St. Marianna University School of Medicineigakukai.marianna-u.ac.jp/idaishi/www/366/06-36-2Yasuhiko...

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臒腸腻腫腾腷膆膋臮膒膬膯 Vol. 36, pp. 521529, 2008 腆腈腇腅腂腊腔腂腕腏 ῒῐ腆腈腇腅腂腖腒腃腑腎腋腐腓腌腉腍腁腀腄ῐῒ ῑ῎ ΐῐ ῒ῏ : 21 2 14 A. 腄腁腅腂 腊腨腠腖腚 shock 腚膐腣臵膛腚臜腙腓腂腕 膺腟膨腢臇腌腂 shock 腚膐腍腘腩腒臠臆膭 臟臭膳膄臅腙腓腂腕膐臕腍腧腠腑腱腺腳腯腚臇腗腐腚膃膛腙腓腂腕膺腟臼腙 septic shock 臚臏臏腱腺腳腯腚膐臫腙腓腂腕膺腟腧B. 腇腉腈腆腃腊腒腃腔腎 腱腺腳腯腚膐臵膛腛臯 12腐腌腕膨腢臇 腌腂臯 3 臎臭腚臵膛腗臜腪膞腑 1腀腑 1 腌腐腃腇腉腈腆腃腊腒 膡膁致膉腪膙腙腱腺腳腯腪臵膛腌腑膾臙腚 腱腺腳腯腲腰腫腱腺腳腯腚膸臂臸1 膱腍 1腠腑膵膹膚膡膁 90 mmHg 膂膉腪臊腗腌臦腚臉 臩膽膣腆腥臵膛腋腨腧腱腺腳腯腚臈臰膙膼腪 2 腙膱腍腖臤臵腋腨腧至臅腚膡膁膟腣臺臛膮腙腤腦 臤臵腋腨腧膡膁腛腁腉腠腖膑臶臱臍腚臨腂膡膖 腚膁腖腁腦臠臆臔腍腧膩膡膖腚 膁腪臋臵腌臻腧腙腍腈腘腂腋腥腙膡膁腛膡膖膁腖腁腦腎腌腢臁臠臆腞腚膡腜腝腜腝腪臲臔腙膈腍腧腢腚腖腛腘腂腀腑 2 腌腐腃腇腉腈腆腃腊腒 膡膁致膉腙膙腔腉腱腺腳腯腚膐腙膷腂膸臂臫膓膲腙自腌腕膿膆腛腝腑腍腥腙膡膁腪臄臀腋腏 腧腊腗腙臘腌腑膶臓腋腨腑膠膌腛膡膁膍腤腦膎臝腪臻腧臂腢腁腧腇腑腗腄膡膁腪膍膅膰腌腕腢臫腚膎臝腪臻腎腘腅臫腚膀膊腣腐 腚膠膌臑臥腚膎臝腇臻腥腨腘腂臂腇臧臌臥膪腍 腧腊腗腪膱腌腑腐腊腖膤腨腑腚腇腱腺腳腯腗腛膡 膁腚致膉腚腡腘腥腎腑腗腄膡膁腇膅膰腋腨腕腢臢 臠臆腞腚腣腜腋臞腇腁腨腜腱腺腳腯腖腁腧腗腂 腃膐腖腁腧2a Ince 腥腇 sublingual sidestream dark- field SDFimaging 腂腕臑臩腚臗膉腚臁臠 臆腚膡腪膗膫腍腧腑腒腪膱腌腑 22b Bate- man 腥腇腭腾腶腵腮腱腾腪臹腌腑腸腬腲 septic shock 腹腴腼腙腅腂腕multiphoton images 腕膗膫腌腑膾膻膕腖腁腧2b 膧臣腛腰腾腵 腽腀腼腚膩膡膖腚臡膦腖腁腧膇臣腛腭腾腶腵腮 腱腾臹膥腖膩膡膖腚臡膦腇臷臖腌腕臁腚膾膻膕臃膏腇腁腧腊腗腪膱腍 3腀腑 3 腌腐腃腇腉腈腆腃腊腒 膡膁致膉臠臆腣腜臃膏腚腘腖腙腆腆腩腥腎臒腸腻腫腾腷膆膋臮膒 膝膜膆膒 1 Shock 腚臵膛腚521 9

Transcript of St. Marianna University School of Medicineigakukai.marianna-u.ac.jp/idaishi/www/366/06-36-2Yasuhiko...

Page 1: St. Marianna University School of Medicineigakukai.marianna-u.ac.jp/idaishi/www/366/06-36-2Yasuhiko Taira.pdf · Vol. 36, pp. 521 529, 2008 : 21 2 14 A. shock ˘ˇ ˆ˙˝˛˚ ˜ !"#$˛shock

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deficit ���� pH ��������7��2008�� Bakker�� “Don’t take vitals, take alactate” �� ���� �������������������������� �� �!"#10��$����������%&���'��

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� �

1� ���� “������� �” ����1990; 14: 1332�

2� Ince, C. “The microcirculation is the motor ofsepsis.” Crit Care 2005; 9 Suppl 4: S13�S19.

3� Bateman, RM and Walley, KR �2005�.“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: 833�842.5� Spronk, PE. “Microcirculatory and mitochon-drial distress syndrome �MMDS�: a new look atsepsis.” Update in Intensive Care Emergency

Medicine 2004; 42: 47�69.6� Rivers, E, Nguyen, B, Havstad, S, et al. “Earlygoal-directed therapy in the treatment of severe

sepsis and septic shock.” N Engl J, Med 2001;

345: 1368�1377.7� Antonelli, M, Levy, M, Andrews, P, et al. “He-modynamic monitoring in shock and implica-

tions for management International Consensus

Conference, Paris, France, 27�28 April 2006.”Intensive Care Med 2007; 33: 575�590.

8� Cooper, N and Forrest, K. Essential Guide toAcute Care. Baltimore 2006.

9� Bakker, J, Co#ernils, M, Leon, M, et al.“Blood lactate levels are superior to oxygen-

derived variables in predicting outcome in hu-

man septic shock.” Chest 1991; 99: 956�962.10� Bakker, J and Jansen, TC. “Don[t take vitals,take a lactate.” Intensive Care Med 2007; 33:

1863�1865.11� ���� “������������ !" Microdialysis #$%&'()*+,-./�01�” 2����34 2006; 12: 460.

12� Lichtwarck-Ascho#, M, Zeravik, J and

Pfei#er, UJ. “Intrathoracic blood volume ac-

curately reflects circulatory volume status in

critically ill patients with mechanical ventila-

tion.” Intensive Care Med 1992; 18: 142�147.13� Marik, P. Handbook of Evidence-Based Criti-cal Care. New York, Springer-Verlag. 2001.

14� “American College of Chest Physicians�Societyof Critical Care Medicine Consensus Confer-

ence: definitions for sepsis and organ failure

and guidelines for the use of innovative thera-

pies in sepsis.” Crit Care Med 1992; 20: 864�874.

15� Bone, RC, Balk, RA, Cerra, FB, et al. “Defin-itions for sepsis and organ failure and guide-

lines for the use of innovative therapies in sep-

sis. The ACCP�SCCM Consensus ConferenceCommittee. American College of Chest Physi-

cians�Society of Critical Care Medicine.” Chest1992; 101: 1644�1655.

16� Gattinoni, L, Brazzi, L, Pelosi, P, et al. “Atrial of goal-oriented hemodynamic therapy in

critically ill patients. SvO 2 Collaborative

Group.” N Engl J Med 1995; 333: 1025�1032.17� 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: 1717�1722.18� 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: 858�873.19� 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: 536�555.20� Dellinger, RP, Levy, MM, Carlet, JM, et al.

“Surviving Sepsis Campaign: international

guidelines for management of severe sepsis and

septic shock: 2008.” Intensive Care Med 2008;

34: 17�60.21� Dellinger, RP, Levy, MM, Carlet, JM, et al.

“Surviving Sepsis Campaign: International

guidelines for management of severe sepsis and

septic shock: 2008.” Crit Care Med 2008; 36:

296�327.

�����56�78 529

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