大島 拓

OBJECTIVE: The aim of this study is to assess the effectiveness of continuous regional arterial infusion (CRAI) of protease inhibitors in patients with severe acute pancreatitis (SAP) including acute necrotizing pancreatitis. METHODS: This retrospective study was conducted among 44 institutions in Japan from 2009 to 2013. Patients 18 years or older diagnosed with SAP according to the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008) were consecutively enrolled. We evaluated the association between CRAI of protease inhibitors and mortality, incidence of infection, and the need for surgical intervention using multivariable logistic regression analysis. RESULTS: Of 1159 patients admitted, 1097 patients with all required data were included for analysis. Three hundred and seventy-four (34.1%) patients underwent CRAI of protease inhibitors and 723 (65.9%) did not. In multivariable analysis, CRAI of protease inhibitors was not associated with a reduction in mortality, infection rate, or need for surgical intervention (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.47-1.32, P = 0.36; OR 0.97, 95% CI 0.61-1.54, P = 0.89; OR 0.76, 95% CI 0.50-1.15, P = 0.19; respectively). CONCLUSIONS: Continuous regional arterial infusion of protease inhibitors was not efficacious in the treatment of patients with SAP.

BACKGROUND: The Japanese severity criteria for acute pancreatitis (AP), which consist of a prognostic factor score and contrast-enhanced computed tomography grade, have been widely used in Japan. OBJECTIVE: This large multicenter retrospective study was conducted to validate the predictive value of the prognostic factor score for mortality and complications in severe AP patients in comparison to the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. METHODS: Data of 1159 patients diagnosed with severe AP according to the Japanese severity criteria for AP were retrospectively collected in 44 institutions. RESULTS: The area under the curve (AUC) for the receiver-operating characteristic curve of the prognostic factor score for predicting mortality was 0.78 (95% confidence interval (CI), 0.74-0.82), whereas the AUC for the APACHE II score was 0.80 (95% CI, 0.76-0.83), respectively. There were no significant differences in the AUC for predicting mortality between two scoring systems. The AUCs of the prognostic factor scores for predicting the need for mechanical ventilation, the development of pancreatic infection, and severe AP according to the revised Atlanta classification were 0.84 (95% CI, 0.81-0.86), 0.73 (95% CI, 0.69-0.77), and 0.83 (95% CI, 0.81-0.86), respectively, which were significantly greater than the AUCs for the APACHE II score; 0.81 (95% CI, 0.78-0.83) for the need for mechanical ventilation (p = 0.03), 0.68 (95% CI, 0.63-0.72) for the development of pancreatic infection (p = 0.02), and 0.80 (95% CI, 0.77-0.82) for severe AP according to the revised Atlanta classification (p = 0.01). CONCLUSION: The prognostic factor score has an equivalent ability for predicting mortality compared with the APACHE II score. Regarding the ability for predicting the development of severe complications during the clinical course of AP, the prognostic factor score may be superior to the APACHE II score.

BACKGROUND & AIMS: Optimal nutritional care for intensive care unit (ICU) patients requires precise determination of energy expenditure (EE) to avoid deleterious under- or overfeeding. The reference method, indirect calorimetry (IC), is rarely accessible and inconstantly feasible. Various equations for predicting EE based on body weight (BW) are available. This study aims at determining the best prediction strategy unless IC is available. METHODS: Mechanically ventilated patients staying ≥72 h in the ICU were included, except those with contraindications for IC measurements. IC and BW measurements were routinely performed. EE was predicted by the ESPEN formula and other predictive equations using BW (i.e. anamnestic (AN), measured (MES), adjusted for cumulated water balance (ADJ), calculated for a body mass index (BMI) of 22.5). Comparisons were made using Pearson correlation and Bland & Altman plots. RESULTS: 85 patients (57 ± 19 y, 61 men, SAPS II 43 ± 16) were included. Correlations between IC and predicted EE using the ESPEN formula with different BW (BWAN, BWMES, BWADJ, and BWBMI22.5) were 0.44, 0.40, 0.36, and 0.47, respectively. Bland & Altman plots showed wide and inconsistent variations. Predictive equations including body temperature and minute ventilation showed the best correlations, but when using various BWs, differences in predicted EE were observed. CONCLUSION: No EE predictive equation, regardless of the BW used, gives statistically identical results to IC. If IC cannot be performed, predictive equations including minute ventilation and body temperature should be preferred. BW has a significant impact on estimated EE and the use of measured BWMES or BW BMI 22.5 is associated with the best EE prediction. Clinical trial registration number on ClinicalTrial.gov: NCT02552446. Ethical committee number: CE-14-070.

BACKGROUND: Methods to calculate energy expenditure (EE) based on CO2 measurements (EEVCO2) have been proposed as a surrogate to indirect calorimetry. This study aimed at evaluating whether EEVCO2 could be considered as an alternative to EE measured by indirect calorimetry. METHODS: Indirect calorimetry measurements conducted for clinical purposes on 278 mechanically ventilated ICU patients were retrospectively analyzed. EEVCO2 was calculated by a converted Weir's equation using CO2 consumption (VCO2) measured by indirect calorimetry and assumed respiratory quotients (RQ): 0.85 (EEVCO2_0.85) and food quotient (FQ; EEVCO2_FQ). Mean calculated EEVCO2 and measured EE were compared by paired t test. Accuracy of EEVCO2 was evaluated according to the clinically relevant standard of 5% accuracy rate to the measured EE, and the more general standard of 10% accuracy rate. The effects of the timing of measurement (before or after the 7th ICU day) and energy provision rates (<90 or ≥90% of EE) on 5% accuracy rates were also analyzed (chi-square tests). RESULTS: Mean biases for EEVCO2_0.85 and EEVCO2_FQ were -21 and -48 kcal/d (p = 0.04 and 0.00, respectively), and 10% accuracy rates were 77.7 and 77.3%, respectively. However, 5% accuracy rates were 46.0 and 46.4%, respectively. Accuracy rates were not affected by the timing of the measurement, or the energy provision rates at the time of measurements. CONCLUSIONS: Calculated EE based on CO2 measurement was not sufficiently accurate to consider the results as an alternative to measured EE by indirect calorimetry. Therefore, EE measured by indirect calorimetry remains as the gold standard to guide nutrition therapy.

BACKGROUND & AIMS: We hypothesize that an optimal and simultaneous provision of energy and protein is favorable to clinical outcome of the critically ill patients. METHODS: We conducted a review of the literature, obtained via electronic databases and focused on the metabolic alterations during critical illness, the estimation of energy and protein requirements, as well as the impact of their administration. RESULTS: Critically ill patients undergo severe metabolic stress during which time a great amount of energy and protein is utilized in a variety of reactions essential for survival. Energy provision for critically ill patients has drawn attention given its association with morbidity, survival and long-term recovery, but protein provision is not sufficiently taken into account as a critical component of nutrition support that influences clinical outcome. Measurement of energy expenditure is done by indirect calorimetry, but protein status cannot be measured with a bedside technology at present. CONCLUSIONS: Recent studies suggest the importance of optimal and combined provision of energy and protein to optimize clinical outcome. Clinical randomized controlled studies measuring energy and protein targets should confirm this hypothesis and therefore establish energy and protein as a power couple.

PURPOSE OF REVIEW: The review focuses on the use of parenteral nutrition and enteral nutrition in critically ill patients to optimize the nutrition care throughout the ICU stay. The key message is: you have the choice! RECENT FINDINGS: Enteral nutrition has been recommended for critically ill patients, whereas parenteral nutrition has been considered harmful and to be avoided. However, recent studies have challenged this theory. They demonstrated that enteral nutrition is frequently associated with energy and protein undernutrition, whereas parenteral nutrition becomes deleterious only if overfeeding is induced. Measuring energy expenditure by indirect calorimetry, in most cases, enables accurate determination of the energy needs to optimize the prescription of nutrition. Protein targets should also be considered for adequate feeding. Parenteral nutrition can be used as a supplement or as an alternative to enteral nutrition in case of gastrointestinal intolerance, to enable adequate energy, and protein provision. SUMMARY: Parenteral nutrition is a powerful tool to optimize nutrition care of critically ill patients to improve clinical outcome, if prescribed according to the individual needs of the patients. After 3-4 days of attempt to feed enterally, enteral nutrition or parenteral nutrition can be used alternatively or combined, as long as the target is reached with special attention to avoid hypercaloric feeding.

This review emphasizes the role of a timely supplemental parenteral nutrition (PN) for critically ill patients. It contradicts the recommendations of current guidelines to avoid the use of PN, as it is associated with risk. Critical illness results in severe metabolic stress. During the early phase, inflammatory cytokines and mediators induce catabolism to meet the increased body energy demands by endogenous sources. This response is not suppressed by exogenous energy administration, and the early use of PN to reach the energy target leads to overfeeding. On the other hand, early and progressive enteral nutrition (EN) is less likely to cause overfeeding because of variable gastrointestinal tolerance, a factor frequently associated with significant energy deficit. Recent studies demonstrate that adequate feeding is beneficial during and after the intensive care unit (ICU) stay. Supplemental PN allows for timely adequate feeding, if sufficient precautions are taken to avoid overfeeding. Indirect calorimetry can precisely define the adequate energy prescription. Our pragmatic approach is to start early EN to progressively test the gut tolerance and add supplemental PN on day 3 or 4 after ICU admission, only if EN does not meet the measured energy target. We believe that supplemental PN plays a pivotal role in the achievement of adequate feeding in critically ill patients with intolerance to EN and does not cause harm if overfeeding is avoided by careful prescription, ideally based on energy expenditure measured by indirect calorimetry.

BACKGROUND: A retrospective study was conducted to investigate the validity and the effectiveness of early empiric antibiotic and de-escalation therapy for the treatment of severe sepsis and septic shock patients in the intensive care unit (ICU). METHODS: Patients admitted to the ICU at Chiba University Hospital from January 1, 2010, to December 31, 2012, for the treatment of severe sepsis or septic shock were selected for analysis. RESULTS: One-hundred and ten patients were enrolled for the analysis. Carbapenems were selected most frequently (57.3%), followed by cephalosporins (22.7%), and penicillins (21.8%). Empiric antibiotic therapy was appropriate for 85 (77.3%) patients. Mortality rates for patients with inappropriate empiric therapy was 36.8%, whereas mortality rates for patients with appropriate empiric therapy was 17.5%. Among the patients with appropriate empiric antibiotic administration, de-escalation was associated with lower mortality rates of 5.0% for severe sepsis and 9.7% for septic shock patients. The mortality rates for the no de-escalation group were 19.0% and 35.7%, respectively. CONCLUSION: Empiric antibiotic therapy was acceptable for severe sepsis and septic shock patients treated in the ICU. The appropriate selection of empiric antibiotics was related to a greater rate of de-escalation and better survival. The risk of multi-drug-resistant bacterial infections was not as high as expected, but will need further attention in the future.

PURPOSE OF REVIEW: The difficulties to feed the patients adequately with enteral nutrition alone have drawn the attention of the clinicians toward the use of parenteral nutrition, although recommendations by the recent guidelines are conflicting. This review focuses on the intrinsic role of parenteral nutrition, its new indication, and modalities of use for the critically ill patients. RECENT FINDINGS: A recent trial demonstrated that selecting either parenteral nutrition or enteral nutrition for early nutrition has no impact on clinical outcomes. However, it must be acknowledged that the risk of relative overfeeding is greater when using parenteral nutrition and the risk of underfeeding is greater when using enteral nutrition because of gastrointestinal intolerance. Both overfeeding and underfeeding in the critically ill patients are associated with deleterious outcomes. Thus, early and adequate feeding according to the specific energy needs can be recommended as the optimal feeding strategy. SUMMARY: Parenteral nutrition can be used to substitute or supplement enteral nutrition, if adequately prescribed. Testing for enteral nutrition tolerance during 2-3 days after ICU admission provides the perfect timing to start parenteral nutrition, if needed. In case of absolute contraindication for enteral nutrition, consider starting parenteral nutrition carefully to avoid overfeeding.

INTRODUCTION: We sought to investigate the energy requirements for patients under therapeutic hypothermia, and the relationship of energy fulfillment to patient outcome. PATIENTS AND METHODS: Adult patients admitted to our ICU after successful resuscitation from cardiac arrest for post resuscitation therapeutic hypothermia from April, 2012 to March, 2014 were enrolled. Body temperature was managed using the surface cooling device (Arctic Sun(®), IMI). Calorimeter module on the ventilator (Engström carestation(®), GE) was used for indirect calorimetry. Energy expenditure (EE) and respiratory quotient (RQ) were recorded continuously, as the average of the recent 2h. Measurements were started at the hypothermic phase and continued until the rewarming was completed. Cumulative energy deficit was calculated as the sum of difference between EE and daily energy provision for the 4 days during hypothermia therapy. RESULTS: Seven patients were eligible for analysis. Median EE for the hypothermic phase (day 1) was 1557.0kcald(-1). EE was elevated according with the rise in body temperature, reaching 2375kcald(-1) at normothermic phase. There was significant association between cumulative energy deficit and the length of ICU stay, among patients with good neurologic recovery (cerebral performance category (CPC): 1-3). CONCLUSION: The EE for patients under therapeutic hypothermia was higher than expected. Meeting the energy demand may improve patient outcome, as observed in the length of ICU stay for the present study. A larger, prospective study is awaited to validate the results of our study.

This review emphasizes the benefits of parenteral nutrition (PN) in critically ill patients, when prescribed for relevant indications, in adequate quantities, and in due time. Critically ill patients are at risk of energy deficit during their ICU stay, a condition which leads to unfavorable outcomes, due to hypercatabolism secondary to the stress response and the difficulty to optimize feeding. Indirect calorimetry is recommended to define the energy target, since no single predictive equation accurately estimates energy expenditure. Energy metabolism is intimately associated with protein metabolism. Recent evidence calls for adequate protein provision, but there is no accurate method to estimate the protein requirements, and recommendations are probably suboptimal. Enteral nutrition (EN) is the preferred route of feeding, but gastrointestinal intolerance limits its efficacy and PN allows for full coverage of energy needs. Seven recent articles concerning PN for critically ill patients were identified and carefully reviewed for the clinical and scientific relevance of their conclusions. One article addressed the unfavorable effects of early PN, although this result should be more correctly regarded as a consequence of glucose load and hypercaloric feeding. The six other articles were either in favor of PN or concluded that there was no difference in the outcome compared with EN. Hypercaloric feeding was not observed in these studies. Hypocaloric feeding led to unfavorable outcomes. This further demonstrates the beneficial effects of an early and adequate feeding with full EN, or in case of failure of EN with exclusive or supplemental PN. EN is the first choice for critically ill patients, but difficulties providing optimal nutrition through exclusive EN are frequently encountered. In cases of insufficient EN, individualized supplemental PN should be administered to reduce the infection rate and the duration of mechanical ventilation. PN is a safe therapeutic option as long as sufficient attention is given to avoid hypercaloric feeding.

Purpose: The final decision for discharge from the intensive care unit (ICU) is uncertain because it is made according to various patient parameters; however, it should be made on an objective evaluation. Previous reports have been inconsistent and unreliable in predicting post-ICU mortality. To identify predictive factors associated with post-ICU mortality, we analyzed physiological and laboratory data at ICU discharge. Methods: Patients admitted to our ICU between September 2012 and August 2013 and staying for critical care. 2 days were included. Sequential Organ Failure Assessment (SOFA) score; systemic inflammatory response syndrome score; white blood cell count; and serum C reactive protein, procalcitonin (PCT), interleukin-6 (IL-6), lactate, albumin, and hemoglobin levels were recorded. The primary end point was 90-day mortality after ICU discharge. Two hundred eighteen patients were enrolled (195 survivors, 23 non-survivors). Results: Non-survivors presented a higher SOFA score and serum PCT, and IL-6 levels, as well as lower serum albumin and hemoglobin levels. Serum PCT, albumin, and SOFA score were associated with 90-day mortality in multiple logistic regression analysis. Hosmer-Lemeshow test showed chi-square value of 6.96, and P value of 0.54. The area under the curve (95% confidence interval) was 0.830 (0.771-0.890) for PCT, 0.688 (0.566-0.810) for albumin, 0.861 (0.796-0.927) for SOFA score, and increased to 0.913 (0.858-0.969) when these were combined. Serum PCT level at 0.57 ng/mL, serum albumin at 2.5 g/dL and SOFA score at 5.5 predict 90-day mortality, and high PCT, low albumin and high SOFA groups had significantly higher mortality. Serum PCT and SOFA score were significantly associated with survival days after ICU discharge in Cox regression analysis. Conclusions: Serum PCT level and SOFA score at ICU discharge predict post-ICU mortality and survival days after ICU discharge. The combination of these two and albumin level might enable accurate prediction.

【目的】今回CHDFを施行する際のヘモフィルタとして，polysulfone（PS）膜ヘモフィルタとcellulose triacetate（CTA）膜ヘモフィルタとの比較を行ったので，報告する。【方法】2011年8月から2012年7月までの1年間にPS膜，CTA膜を用いてrenal indicationでCHDFを施行した症例について後ろ向き観察研究を行い，各膜のライフタイムについてTMPの上昇率を指標として検討した。【結果】対象となったPS膜の延べ使用本数は107本，CTA膜は113本であった。膜交換時の平均TMP上昇率は0.52±0.54，0.83±0.71（p＝0.002）であった。【考察】PS膜はCTA膜と遜色ないライフタイムを示し，TMPの上昇率についてはPS膜の方が有意に低値であった。【まとめ】今回の検討では，CTA膜と比較してPS膜の方がライフタイムの指標として用いたTMPの上昇率において優位であった。

要旨：腹腔内圧（IAP）は正常値5～7（mmHg）で，通常膀胱内圧で代用する。IAP≧12をintra-abdominal hypertension（IAH）とし，IAP＞20が持続し，新規臓器不全発症があるものをabdominal compartment syndrome（ACS）とする。ACSは腹部疾患由来のprimary ACS，腹腔外要因由来のsecondary ACS，およびACSに陥った腹部の再閉鎖等により発生するrecurrent ACSに分類される。治療は，(1)腸管内容物排除，(2)腹腔内フリースペース内容物の排除，(3)腹壁コンプライアンスの改善，(4)輸液管理最適化，(5)臓器潅流適正化を段階的に行う。IAHが改善しない場合，開腹管理を行う。近年ACS防止のために輸液を制限するdamage control resuscitationが推奨され，開腹管理後の創閉鎖についてもさまざまな方法が報告されている。

Purpose: Cytokines play pivotal roles in the pathophysiology of severe sepsis/septic shock, and continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA-CHDF) removes cytokines efficiently and continuously, mainly through adsorption to a hemofilter membrane. The aim of this study was to investigate the clinical efficacy of enhanced intensity PMMA-CHDF in treating refractory septic shock. Methods: Seventy-two septic shock patients admitted to the intensive care unit (ICU) underwent critical care including PMMA-CHDF We employed enhanced intensity PMMA-CHDF to improve the cytokine removal rate by increasing the hemofilter membrane area in 10 refractory septic shock patients (enhanced intensity group, El group; 2 extracorporeal CHDF circuits using the hemofilter with a larger membrane area of 2.1 m(2)). Other patients undergoing conventional PMMA-CHDF and matched for severity with the El group, comprised a matched conventional group (MC group; using a PMMA membrane hemofilter with a membrane area of 1.0 m(2); n=15). The case-control comparison was performed between the 2 groups. Results: Enhanced intensity PMMA-CHDF significantly increased mean arterial pressure by 23.8% in 1 hour (p=0.037), decreased the blood lactate level by 28.6% in 12 hours (p=0.006), and reduced blood IL-6 level in 24 hours (p=0.005). The ICU survival rate in the El group was significantly better than that in the MC group (60% vs. 13.3%, p=0.028). Conclusion: Enhanced intensity PMMA-CHDF may improve hemodynamics and survival rate in patients with refractory septic shock.

In response to a central nervous system (CNS) injury, microglia and astrocytes release tumor necrosis factor-alpha (TNF-alpha). This proinflammatory cytokine has been implicated in both neuronal cell death and survival. Here, we show that TNF-alpha is involved in the recovery of neuromotor function following traumatic brain injury. Composite neuroscore and accel rotarod were employed to measure neuromotor function. TNF-alpha-deficient (TNF-alpha(-/-)) mice showed no improvement in their locomotor function up to 28 days following controlled cortical impact brain injury. Although collateral sprouting of the unlesioned corticospinal tract, as assessed by retrograde biotin dextran amine labeling, at the cervical spinal cord was observed following injury in the wild-type mice, such changes were not induced in the TNF-alpha(-/-) mice at 4 weeks after injury. These results provide evidence that TNF-alpha is involved in neuroanatomical plasticity and functional recovery following CNS injury.

BACKGROUND AND PURPOSE: Injurious ventilation with high peak inspiratory pressure (PIP) is known to cause systemic inflammatory response through cytokine production. This study was performed to examine whether body temperature could regulate cytokine production in ventilator-induced lung injury (VILI) model. METHODS: After performing anesthesia, tracheostomy, and catheter insertion, rats were ventilated with 17cmH(2)O of PIP in the low-pressure (LP) group or 35cmH(2)O in the high-pressure (HP) group. Then, each group was divided into three subgroups; hyperthermia (39 degrees C), normothermia (37 degrees C), and hypothermia (34 degrees C) group. Six groups were observed for 6h. RESULTS: Plasma levels of pro-inflammatory cytokines, TNF-a and IL-6 at 1h after the start of observation were highest in 39 degrees C-HP group and were lowest in 34 degrees C-HP group. Furthermore, sustained high plasma levels of IL-6 were observed only in 39 degrees C-HP group. In contrast, plasma levels of anti-inflammatory cytokine, IL-10 at 1h were highest in 34 degrees C-HP group, and lowest in 39 degrees C-HP group. CONCLUSION: The body temperature significantly affects cytokine production in a model of VILI. Body temperature control may be a potentially effective therapeutic modality to regulate cytokine production in VILI.

56歳、男性。胆石膵炎に対し加療受けるも改善せず当院紹介となった。厚生労働省の急性膵炎重症度スコアは転院時13点、CT gradeはVであった。胆石は自然排石していた。PMMA-CHDFやSDDを含む集中治療を開始したが、経過中septic shockに陥り、steroidの使用を余儀なくされた。さらに感染性膵壊死を合併し、第40病日にnecrosectomy+open peritoneal drainageを施行した。当初腹腔内は細菌感染が主であったが、その後真菌が検出されmicafungin sodiumの投与を開始した。しかしその後も感染が制御できず炎症反応高値が遷延し、血液培養からTrichosporon asahiiが検出された。抗真菌薬をfluconazoleへ変更し血液培養は陰性化したが、他の感染を制御できず第138病日に永眠された。近年新しい抗真菌薬の開発・使用に伴い、真菌のbreakthroughが問題となっている。本症例のように著しい免疫不全の状態にある重症患者では特に注意が必要である。(著者抄録)

急性膵炎の診療ガイドラインの導入効果を検証するために, ICUにおける本ガイドライン公表前後の診療の変化を検討した。結果, 公表前 (n=36) の前医における厚労省重症度判定率は6.5%, 重症化からICU入室までの日数は2.4&plusmn;5.2日であり, 入室時厚労省重症度スコアは8.9&plusmn;2.9であった。一方, 公表後 (n=30) の重症度判定率は37.8%と上昇 (P<0.01), ICU入室までの日数も0.6&plusmn;1.4日と短縮 (P<0.03), 重症度スコアは6.4&plusmn;3.5と低くなった (P<0.03)。しかし, 前医におけるガイドラインの活用率は50%に過ぎなかった。ICUにおける治療法は公表前後で差異はなく, 救命率にも有意差は認められなかった。考察, 本ガイドライン公表後は重症急性膵炎が致死率の高い病態であるとの認識が一般臨床医にも広まり, 重症化からICU入室までの日数も短縮された。しかし, 予後判定が煩雑で, 本ガイドラインの搬送基準が十分に活用されているとは言えなかった。

過去10年間に経験した周術期慢性透析患者177症例(平均55.9±12.7歳)中41例が術後ICU入室となり,ICUにて持続的血液濾過透析(CHDF)を15例,EVAL膜を用いた持続的血液透析を3例に施行した.透析室では血液濾過透析(HDF)を7例,緩徐式血液濾過透析(S-HDF)を1例,大多数の151例は通常の血液透析(HD)を施行した.周術期慢性透析患者に対する血液浄化法の選択は,軽症で予定手術の場合は術前に2日続けてHDを施行し,手術翌々日より通常のHDを再開している.重症の場合は術後CHDFで管理し,緊急手術では術中や術前からCHDFを用いて管理し,病態の安定後に通常のHDに移行している.慢性透析患者では手術時の出血のリスクが高く,輸液のスペースも狭い為,周術期管理は細心の注意が必要であり,重症例ではICUに入室させて多彩な効果が期待できるCHDFで管理すべきであると考えられた

過去13年間に持続的血液濾過透析(CHDF)を施行した小児患者51症例(男児23例・女児28例,平均4.70±4.56歳,平均体重17.7±13.4kg)の状況について検討した.CHDFの適応疾患は,先天性奇形周術期13例,重症・劇症肝炎9例,先天性代謝異常8例,溶血性尿毒症症候群/血栓性血小板減少性紫斑病4例,急性脳炎3例,血液疾患・悪性腫瘍・EBウイルス感染症が各2例であった.CHDF施行期間は平均6.71±6.49日で最長では33日間連続で行った.血流量は1〜1.5ml/kg/min,濾過流量は3〜20ml/kg/hr,透析液流量は10〜20ml/kg/hrで施行した.ブラッドアクセスは脱血・返血とも静脈を用いた症例が33例,動脈より脱血・静脈に返血した症例が18例であり,51例中25例(49.0%)を救命し得た.小児においてもCHDFは成人同様に多彩な有効性が期待でき第一選択の血液浄化療法となっている.小児に対するCHDFはブラッドアクセスの確保や保温等に工夫を施し,慎重,緩徐かつ正確に施行することが必要である

急性腎不全(ARF)に対して間欠的血液透析(IHD)施行の16症例,持続的血液濾過(CHF)にIHDを併用した治療法(CHF+IHD)施行の22症例および持続的血液濾過透析(CHDF)施行の38症例の臨床効果について比較検討した.その結果,年齢,性別,APACHE H scoreなど背景因子は3群間に有意差は認めず,平均不全臓器数はIHD群3.6±1.2,CHF+IHD群3.6±1.4,CHDF群2.2±1.1で,CHDF群と他の2群間に有意差を認めた.施行時の副作用ではIHD群で血圧低下と尿量低下が他の2群より有意に多く,血圧上昇と急激な尿量増加はCHDF群でIHD群より有意に多かった.入院期間中の全体の救命率はIHD群で31.3%,CHF+IHD群54.5%,CHDF群63.2%とCHDF群がIHD群より有意に高かった.以上よりARFの治療における血液浄化療法はIHDと比較してCHDFが有用であり,第一選択として用いるべきである