2a Ince sublingual sidestream darkfield SDF imaging

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1 521 Vol. 36, pp , 2008 : A. shock shock septic shock B mmhg Shock 2a Ince sublingual sidestream darkfield SDF imaging 2 2b Bateman septic shock multiphoton images 2b 3 3 9

2 Connett dysoxia dysoxia Spronk Microcirculatory and mitochondrial distress syndrome MMDS sepsis microcirculatory disorder Ince dysoxia 2 C SV CO HR SVR MAP pre-shock 4 septic shock CO SVRI D.? 10

3 523 2 Microcirculatory dysfunction in sepsisseptic shock 3 3 shock 4 dysoxia 4 dysoxia dysoxia 11

4 CaO 2 CvO 2 Hb SaO PaO 2 40 mmhg PaO 2 DO 2 DO 2 Hb SaO 2 CaO 2 CO VO 2 VO 2 CaO 2 CvO 2 CvO 2 PAC pulmonary artery catheter, Swan-Ganz catheter SvO 2 VO 2CaO 2CvO 2CO10 VO 2 CaO 2 CO DO 2 CvO 2 CvO 2 O 2 extraction: O 2ER VO 2DO 2 O 2ER 2030 O 2ER 50 DO 2 O 2ER VO 2 O 2ER DO 2 DO 2 1 VO 2 DO 2 VO 2 sepsis VO 2 DO 2 O 2ER ATP NADH aa3 tissue hypoxia gold standard ph, PaO 2,SaO 2,HCO 3, DO 2 VO 2, central venous pressure: CVP, pulmonary artery wedge pressure: PAWP SvO 2 ScvO 2 ph gastric phi tissue hypoxia, dysoxia E. EGDT early goal-directed therapy MAP: mean arterial pressure 6590 mmhg 0.5 mlkg 6 manometer 12

5 525 4 DO 2,VO 2,O 2ER MAP: mean arterial pressure Antonelli 7 dysoxia ph, PaO 2, SaO 2,HCO 3, SaO 2 PaO 2 septic shock 4 VO 2 DO 2 O 2 extraction: O 2ER VO 2DO 2 O 2ER 2030 O 2ER 50 DO 2 O 2ER VO 2 O 2ER DO 2 DO 2 4 VO 2 DO 2 VO 2 septic shock VO 2 DO 2 O 2ER septic shock DO Antonelli ScvO 2 SvO 2 base 13

6 526 deficit ph Bakker Don t take vitals, take a lactate 10 re-distribution Microdialysis LPS 11 CVP: central venous pressure preload CO DO 2 EGDT 812 mmhg 1992 Lichtwarck-Ascho# Marik CVP 13 PAWP PAC Pulmonary artery catheter Swan-Ganz catheter preload Marik CVP preload PAWP LVEDP preload LVEDV 8 LVEP LVEDV compliance PEEP, SvO 2 ScvO 2 SvO 2 Hb DO 2 SaO 2 DO 2 CO DO 2 VO 2 40 mmhg 70 EGDT SvO gastric phi ph phi ph phi Antonelli gastric phi 7 F. sepsis, severe shock, septic shock SIRS systemic inflammatory response syndrome: SIRS SIRS 1 humoral mediator, cytokine 14

7 527 5 SIRS Systemic Inflammatory Response Syndrome SIRS TNF-a, IL-1, IL-6, IL-8 SIRS SIRS 1991 American College of Chest Physicians Society of Critical Care Medicine 2 ACCP SCCM Consensus Conference sepsis, SIRS, sepsis Sepsis 1 SIRS sepsis 5 sepsis sepsis SIRS sepsis sepsis severe sepsis sepsis septic shock sepsis G. EGDT SSC Early goal-directed therapy EGDT severe sepsis, septic shock Rivers CVP MAP, SvO 2 or ScvO 2 bundle ICU ER 6 bundle severe sepsis septic shock EGDT 6 Rivers EGDT control Standard therapy 6 EGDT EGDT standard therapy CVP, MAP, ScvO 2 SvO 270 SSC Surviving sepsis campaign guidelines SCC 2004 sepsis 11 sepsis 15

8 528 6 EGDT Usual care EGDT 7 SSC 2008 medicine experience based medicine H. 19 grading evidence 2004 Critical Care Medicine Intensive Care Medicine SSC A S 19 A E SSC A. Initial Resuscitation EGDT SSC 2004 guideline 2008 SCC 2008 SSC intensivist severe sepsis septic shock evidence based initial resuscitation 5 SIRS 1 humoral mediator, cytokine 6 sepsis SIRS 7 SSC Surviving Sepsis Campaign sepsis septic shock sepsis 8 EGDT Early goal-directed therapy SSC I Management of severe sepsis 16

9 ; 14: Ince, C. The microcirculation is the motor of sepsis. Crit Care 2005; 9 Suppl 4: S13S19. 3 Bateman, RM and Walley, KR Microvascular resuscitation as a therapeutic goal in severe sepsis. Crit Care 9 Suppl 4: S27 S32. 4 Connett, RJ, Honig, CR, Gayeski, TE, et al. Defining hypoxia: a systems view of VO2, glycolysis, energetics, and intracellular PO2. J Appl Physiol 1990; 68: Spronk, PE. Microcirculatory and mitochondrial distress syndrome MMDS: a new look at sepsis. Update in Intensive Care Emergency Medicine 2004; 42: Rivers, E, Nguyen, B, Havstad, S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J, Med 2001; 345: Antonelli, M, Levy, M, Andrews, P, et al. Hemodynamic monitoring in shock and implications for management International Consensus Conference, Paris, France, 2728 April Intensive Care Med 2007; 33: Cooper, N and Forrest, K. Essential Guide to Acute Care. Baltimore Bakker, J, Co#ernils, M, Leon, M, et al. Blood lactate levels are superior to oxygenderived variables in predicting outcome in human septic shock. Chest 1991; 99: Bakker, J and Jansen, TC. Don[t take vitals, take a lactate. Intensive Care Med 2007; 33: Microdialysis 2006; 12: Lichtwarck-Ascho#, M, Zeravik, J and Pfei#er, UJ. Intrathoracic blood volume accurately reflects circulatory volume status in critically ill patients with mechanical ventilation. Intensive Care Med 1992; 18: Marik, P. Handbook of Evidence-Based Critical Care. New York, Springer-Verlag American College of Chest PhysiciansSociety of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20: Bone, RC, Balk, RA, Cerra, FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCPSCCM Consensus Conference Committee. American College of Chest PhysiciansSociety of Critical Care Medicine. Chest 1992; 101: Gattinoni, L, Brazzi, L, Pelosi, P, et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO 2 Collaborative Group. N Engl J Med 1995; 333: Hayes, MA, Timmins, AC, Yau, EH, et al. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 1994; 330: Dellinger, RP, Carlet, JM, Masur, H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32: Dellinger, RP, Carlet, JM, Masur, H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med 2004; 30: Dellinger, RP, Levy, MM, Carlet, JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: Intensive Care Med 2008; 34: Dellinger, RP, Levy, MM, Carlet, JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: Crit Care Med 2008; 36: