今日の臨床サポート

ICUルーチン

著者: 飯尾純一郎 済生会熊本病院 救急総合診療部

監修: 藤谷茂樹1) 聖マリアンナ医科大学 救急医学

監修: 安宅一晃2) 奈良県立病院機構 医療専門職教育研修センター/奈良県総合医療センター 集中治療部 

著者校正/監修レビュー済:2019/08/17

概要・推奨   

  1. 刻一刻と治療内容が変化するICU診療において、バイタル、身体所見、各種検査、その日のin/outバランス、使用デバイス、使用薬剤などを毎日的確に把握する必要がある。
  1. ICUでのプレゼンテーション、カルテ記載はby problemではなく、by systemで行う。
  1. by systemは、①神経、②循環、③呼吸、④消化管 肝臓 栄養、⑤腎臓 電解質、⑥内分泌、⑦血液 凝固、⑧感染症、⑨予防、⑩To Doの順に行う。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
飯尾純一郎 : 特に申告事項無し[2021年]
監修:藤谷茂樹 : 特に申告事項無し[2021年]
監修:安宅一晃 : 特に申告事項無し[2021年]

病態・疫学・診察

はじめに  
  1. ICU入院患者は、Problem list形式で、評価していくと、多くの臓器障害を伴っているため、見逃してしまう危険性が高い。そのため、システムベースで、評価とプランを系統的に立てていく必要がある。
  1. ICUに入室してくるパターンとして、一般病棟から、院内急変で、手術後、ER/一般外来から重症患者がある。新たに入室した患者の評価ではなく、少なくとも前日評価している患者をどのような手順で診ていくかを本稿では扱うことにする。

各論

朝、出勤して真っ先に確認する項目  
ベッドサイドにて(2-3分での評価):
  1. すばやく担当患者観察の状況を把握する。
  1. Eye ball (パッと見ること)
  1. 輸液ボトル、昇圧剤、ドレーン、人工呼吸器セッティング、その他どのようなデバイスが接続されているか。
  1. ABCDの評価
  1. A:気管挿管中でもチューブの深さ、閉塞の有無の確認を行う。
  1. B:人工呼吸器の設定、SpO2、呼気終末CO2濃度の値、呼吸器との同調性、聴診での左右差を確認する。
  1. C:昇圧剤とモニターの血圧、脈拍、末梢循環の確認をする。
  1. D:GCSの確認を、部門システム上で確認をする。
 
夜勤看護師とオンコール医師から:
  1. 夜間に起きたイベントはとても重要な情報であるので、部門システム上で確認をするのと同様に必ず手短でいいので情報を聞き出しておく。
  1. 例として、出血量、せん妄にて薬剤投与、SpO2の低下、利尿剤の投与などがある。
 
客観的所見のデータ収集:
  1. バイタルサイン
  1. 身体所見
  1. I/O バランス
  1. 栄養
  1. 輸液
  1. ドレーン
  1. 利尿
  1. 生体index
  1. モニター類の数値
  1. デバイス
  1. 人工呼吸器
  1. CRRT
  1. スワンガンツの数値、IABPの設定
  1. その他デバイス
  1. 検査値
  1. 薬剤
 
ICU daily progress note

毎日のICUでのcheck項目を一覧にしたプログレスノート。

出典

 
By system:
  1. Problem basedなアセスメントにすると漏れが出てくることがあるので、ICUではSystem basedにプロブレムを列挙し、それぞれに対してアセスメントとプランを立てる。
  1. また共通認識のフォーマットとしても利用可能であり、他職種、新規ローテーターでも同様の管理ができる点からSystem basedな管理が望ましい。上記に示した客観的データを元に、システムごとにアセスメントとプランを立てて方針を確認するプロセスである。
神経  
意識の評価:
  1. 意識障害の原因については他項に譲る。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

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文献 

著者: John W Devlin, Yoanna Skrobik, Céline Gélinas, Dale M Needham, Arjen J C Slooter, Pratik P Pandharipande, Paula L Watson, Gerald L Weinhouse, Mark E Nunnally, Bram Rochwerg, Michele C Balas, Mark van den Boogaard, Karen J Bosma, Nathaniel E Brummel, Gerald Chanques, Linda Denehy, Xavier Drouot, Gilles L Fraser, Jocelyn E Harris, Aaron M Joffe, Michelle E Kho, John P Kress, Julie A Lanphere, Sharon McKinley, Karin J Neufeld, Margaret A Pisani, Jean-Francois Payen, Brenda T Pun, Kathleen A Puntillo, Richard R Riker, Bryce R H Robinson, Yahya Shehabi, Paul M Szumita, Chris Winkelman, John E Centofanti, Carrie Price, Sina Nikayin, Cheryl J Misak, Pamela D Flood, Ken Kiedrowski, Waleed Alhazzani
雑誌名: Crit Care Med. 2018 Sep;46(9):e825-e873. doi: 10.1097/CCM.0000000000003299.
Abstract/Text OBJECTIVE: To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.
DESIGN: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.
METHODS: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.
RESULTS: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.
CONCLUSIONS: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

PMID 30113379  Crit Care Med. 2018 Sep;46(9):e825-e873. doi: 10.1097/C・・・
著者: Michele C Balas, Eduard E Vasilevskis, Keith M Olsen, Kendra K Schmid, Valerie Shostrom, Marlene Z Cohen, Gregory Peitz, David E Gannon, Joseph Sisson, James Sullivan, Joseph C Stothert, Julie Lazure, Suzanne L Nuss, Randeep S Jawa, Frank Freihaut, E Wesley Ely, William J Burke
雑誌名: Crit Care Med. 2014 May;42(5):1024-36. doi: 10.1097/CCM.0000000000000129.
Abstract/Text OBJECTIVE: The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice.
DESIGN: Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012.
SETTING: Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center.
PATIENTS: Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions' medical or surgical critical care service.
INTERVENTIONS: Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle.
MEASUREMENTS AND MAIN RESULTS: For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7-26] vs 21 [0-25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33-0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29-3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates.
CONCLUSIONS: Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

PMID 24394627  Crit Care Med. 2014 May;42(5):1024-36. doi: 10.1097/CCM・・・
著者: David Osman, Christophe Ridel, Patrick Ray, Xavier Monnet, Nadia Anguel, Christian Richard, Jean-Louis Teboul
雑誌名: Crit Care Med. 2007 Jan;35(1):64-8. doi: 10.1097/01.CCM.0000249851.94101.4F.
Abstract/Text OBJECTIVE: Values of central venous pressure of 8-12 mm Hg and of pulmonary artery occlusion pressure of 12-15 mm Hg have been proposed as volume resuscitation targets in recent international guidelines on management of severe sepsis. By analyzing a large number of volume challenges, our aim was to test the significance of the recommended target values in terms of prediction of volume responsiveness.
DESIGN: Retrospective study.
SETTING: A 24-bed medical intensive care unit.
PATIENTS: All consecutive septic patients monitored with a pulmonary artery catheter who underwent a volume challenge between 2001 and 2004.
INTERVENTION: None.
MEASUREMENTS AND MAIN RESULTS: A total of 150 volume challenges in 96 patients were reviewed. In 65 instances, the volume challenge resulted in an increase in cardiac index of > or =15% (responders). The pre-infusion central venous pressure was similar in responders and nonresponders (8 +/- 4 vs. 9 +/- 4 mm Hg). The pre-infusion pulmonary artery occlusion pressure was slightly lower in responders (10 +/- 4 vs. 11 +/- 4 mm Hg, p < .05). However, the significance of pulmonary artery occlusion pressure to predict fluid responsiveness was poor and similar to that of central venous pressure, as indicated by low values of areas under the receiver operating characteristic curves (0.58 and 0.63, respectively). A central venous pressure of <8 mm Hg and a pulmonary artery occlusion pressure of <12 mm Hg predicted volume responsiveness with a positive predictive value of only 47% and 54%, respectively. With the knowledge of a low stroke volume index (<30 mL.m), their positive predictive values were still unsatisfactory: 61% and 69%, respectively. When the combination of central venous pressure and pulmonary artery occlusion pressure was considered instead of either pressure alone, the degree of prediction of volume responsiveness was not improved.
CONCLUSION: Our study demonstrates that cardiac filling pressures are poor predictors of fluid responsiveness in septic patients. Therefore, their use as targets for volume resuscitation must be discouraged, at least after the early phase of sepsis has concluded.

PMID 17080001  Crit Care Med. 2007 Jan;35(1):64-8. doi: 10.1097/01.CCM・・・
著者: F Michard, S Boussat, D Chemla, N Anguel, A Mercat, Y Lecarpentier, C Richard, M R Pinsky, J L Teboul
雑誌名: Am J Respir Crit Care Med. 2000 Jul;162(1):134-8. doi: 10.1164/ajrccm.162.1.9903035.
Abstract/Text In mechanically ventilated patients with acute circulatory failure related to sepsis, we investigated whether the respiratory changes in arterial pressure could be related to the effects of volume expansion (VE) on cardiac index (CI). Forty patients instrumented with indwelling systemic and pulmonary artery catheters were studied before and after VE. Maximal and minimal values of pulse pressure (Pp(max) and Pp(min)) and systolic pressure (Ps(max) and Ps(min)) were determined over one respiratory cycle. The respiratory changes in pulse pressure (DeltaPp) were calculated as the difference between Pp(max) and Pp(min) divided by the mean of the two values and were expressed as a percentage. The respiratory changes in systolic pressure (DeltaPs) were calculated using a similar formula. The VE-induced increase in CI was >/= 15% in 16 patients (responders) and < 15% in 24 patients (nonresponders). Before VE, DeltaPp (24 +/- 9 versus 7 +/- 3%, p < 0.001) and DeltaPs (15 +/- 5 versus 6 +/- 3%, p < 0.001) were higher in responders than in nonresponders. Receiver operating characteristic (ROC) curves analysis showed that DeltaPp was a more accurate indicator of fluid responsiveness than DeltaPs. Before VE, a DeltaPp value of 13% allowed discrimination between responders and nonresponders with a sensitivity of 94% and a specificity of 96%. VE-induced changes in CI closely correlated with DeltaPp before volume expansion (r(2) = 0. 85, p < 0.001). VE decreased DeltaPp from 14 +/- 10 to 7 +/- 5% (p < 0.001) and VE-induced changes in DeltaPp correlated with VE-induced changes in CI (r(2) = 0.72, p < 0.001). It was concluded that in mechanically ventilated patients with acute circulatory failure related to sepsis, analysis of DeltaPp is a simple method for predicting and assessing the hemodynamic effects of VE, and that DeltaPp is a more reliable indicator of fluid responsiveness than DeltaPs.

PMID 10903232  Am J Respir Crit Care Med. 2000 Jul;162(1):134-8. doi: ・・・
著者: Joseph Boullata, Jennifer Williams, Faith Cottrell, Lauren Hudson, Charlene Compher
雑誌名: J Am Diet Assoc. 2007 Mar;107(3):393-401. doi: 10.1016/j.jada.2006.12.014.
Abstract/Text OBJECTIVE: To evaluate the accuracy of seven predictive equations, including the Harris-Benedict and the Mifflin equations, against measured resting energy expenditure (REE) in hospitalized patients, including patients with obesity and critical illness.
DESIGN: A retrospective evaluation using the nutrition support service database of a patient cohort from a similar timeframe as those used to develop the Mifflin equations.
SUBJECTS/SETTING: All patients with an ordered nutrition assessment who underwent indirect calorimetry at our institution over a 1-year period were included.
INTERVENTION: Available data was applied to REE predictive equations, and results were compared to REE measurements.
MAIN OUTCOME MEASURES: Accuracy was defined as predictions within 90% to 110% of the measured REE. Differences >10% or 250 kcal from REE were considered clinically unacceptable.
STATISTICAL ANALYSES PERFORMED: Regression analysis was performed to identify variables that may predict accuracy. Limits-of-agreement analysis was carried out to describe the level of bias for each equation.
RESULTS: A total of 395 patients, mostly white (61%) and African American (36%), were included in this analysis. Mean age+/-standard deviation was 56+/-18 years (range 16 to 92 years) in this group, and mean body mass index was 24+/-5.6 (range 13 to 53). Measured REE was 1,617+/-355 kcal/day for the entire group, 1,790+/-397 kcal/day in the obese group (n=51), and 1,730+/-402 kcal/day in the critically ill group (n=141). The most accurate prediction was the Harris-Benedict equation when a factor of 1.1 was multiplied to the equation (Harris-Benedict 1.1), but only in 61% of all the patients, with significant under- and over-predictions. In the patients with obesity, the Harris-Benedict equation using actual weight was most accurate, but only in 62% of patients; and in the critically ill patients the Harris-Benedict 1.1 was most accurate, but only in 55% of patients. The bias was also lowest with Harris-Benedict 1.1 (mean error -9 kcal/day, range +403 to -421 kcal/day); but errors across all equations were clinically unacceptable.
CONCLUSIONS: No equation accurately predicted REE in most hospitalized patients. Without a reliable predictive equation, only indirect calorimetry will provide accurate assessment of energy needs. Although indirect calorimetry is considered the standard for assessing REE in hospitalized patients, several predictive equations are commonly used in practice. Their accuracy in hospitalized patients has been questioned. This study evaluated several of these equations, and found that even the most accurate equation (the Harris-Benedict 1.1) was inaccurate in 39% of patients and had an unacceptably high error. Without knowing which patient's REE is being accurately predicted, indirect calorimetry may still be necessary in difficult to manage hospitalized patients.

PMID 17324656  J Am Diet Assoc. 2007 Mar;107(3):393-401. doi: 10.1016/・・・
著者: Vasken Artinian, Hicham Krayem, Bruno DiGiovine
雑誌名: Chest. 2006 Apr;129(4):960-7. doi: 10.1378/chest.129.4.960.
Abstract/Text STUDY OBJECTIVES: To determine the impact of early enteral feeding on the outcome of critically ill medical patients.
DESIGN: Retrospective analysis of a prospectively collected large multi-institutional ICU database.
PATIENTS: A total of 4,049 patients requiring mechanical ventilation for > 2 days.
MEASUREMENTS AND RESULTS: Patients were classified according to whether or not they received enteral feeding within 48 h of mechanical ventilation onset. The 2,537 patients (63%) who did receive enteral feeding were labeled as the "early feeding group," and the remaining 1,512 patients (37%) were labeled as the "late feeding group." The overall ICU and hospital mortality were lower in the early feeding group (18.1% vs 21.4%, p = 0.01; and 28.7% vs 33.5%, p = 0.001, respectively). The lower mortality rates in the early feeding group were most evident in the sickest group as defined by quartiles of severity of illness scores. Three separate models were done using each of the different scores (acute physiology and chronic health evaluation II, simplified acute physiology score II, and mortality prediction model at time 0). In all models, early enteral feeding was associated with an approximately 20% decrease in ICU mortality and a 25% decrease in hospital mortality. We also analyzed the data after controlling for confounding by matching for propensity score. In this analysis, early feeding was again associated with decreased ICU and hospital mortality. In all adjusted analysis, early feeding was found to be independently associated with an increased risk of ventilator-associated pneumonia (VAP) developing.
CONCLUSION: Early feeding significantly reduces ICU and hospital mortality based mainly on improvements in the sickest patients, despite being associated with an increased risk of VAP developing. Routine administration of such therapy in medical patients receiving mechanical ventilation is suggested, especially in patients at high risk of death.

PMID 16608945  Chest. 2006 Apr;129(4):960-7. doi: 10.1378/chest.129.4.・・・
著者: Annika Reintam Blaser, Joel Starkopf, Waleed Alhazzani, Mette M Berger, Michael P Casaer, Adam M Deane, Sonja Fruhwald, Michael Hiesmayr, Carole Ichai, Stephan M Jakob, Cecilia I Loudet, Manu L N G Malbrain, Juan C Montejo González, Catherine Paugam-Burtz, Martijn Poeze, Jean-Charles Preiser, Pierre Singer, Arthur R H van Zanten, Jan De Waele, Julia Wendon, Jan Wernerman, Tony Whitehouse, Alexander Wilmer, Heleen M Oudemans-van Straaten, ESICM Working Group on Gastrointestinal Function
雑誌名: Intensive Care Med. 2017 Mar;43(3):380-398. doi: 10.1007/s00134-016-4665-0. Epub 2017 Feb 6.
Abstract/Text PURPOSE: To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.
METHODS: We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.
RESULTS: We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.
CONCLUSIONS: We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

PMID 28168570  Intensive Care Med. 2017 Mar;43(3):380-398. doi: 10.100・・・
著者: Melanie Meersch, Christoph Schmidt, Andreas Hoffmeier, Hugo Van Aken, Carola Wempe, Joachim Gerss, Alexander Zarbock
雑誌名: Intensive Care Med. 2017 Nov;43(11):1551-1561. doi: 10.1007/s00134-016-4670-3. Epub 2017 Jan 21.
Abstract/Text PURPOSE: Care bundles are recommended in patients at high risk for acute kidney injury (AKI), although they have not been proven to improve outcomes. We sought to establish the efficacy of an implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines to prevent cardiac surgery-associated AKI in high risk patients defined by renal biomarkers.
METHODS: In this single-center trial, we examined the effect of a "KDIGO bundle" consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high risk patients defined as urinary [TIMP-2]·[IGFBP7] > 0.3 undergoing cardiac surgery. The primary endpoint was the rate of AKI defined by KDIGO criteria within the first 72 h after surgery. Secondary endpoints included AKI severity, need for dialysis, length of stay, and major adverse kidney events (MAKE) at days 30, 60, and 90.
RESULTS: AKI was significantly reduced with the intervention compared to controls [55.1 vs. 71.7%; ARR 16.6% (95 CI 5.5-27.9%); p = 0.004]. The implementation of the bundle resulted in significantly improved hemodynamic parameters at different time points (p < 0.05), less hyperglycemia (p < 0.001) and use of ACEi/ARBs (p < 0.001) compared to controls. Rates of moderate to severe AKI were also significantly reduced by the intervention compared to controls. There were no significant effects on other secondary outcomes.
CONCLUSION: An implementation of the KDIGO guidelines compared with standard care reduced the frequency and severity of AKI after cardiac surgery in high risk patients. Adequately powered multicenter trials are warranted to examine mortality and long-term renal outcomes.

PMID 28110412  Intensive Care Med. 2017 Nov;43(11):1551-1561. doi: 10.・・・
著者: Djillali Annane, Stephen M Pastores, Bram Rochwerg, Wiebke Arlt, Robert A Balk, Albertus Beishuizen, Josef Briegel, Joseph Carcillo, Mirjam Christ-Crain, Mark S Cooper, Paul E Marik, Gianfranco Umberto Meduri, Keith M Olsen, Sophia C Rodgers, James A Russell, Greet Van den Berghe
雑誌名: Crit Care Med. 2017 Dec;45(12):2078-2088. doi: 10.1097/CCM.0000000000002737.
Abstract/Text OBJECTIVE: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.
PARTICIPANTS: A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine.
DESIGN/METHODS: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members.
RESULTS: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of < 9 μg/dL) after cosyntropin (250 μg) administration and a random plasma cortisol of < 10 μg/dL may be used by clinicians. We suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using IV hydrocortisone < 400 mg/day for ≥ 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence).
CONCLUSIONS: Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.

PMID 28938253  Crit Care Med. 2017 Dec;45(12):2078-2088. doi: 10.1097/・・・
著者: Jeffrey L Carson, Brenda J Grossman, Steven Kleinman, Alan T Tinmouth, Marisa B Marques, Mark K Fung, John B Holcomb, Orieji Illoh, Lewis J Kaplan, Louis M Katz, Sunil V Rao, John D Roback, Aryeh Shander, Aaron A R Tobian, Robert Weinstein, Lisa Grace Swinton McLaughlin, Benjamin Djulbegovic, Clinical Transfusion Medicine Committee of the AABB
雑誌名: Ann Intern Med. 2012 Jul 3;157(1):49-58. doi: 10.7326/0003-4819-157-1-201206190-00429.
Abstract/Text DESCRIPTION: Although approximately 85 million units of red blood cells (RBCs) are transfused annually worldwide, transfusion practices vary widely. The AABB (formerly, the American Association of Blood Banks) developed this guideline to provide clinical recommendations about hemoglobin concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children.
METHODS: These guidelines are based on a systematic review of randomized clinical trials evaluating transfusion thresholds. We performed a literature search from 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay. RECOMMENDATION 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence). RECOMMENDATION 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence). RECOMMENDATION 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence). RECOMMENDATION 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

PMID 22751760  Ann Intern Med. 2012 Jul 3;157(1):49-58. doi: 10.7326/0・・・
著者: Mitchell M Levy, Laura E Evans, Andrew Rhodes
雑誌名: Intensive Care Med. 2018 Jun;44(6):925-928. doi: 10.1007/s00134-018-5085-0. Epub 2018 Apr 19.
Abstract/Text
PMID 29675566  Intensive Care Med. 2018 Jun;44(6):925-928. doi: 10.100・・・
著者: J Garnacho-Montero, A Gutiérrez-Pizarraya, A Escoresca-Ortega, Y Corcia-Palomo, Esperanza Fernández-Delgado, I Herrera-Melero, C Ortiz-Leyba, J A Márquez-Vácaro
雑誌名: Intensive Care Med. 2014 Jan;40(1):32-40. doi: 10.1007/s00134-013-3077-7. Epub 2013 Sep 12.
Abstract/Text PURPOSES: We set out to assess the safety and the impact on in-hospital and 90-day mortality of antibiotic de-escalation in patients admitted to the ICU with severe sepsis or septic shock.
METHODS: We carried out a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock. De-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. To control for confounding variables, we performed a conventional regression analysis and a propensity score (PS) adjusted-multivariable analysis.
RESULTS: A total of 712 patients with severe sepsis or septic shock at ICU admission were treated empirically with broad-spectrum antibiotics. Of these, 628 were evaluated (84 died before cultures were available). De-escalation was applied in 219 patients (34.9%). By multivariate analysis, factors independently associated with in-hospital mortality were septic shock, SOFA score the day of culture results, and inadequate empirical antimicrobial therapy, whereas de-escalation therapy was a protective factor [Odds-Ratio (OR) 0.58; 95% confidence interval (CI) 0.36-0.93). Analysis of the 403 patients with adequate empirical therapy revealed that the factor associated with mortality was SOFA score on the day of culture results, whereas de-escalation therapy was a protective factor (OR 0.54; 95% CI 0.33-0.89). The PS-adjusted logistic regression models confirmed that de-escalation therapy was a protective factor in both analyses. De-escalation therapy was also a protective factor for 90-day mortality.
CONCLUSIONS: De-escalation therapy for severe sepsis and septic shock is a safe strategy associated with a lower mortality. Efforts to increase the frequency of this strategy are fully justified.

PMID 24026297  Intensive Care Med. 2014 Jan;40(1):32-40. doi: 10.1007/・・・
著者: Michael Klompas, Richard Branson, Eric C Eichenwald, Linda R Greene, Michael D Howell, Grace Lee, Shelley S Magill, Lisa L Maragakis, Gregory P Priebe, Kathleen Speck, Deborah S Yokoe, Sean M Berenholtz, Society for Healthcare Epidemiology of America (SHEA)
雑誌名: Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. doi: 10.1086/677144.
Abstract/Text
PMID 25026607  Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. d・・・
著者:
雑誌名: Am J Health Syst Pharm. 1999 Feb 15;56(4):347-79. doi: 10.1093/ajhp/56.4.347.
Abstract/Text
PMID 10690219  Am J Health Syst Pharm. 1999 Feb 15;56(4):347-79. doi: ・・・

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