慈恵ICU勉強会$ 2015/09/01$ 林 怜史

ICU
$
2015/09/01$
•  2007
ICH
AHA/ASA
$
•  2010
•  2015
$
$
$
• 
SAH
$
$
• 
• 
$
• 
2010
1.$Emergency$Diagnosis$and$Assessment$
2.$Hemostasis$and$Coagulopathy,$AnDplatelet$Agents,$and$DVT$Prophylaxis$
3.$Blood$Pressure$
4.$General$Monitoring$and$Nursing$Care$
5.$Glucose$Management$
6.$Temperature$Management$
7.$Seizures$and$AnDseizure$Drugs$
8.$Management$of$Medical$ComplicaDons$
9.$ICP$Monitoring$and$Treatment$
10.$IVH$(Intraventricular$Hemorrhage)$
11.$Surgical$treatment$of$ICH$
12.$Outcome$PredicDon$and$Withdrawal$of$Technological$Support$$
13.$PrevenDon$of$Recurrent$ICH$
14.$RehabilitaDon$and$Recovery
1.Emergency$Diagnosis$and$Assessment$
$
$
New$recommendaDon$
Class $Level$of$Evidence$B
CT MRI
2010
$
Class $Level$of$Evidence$A
$
CTA
CT
CTA
CT
$
MRI MRA
2010
$
Class b$Level$of$Evidence$B
•  NIHSS
ICH
ICH
$
$
Neurocrit)Care.$2004;1:53–60.
Stroke$2001;32:891–897.
2.Hemostasis$and$Coagulopathy,$
AnDplatelet$Agents,$and$DVT$Prophylaxis$
$
2010
$
Class $Level$of$Evidence$C
K
$
PCCs
FFP
rF
a
INR
K
INR
Class
FFP
$
$Level$of$Evidence$C
INR
Class
b$Level$of$Evidence$B
$
INR
Class
$Level$of$Evidence$C
$
2.Hemostasis$and$Coagulopathy,$
AnDplatelet$Agents,$and$DVT$Prophylaxis$
PCCs FEIBA
$
2
F
a
$
New$recommendaDon$
Class b$Level$of$Evidence$C
2.Hemostasis$and$Coagulopathy,$
AnDplatelet$Agents,$and$DVT$Prophylaxis$
$
New$recommendaDon$
Class b$Level$of$Evidence$C
$
Class
F
b$Level$of$Evidence$C
a
F
a
2010
$
Class $Level$of$Evidence$A
$
2.Hemostasis$and$Coagulopathy,$
AnDplatelet$Agents,$and$DVT$Prophylaxis$
DVT
$
$
DVT
Class
$
Class
1 4
$Level$of$Evidence$A
$Level$of$Evidence$A
$
DVT
$
2010
$
Class b$Level$of$Evidence$B
$
2.Hemostasis$and$Coagulopathy,$
AnDplatelet$Agents,$and$DVT$Prophylaxis$
PE DVT
IVC
$
New$recommendaDon$
Class a$Level$of$Evidence$B
• 
$
FEIBA PCCs rF
K
• 
• FEIBA
• PCCs
$
• 
• 
$
• 
F
a
a
FFP
$
$
Am)J)Hematol.$2012;87
2
$
$
Best)Pract)Res)Clin)Haematol.$2013;26:191–202
N)Engl)J)Med)2015;373:511B20.
•  FEIBA(factor$
$inhibitor$bypassing$acDvity)$
IX
– 
$
•  PCCs(prothrombin$complex$concentrates)$
– 
$
3
$
VKA
•  F
– 
INR
a(Recombinant$factor$ a)$
90
4
$
$
Am)J)Hematol.$2008;83:137–143.
$
$
Cochrane)Database)Syst)Rev)2009
DVT
• 
$
• 
DVT
$
Am)J)Phys)Med)Rehabil.2003;82:364–369
IPC(intermicent$pneumaDc$compression)
$
• 
$
$
Lancet.$2009;373:1958–1965
• 
• 
3
55
2518 $
2518
DVT
• 
$
$
DVT
$
$
$
• 
UK 94
• 
2876
• 
DVT
2876 $
Lancet.2013;382:516–524.
$
$
30
IPC
DVT
IVC
IVC
• 
$
• 
DVT
IVC
$
•  IVC
Chest.$2012;141:7Sd47S
3.Blood$Pressure$
$
140
150 220
$
Class
$Level$of$Evidence$A
$
2010
$
Class a$Level$of$Evidence$B
220 New$recommendaDon$
Class b$Level$of$Evidence$C
ATTACH
INTERACT
INTERACT2
N)Engl)J)Med.$2013;368:2355–2365
$
21
144
2839 $
$
$
1
180
2839
SBP140
$
$
$
$
$
$
$
4.General$Monitoring$and$Nursing$
Care$
ICU
Class
$Level$of$Evidence$B
$
49
• 
$
• 
86
3
30
d
Nurs)Res.$2005;54:74–84
$
J)Neurol)Neurosurg)Psychiatry.$2009;80:881–887.
5.Glucose$Management$
Class
$Level$of$Evidence$C
$
6.Temperature$Management$
$
$
New$recommendaDon$
Class b$Level$of$Evidence$C
$
• 
Anesthesiology.1991;75:130–136.
• 
Stroke.$2009;40:e657–e665.
• 
$
Stroke.$2010;41:1684–1689
• 
$
• 
19
Unit$1696
48
• 
$
500
$
acute$Stroke$
$
626
$
Lancet.2011;378:1699–1706.
• 
$
7.Seizures$and$AnDseizure$Drugs$
$
2010
$
Class $Level$of$Evidence$A
$
$
2010
$
Class $Level$of$Evidence$C
Class
a$Level$of$Evidence$C
2010
$
Class $Level$of$Evidence$B
$
8.Management$of$Medical$
ComplicaDons$
$
$
New$recommendaDon$
Class $Level$of$Evidence$B
ECG
New$recommendaDon$
Class a$Level$of$Evidence$C
• 
$
• 
(5.6%)
(2%) PE$(1.3%) sepsis$(1.7%)
(2.6%) $
$
Stroke.2007;38:2262–2269.
15
5.3%
2.4%
Stroke.$2005;36:1972–1976
9.ICP$Monitoring$and$Treatment$
$
$
Class
GCS
8
$
50 70
$
$
a$Level$of$Evidence$B
ICP
2010
$
Class b$Level$of$Evidence$C
$
$
ICP
New$recommendaDon$
Class $Level$of$Evidence$B
$
ICP
• 
ICP
N)Engl)J)Med.1987;316:1229–1233.
10.IVH(Intraventricular$Hemorrhage)$
IVH
PA
$
Class
b$Level$of$Evidence$B
IVH
New$recommendaDon$
Class b$Level$of$Evidence$B
$
11.Surgical$treatment$of$ICH$
$
Class
$
$Level$of$Evidence$B
2010
$
Class $Level$of$Evidence$C
$
Class
b$Level$of$Evidence$A
$
11.Surgical$treatment$of$ICH$
$
$
ICP
DC(Decompressive$Crainectomy)
$
New$recommendaDon$
Class b$Level$of$Evidence$A
New$recommendaDon$
Class b$Level$of$Evidence$C
New$recommendaDon$
Class b$Level$of$Evidence$C
Class
b$Level$of$Evidence$B
$
$
• 
• 
$
2cm GCS5
503
530
$
• 
6
(GOS)
$
$
Lancet.2005$
;365:387–397.
• 
$
1cm
• 
601
$
• 
307
27
78
$
48
10 100ml $
1cm
$
294
$
• 
mRS
Lancet.$2013;382:397–408.
6
$
GOSE
$
$
12.Outcome$PredicDon$and$
Withdrawal$of$Technological$Support$$
DNAR
$
Class
a$Level$of$Evidence$B
DNAR
$
DNAR
$
DNAR
Class
$Level$of$Evidence$C
$
• 
$
• 
DNAR
DNAR
Neurology.$2010;75:626–633.
13.PrevenDon$of$Recurrent$ICH$
Eε2 ε4
$
$
MRI
$
Class
a$Level$of$Evidence$B
$
$
$
$
$
Class
$
$
$
New$recommendaDon$
Class $Level$of$Evidence$A
$Level$of$Evidence$A
$
$
SBP<130mmHg DBP<80mmHg
Class
$
a$Level$of$Evidence$B
$
13.PrevenDon$of$Recurrent$ICH$
1 2
$
OSAS
$
Class
a$Level$of$Evidence$B
$
$
2010
$
Class a$Level$of$Evidence$B
Class
b$Level$of$Evidence$B
$
13.PrevenDon$of$Recurrent$ICH$
4
$
New$recommendaDon$
Class b$Level$of$Evidence$B
$
$
New$recommendaDon$
Class a$Level$of$Evidence$B
$
New$recommendaDon$
Class b$Level$of$Evidence$C
2010
$
Class b$Level$of$Evidence$C
• 
1 5%
$
• 
1
Stroke.$2006;37:1497–1502
:
SBP 130
$
• 
Am)J)Hypertens.$2013;26:1114–1122
• 
DBP80
CKD
$
SBP130
JAMA.2003;289:2560–2572
• 
INTERACT2
SBP 140
$
SBP130 DBP80
$
• 
$
• 
$
Neurology.2006;66:206–209.
• 
$
14.RehabilitaDon$and$Recovery
$
Class
$Level$of$Evidence$A
2010
$
Class a$Level$of$Evidence$B
$
class1
•  INTERECT2
ATACH2
$
• 
$
• 
• 
• 
$
$
$
• 
• 
• 
2015
$
$
INTERACT2
$
STICH2
$
$
SBP135
SBP160
j$hypertens$2012;30:2357d2364$
j$hypertens$2012;30:2357d2364$
• 
• 
• 
$211
211
SBP160
$
3
$
• 
$
• 
• 
$
ICU