521 Vol. 36, pp. 521529, 2008 : 21 2 14 A. shock shock septic shock B. 1 2 3 1 1 1 1 90 mmhg 2 2 1 Shock 2a Ince sublingual sidestream darkfield SDF imaging 2 2b Bateman septic shock multiphoton images 2b 3 3 9
522 1 5 510 11 2 1990 Connett dysoxia dysoxia 4 2004 Spronk Microcirculatory and mitochondrial distress syndrome MMDS sepsis microcirculatory disorder 5 2005 Ince dysoxia 2 C. 3 3 1 SV CO HR SVR MAP pre-shock 4 septic shock CO SVRI D.? 10
523 2 Microcirculatory dysfunction in sepsisseptic shock 3 3 shock 4 dysoxia 4 dysoxia dysoxia 11
524 5 5 CaO 2 CvO 2 Hb SaO 2 0.003 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
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 2 8 9 Antonelli ScvO 2 SvO 2 base 13
526 deficit ph 7 2008 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# 12 2001 Marik CVP 13 PAWP PAC Pulmonary artery catheter Swan-Ganz catheter preload Marik CVP preload PAWP LVEDP preload LVEDV 8 LVEP LVEDV compliance PEEP, 12 13 SvO 2 ScvO 2 SvO 2 Hb DO 2 SaO 2 DO 2 CO DO 2 VO 2 40 mmhg 70 EGDT SvO 2 70 1 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
527 5 SIRS Systemic Inflammatory Response Syndrome SIRS TNF-a, IL-1, IL-6, IL-8 SIRS 5 4 2 SIRS 1991 American College of Chest Physicians Society of Critical Care Medicine 2 ACCP SCCM Consensus Conference sepsis, SIRS, sepsis 14 15 Sepsis 1 SIRS sepsis 5 sepsis sepsis SIRS sepsis 14 15 sepsis severe sepsis sepsis septic shock sepsis G. EGDT SSC Early goal-directed therapy EGDT severe sepsis, septic shock 16 17 2001 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
528 6 EGDT Usual care EGDT 7 SSC 2008 medicine experience based medicine H. 19 grading evidence 2004 Critical Care Medicine Intensive Care Medicine 18 19 SSC A S 19 A E SSC A. Initial Resuscitation EGDT 18 19 SSC 2004 guideline 2008 SCC 2008 SSC 2008 7 20 21 intensivist severe sepsis septic shock evidence based 1 2 3 4 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
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