline IVC , cIVC, VTI , 4% gelatin 500ml 30 . IVC: -IVC or 3-4cm . cIVC=(IVCmax-IVCmin)/IVCmax Responder; fluid expansion VTI 10% Nonresponder; fluid expansion VTI<10%. Preau S, et al. Crit Care Med. 2017; 45(3): e290-e297. standardized inspiration: (-5 to -10mmH2O), <5 . 53% cIVC-st iIVC-st cIVC-sp iIVC-sp cIVC-st iIVC-st cIVC-sp iIVC-sp cIVC-st 39% <11mm 37% <14mm iIVC-st 93% 83% 66% 79% . 88% 88% 85% 81%. 89% 87% 80% 78%. cIVC-sp . 93% 84% 70% 82%.

6 IIVC-sp . AUC gray zone 39-48% 9-13mm Meta-analysis . ( : TV 8ml/kg, PEEP 5cmH2O). IVC: >42%. IVC: >16%. 80%, 94%, AUC: 31%, 97%. 90%, 59%. AUC: .. Anesth Analg. 2018; 127(5): 1157-1164 Critical Care. 2015; 19: 400-7. (af, PAC>6/min). (IAP 12mmHg) ( , <5s) ( ). IVCEE: 13% cIVC-st: 39%, iIVC-st: <11mm cIVC-sp: 37%, iIVC-sp: <14mm cIVC-st cIVC-sp 93%, 88%, 66%, 85%, , 80%, 89%, 93% 80%, 70%. , 64% AUC: AUC: AUC: iIVC-st iIVC-sp 83%, 88%, 79%, 81%, 87%, 84% 78%, 82%. AUC: AUC: , . Intensive Care Med. 2018; 44: 197-203 Ann Intensive Care. 2018; 8: 79-90.. IVC .. -IVC ? - ? .. heart-lung interaction .. Marik PE, et al. British Journal of Anaesthesia. 2014; 112(4): 617-20. SVC. Charbonneau H, et al. Critical Care. 2014; 18: 473-481. SVC ( SVC) IVC ( IVC) . , ICU, (VC, TV 8-10ml/kg) septic shock 44 . ( , , , ), ( , ). 7ml/kg 6% 15.

7 IVC: TTE -IVC IVC=(IVCmax-IVCmin)/IVCmin SVC: TEE SVC=(SVCmax-SVCmin)/SVCmax Responder; fluid expansion CI 15% Nonresponder; fluid expansion CI<15%. 59%. SVC. IVC. SVC : >29%. : 54%(95% CI, 35-73). : 94%(95% CI, 83-105). NR: nonresponders SVC : >36%. R: responders Intensive Care Med. 2004; 30: 1734-1739. : 42%(95% CI, 23-61). : 100%(95% CI, 100-100). : 100%(95% CI, 100-100). : 55%(95% CI, 38-72). IVC : >21%. : 38%(95% CI, 19-57). NR: nonresponders : 61%(95% CI, 38-84). R: responders SVC. AUC: (95% CI, ). SVC . SVC . IVC. AUC: (95% CI, ). right parasternal view Arisha MJ, et al. Echocardiography. 2017; 34: 1919-1929.. supraclavicular view Kosaka M, et al. J Vasc Access. 2019; 20: 19-23. Ugalde D, et al. Intensive Care Med. 2019; 45: 1052-1054.. 1. 2-4 , . 2. CV. SVC. 3. 30-45 . 66 TTE , 77% SVC . (BMI , COPD ). SVC 16 . *.

8 TTE TEE . (p< , r2= ). TEE SVC . SVC . Jugular vein Guarracino F, et al. Critical Care. 2014; 18: 647-654. (IJV) . , 50 . : Pplat <30cmH2O( 20), TV 6-8ml/kg, PEEP 6cmH2O( 6). 7ml/kg 30 , . IJV: ( 30 ), , . IJV distensibility=( - )/ . Responder; fluid expansion CI 15% Nonresponder; fluid expansion CI<15%. Responders: n=30(60%). T0: . T1: . IJV distensibility AUC: (95% CI, ). IJV distensibility : >18%. : 80%(95% CI, ). : 95%(95% CI, ). IJV . PPV. AUC: (95% CI, ). PPV : > : 96%(95% CI, ). : 55%(95% CI, ). IJV distensibity > + PPV >12% : 100%, : 95%. IJV distensibity PPV .. IVC .. -IVC ? - ? IVC ? IVC. IVC . NPPV , asthma/COPD, . SVC . IVC , SVC .. SVC . SVC TTE , IVC . IVC .. IVDI: inferior vena cava distensibility index IVDI=(IVCmax-IVCmin)/IVCmin Theerawit P, et al. Critical Care. 2016; 36: 246-251. PPV SVV. 1). , 2). TV>8ml/kg3) PPV SVV.

9 4) 1)Durairaj L, et al. Chest. 2008; 133: 252-63. 2)Soubrier S, et al. Intensive Care Med. 2007; 33: 1117-24. 3)De Backer D, et al. Intensive Care Med. 2005; 31: 517-23. 4)Wyler von Ballmoos, et al. Critical Care. 2010; 14: R111. IVJ .. PPV . , . PLR. aortic blood flow 10% : 97%, : 94%, AUC: , , . Monnet X, et al. Critical Care. 2006; 34(5): 1402-1407. : PPV or SVV or PPV+IJV. , : PLR.. IVC . , . PPV SVV . IJV , . , , PLR . ? . 50% . Michard F, et al. Chest. 2002; 121: 2000-2008. 4 patients NR: non-responders PR: persistent responders TR: transient responders 37 patients(TR). , 30 49% NR .. Roger C, et al. Critical Care. 2019; 23: 179-188.. , . VS.. , .. 1990 40-50%. 2001 EGDT . 20-30 ml/kg in 30min Rivers E, et al. N Engl J Med. 2001; 345: 1368-77. CVP 8-12 mmHg 500ml . 30 .. : EGDT : (p= ). EGDT , . , 10 EGDT .. 3 trial ProCESS: Protocolized Care for Early Septic Shock ARISE: Australasian Resuscitation in Sepsis Evaluation ProMISe: Protocolized Management in Sepsis.

10 EGDT , ( 3 ).. Kalil AC, et al. Crit Care Med. 2017; 45: 607-614. EGDT ProCESS ARISE ProMISe Publish 2001 2014 2014 2015. / US/1 US/31 AUS1 NZ/51 UK/56. 263 1341 1600 1260. APACHE EGDT: EGDT: EGDT: EGDT: UC: UC: UC: UC: 6h 89 97 100 100. (%). 20-30 ml/kg 20 ml/kg 1000 ml 1000 ml 6h EGDT: 4981 EGDT: 2800 EGDT: 2515 EGDT: 2000. (ml) UC: 3499 UC: 2300 UC: 2591 UC:1784. (%) EGDT: 33 EGDT: 21 EGDT: 19 EGDT: 29. UC: 50 UC: 19 UC: 19 UC: 29. 60 90 90 . (%) EGDT: EGDT: EGDT: EGDT: UC: UC: UC: UC: UC: usual care . EGDT . , . ProCESS ARISE ProMISe ED EGDT: 197min EGDT: EGDT: UC: 185min UC: UC: Nguyen HB, et al. Critical Care. 2016; 20: 160-165. , 4-5L . vs .. , , / . Anantasit N, et al. Crit Care Med. 2014; 42:1812-20. Byrne L, et al. Am J Respir Crit Care Med. 2018; 198(8):1043-1054. FR: 40ml/kg of saline, 1h noradrenaline and vaspressin (n=8).