nishida osamu

2012年に日本集中治療医学会が発表した日本版敗血症診療ガイドラインの改訂に際し、日本集中治療医学会と日本救急医学会合同の特別委員会が組織された。単なる改訂版の位置づけではなく、一般臨床家にも理解しやすく、かつ質の高いガイドラインとすることで、広い普及を目指した。いくつかの注目すべき領域と小児領域を新たに追加し、計19領域、89に及ぶ臨床課題[クリニカルクエスチョン(clinical question、CQ)]を網羅した。大規模ガイドラインであることや、この領域における本邦の実情を鑑みて組織編成を行い、中立的な立場で横断的に活躍するアカデミックガイドライン推進班を組織した。質の担保と作業過程の透明化を図るための様々な工夫を行い、パブリックコメントの募集は計3回行った。さらに、将来への橋渡しとなることを企図して、多くの若手医師をメンバーに登用した。当初の狙い通り、学会や施設の垣根を越えたネットワーク構築が進み、これを基盤に、ガイドラインとは独立して多施設研究や独自のシステマティックレビューを行い論文化するなどの動きが生まれ、今なお活発となっている。また、敗血症診療を広くカバーする意味でも、両学会が協力して作成した意義は大きい。本ガイドラインがベースとなり、救急・集中治療領域における本邦からのエビデンス発信のプラットフォームが形成されることを願ってやまない。なお、本ガイドラインは、日本集中治療医学会と日本救急医学会の両機関誌のガイドライン増刊号として同時掲載するものである。(著者抄録)

The usefulness of plasma exchange (PE) for hemolytic uremic syndrome (HUS) by enterohemorrhagic Escherichia coli (EHEC) is unclear. On the other hand, there were no reports of the relationship between central nervous system (CNS) disorder and renal dysfunction. We report three pediatric patients with HUS by EHEC, two patients with PE and one without PE, and their renal dysfunction. The subjects were 3 patients with HUS by EHEC admitted to the ICU. On admission, anuria was noted in all subjects. Continuous hemodiafiltration (CHDF) was started. In 2 patients with CNS disorder, PE was performed for 3 days starting from 9 and 10 days after the onset of digestive symptoms, respectively. In these patients, CNS disorder was not observed on discharge from the ICU. The CHDF period was 9 and 13 days, respectively. It was 36 days in a non-PE-treated patient without CNS disorder.

<p>Objective: Previous studies have suggested that transpulmonary thermodilution (TPTD) measurements are influenced by extracorporeal circulation methods, such as blood purification. Using pigs, we investigated the effect of extracorporeal circulation on hemodynamic measurements at two sites of cold saline injection. </p><p>Methods: Six female outbred pigs were included in the study. A vascular access site was made in the left external jugular vein. Cold saline was injected in the right external jugular vein or the right femoral vein. Hemodynamic monitoring was performed using TPTD (EV1000). Cardiac output (CO), global end-diastolic volume (GEDV), and extravascular lung water (EVLW) values were compared between extracorporeal circulation and no extracorporeal circulation. All data are expressed as median values.</p><p>Results: The following data were obtained when cold saline was injected into the jugular vein (circulation on vs. circulation off): CO, 2.7 vs. 2.9 L/min (P = 0.04); GEDV, 403 vs. 438 ml (P = 0.04); and EVLW, 310 vs. 306 ml (P = 0.92). The following data were obtained when cold saline was injected into the femoral vein (circulation on vs. circulation off): CO, 2.6 vs. 2.8 L/min (P = 0.18); GEDV, 497 vs. 500 ml (P = 0.18); and EVLW, 341 vs. 345 ml (P = 0.44).</p><p>Conclusions: Extracorporeal circulation has an effect on the accuracy of measurement of TPTD injection through the jugular vein. In contrast, no effect of extracorporeal circulation was observed when the femoral vein was used.</p>

Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) therapy is widely used for the treatment of severe sepsis and septic shock, and is generally performed for 2 h. Although previous studies demonstrated the efficacy of PMX-DHP therapy, it currently remains unclear whether its optimal duration is 2 h. This retrospective study analyzed 37 patients with septic shock who showed a poor clinical response to 2 h of PMX-DHP, and underwent a longer duration of this therapy. The mean duration of PMX-DHP therapy was 15.8 +/- 7.9 h, and none of the patients developed adverse events, which enabled the therapy to be performed safely. The pressure catecholamine index [CAIP = catecholamine index/mean arterial pressure; catecholamine index = dopamine + dobutamine + (adrenaline + noradrenaline) x 100 mu g/kg per min], as an indicator of hemodynamics, improved significantly in the survival group in the period between the start and 24 h after the end of PMX-DHP therapy (P &lt; 0.01), and between 2 h after the start of and the end of this therapy (P &lt; 0.05). In addition, the P/F ratio improved significantly in the group of surviving patients with acute respiratory distress syndrome (ARDS) in the period between the start and 24 h after the end of PMX-DHP therapy (P &lt; 0.01), and between 2 h after the start of and the end of this therapy (P &lt; 0.01). These results suggest that a longer duration of PMX-DHP therapy can be expected to improve the hemodynamics and pulmonary oxygenation capacity of patients with severe sepsis/septic shock. Strict prospective studies are needed in the future.