敗血症の輸液について 真剣に考える - JSEPTIC

1 ICU .. Crit Care Med 2013;41:580- 637 1. a) CVP 8- 12mmHg b) MAP 65mmHg c) d) ScvO2 SvO2 70% 65% 6 2. CVP 8- 12mmHg 1983 15 MAP 65mmHg Helsinki University Hospital 9 ICU 1999 2002 1419 sepsis 48 vasopressor support 111 MAP60/65/70/75mmHg Area under MAP 30 MAP<65mmHg AUC- ROC (95% CI ) MAP 65mmHg 85mmHg 65mmHg 70mmHg? 75mmHg? 80mmHg? AKI RIFLE AKIN 6 AKI , 4. 30ml/kg fluid challenge challenge SSCG 1C 2001 Rivers EGDT Resuscita]on N Engl J Med.

2 2001 Nov;345(19):- 1368- 1377 RCT 263 vs. EGDT CVP,MAP, ,ScvO2 or SvO2 4 6 resuscita]on bundle 28 46% 30% Rivers 4 CVP,ScvO2 SSCG 4 EGDT EGDT RCT Rivers 3 RCT 1 ProCESS trial Resuscitation Standard usual care Methods 31 Resuscitation SSCG Resuscitation ScvO2 2008. 3 2013. 5 18 SIRS 2 Fluid challenge SBP 90 mmHg> or 4mmol /L 3 Protocol-based EGDT vs. Protocol-based standard therapy vs. Usual care 60 2 90 90 ICU disposition Protocol- based EGDT ScvO2 CVP MAP inotrope ScvO2 15-30 Protocol- based standard therapy CV SBP Shock Index(SI) JVD,rales IAP , Baseline 10% pass MAP<65, lactate >4,mottled skin, , Hb < Usual care web- based exam Results 1 standard usual 60 90 Results 2 , , standard Results ResuscitaPon and processes Standard 3285 vs.

3 2279 Vasopressor Standard Resuscitation Results ResuscitaPon and processes Standard 72hr 8193 vs. 6633 Standard 6 6 MAP Standard 6 pH Usual EGDT , usual ,Standard Usual 6 Standard , pH Usual Cl Standard , ,RRT ICU , Rivers ProCESS 1 20% RCT , , EGDT 1. ORIGINALSTUDYP rehospital Intravenous Fluid Administration Is Associated WithHigher Mortality in Trauma Patients: A National Trauma DataBank AnalysisElliott R.

4 Haut, MD , Brian T. Kalish, BA , Bryan A. Cotton, MD, MPH , ,MD ,Adil H. Haider, MD, MPH , Kent A. Stevens, MD, MPH , Alicia N. Kieninger, MD ,Edward E. Cornwell, III, MD , and David C. Chang, MBA, MPH, PhD Objective:Prehospital intravenous (IV) fluid administration is common intrauma patients, although little evidence supports this practice. We hypoth-esized that trauma patients who received prehospital IV fluids have highermortality than trauma patients who did not receive IV fluids in the :We performed a retrospective cohort study of patients from theNational Trauma Data Bank. Multiple logistic regression was used withmortality as the primary outcome measure. We compared patients with ver-sus without prehospital IV fluid administration, using patient demographics,mechanism, physiologic and anatomic injury severity, and other prehospitalprocedures as covariates. Subset analysis was performed based on mechanism(blunt/penetrating), hypotension, immediate surgery, severe head injury, andinjury severity :A total of 776,734 patients were studied.

5 Approximately half ( )received prehospital IV. Overall mortality was Unadjusted mortalitywas significantly higher in patients receiving prehospital IV fluids ( ,P< ). Multivariable analysis demonstrated that patients receivingIV fluids were significantly more likely to die (odds ratio [OR] , 95%confidence interval [CI] ). The association was identified in nearly allsubsets of trauma patients. It is especially marked in patients with penetratingmechanism (OR , 95% CI ), hypotension (OR , 95% ), severe head injury (OR , 95% CI ), and patientsundergoing immediate surgery (OR , 95% CI ).Conclusions:The harm associated with prehospital IV fluid administrationis significant for victims of trauma. The routine use of prehospital IV fluidadministration for all trauma patients should be discouraged.(Ann Surg2011;253:371 378)The administration of intravenous (IV) fluids has been a key com-ponent of the prehospital treatment of trauma patients since theadvent of paramedic emergency medical systems (EMS).

6 Prehospi-tal IV fluid resuscitation is intended to hemodynamically stabilizetrauma patients by replacing intravascular volume and maintainingFrom the Division of Acute Care Surgery, Department of Surgery, The JohnsHopkins University School of Medicine, Baltimore, MD; Department ofSurgery and The Center for Translational Injury Research, The University ofTexas Health Science Center at Houston, Houston, TX; Department of HealthPolicy and Management, The Johns Hopkins University Bloomberg Schoolof Public Health; Department of Surgery, Washington University School ofMedicine, St. Louis, MO; Department of Surgery, Howard University Collegeof Medicine, Washington, DC; and Director of Outcomes Research, Depart-ment of Surgery, University of California San Diego, San Diego, Disclosures: noneThis work was presented at the Eastern Association for the Surgery of Trauma(EAST) Annual Meeting, Orlando, FL, on January 16, : Elliott R.

7 Haut, MD, FACS, Division of Acute Care Surgery, Departmentof Surgery, The Johns Hopkins Hospital, 600 N. Wolfe St., 625 Osler, Baltimore,MD 21287. E-mail: 2011 by Lippincott Williams & WilkinsISSN: 0003-4932/11/25302-0371 DOI: organ its inception, the American College ofSurgeons Advanced Trauma Life Support course has emphasized im-mediate treatment of trauma patients with IV fluids, although in thenewest eighth edition, the course now emphasizes a more balanced routine practice of IV fluid administration in the pre-hospital arena is touted with great enthusiasm but little data exist tosupport its ,4An increasing body of evidence has demonstrated that IV fluidadministration does not improve survival in trauma and may actuallybe of harm in certain subsets of trauma 9 One theory for thepossibility of harm is based upon the delay of transport to definitivecare. Scene placement of venous access is not only associated withincreased scene time but also increased overall time to hospital, insome cases the time to place an IV exceeds that of the actual hypotensive patients and those with primary torso injuries,scene placement times exceed that of en route IV line ,12 Many trauma providers believe that the scoop and run approach,which minimizes prehospital procedures in favor of rapid transportto definitive care, is preferable to the stay and play model of pre-hospital trauma ,14 The second main theory regarding the potential harm of IVfluids is based upon the idea of popping the clot.

8 This theorysuggests that in patients, who have stopped bleeding temporarily fromvasoconstriction and hypotension, IV fluids will raise systolic bloodpressure and cause patients to rebleed if their bleeding source is notyet surgically controlled. This theory is supported by one of the fewprospective randomized studies of prehospital IV fluid resuscitationin trauma patients. Bickell et al15showed that delaying aggressivefluid resuscitation until surgery significantly improved outcome inhypotensive patients with penetrating torso injuries. On the basisof these data, a new Eastern Association for the Surgery of Traumapractice management guideline advocates limited prehospital IV the previous data, we chose to examine the impact ofprehospital IV catheter placement and fluid administration on survivalfollowing traumatic injury using the National Trauma Data Bank(NTDB), which is the largest dataset of trauma patients ever hypothesize that trauma patients receiving prehospital IV catheterplacement (with or without IV fluids) have higher mortality thantrauma patients who did not receive an IV or retrospective study used 5 years (2001 2005) worth ofdata from the American College of Surgeons NTDB (Version ).

9 The NTDB is the largest collection of trauma data, with approxi-mately million records from more than 600 US trauma from the NTDB are deidentified to comply with The HealthInsurance Portability and Accountability Act (HIPAA) review board exemption was obtained from the JohnsHopkins institutional review board. All trauma patients who sufferedCopyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is !Volume 253, Number 2, February |371 Annals of Surfery, Volume 253, Munber 2, February 2011: 371-377 , , , , , , , , Annals of Surgery!Volume 253, Number 2, February 2011 Prehospital IV Fluids in TraumaFIGURE logistic regressionshowing odds ratio of death for traumapatients with prehospital IV fluidadministration subset analyses.

10 GSWindicates gunshot overall outcomes with IV fluid administration in patients withGCS<9 and in the most severely brain injured patients (GCS<9and head AIS 3 5). This data are consistent with a prospective studyevaluating the use of prehospital hypersonic saline administration onpatients with severe TBI that showed no benefit in the fluid supporting the scoop and run approach to prehospitalcare suggest that performing more prehospital procedures on traumapatients may be detrimental. In an urban setting, the time neces-sary to establish IV access may be greater than the time of transportand prehospital procedures may delay necessary surgical interven-tion for patients with potentially survivable et al13reported that prehospital procedures were associated with lower sur-vival in patients undergoing emergency department thoracotomy inan urban level 1 trauma center. Prehospital spine immobilization isassociated with higher mortality in patients with penetrating trauma inthe Los Angeles, trauma patients had improved survivalif they were transported by private vehicles rather than being treatedand transported by EMS providers after sustaining severe study from the same institution used a case control method-ology to identify similarly injured patients in EMS and non-EMStransported groups.