PICSは予防可能か? 集中治療、敗血症、後に起こるPICS

PICSは予防可能か? 
集中治療、敗血症後に起こるPICS




皆様はPICSという言葉をご存知でしょうか?Post Intensive Care Syndromeの略でPICS (ピックス)と呼ばれ日本語では”集中治療後症候群”と呼ばれます。廃用症候群とは違いますし、近年SCCMより打ち出された新しい概念です。PICSをICU退出後の症候群と誤解している人も多く、”ICUにいる間にもPICSは発症します!”ので要注意です。

PICSに関して小さなまとめをどうぞ。




PICSは予防可能か?
ドクターK

 そもそもPICSに予防という概念自体が存在するのか、と考える方も多いのではないだろうか。以前より集中治療医の間でも「重症敗血症になった時点で後遺症はある程度残るものだ、ADLが低下することは仕方がない。」と考えられてきた。しかしながら近年、集中治療患者の環境因子や治療等への介入によりこれらの後遺症を減らす可能性が唱えられた1)。これが、「PICSの予防」の概念の始まりである。
 PICSの患者は主に①精神障害、②認知機能障害、③身体障害、に大別されるがその発症に関わる因子は様々である。PICSを予防することが出来るとしたら、どのような介入が可能であろうか。2000年にNelsonらは急性肺障害の患者に対しICUでの薬剤投与がどのような影響を与えているかを調べた。小規模の後ろ向きの観察研究ながら、鎮静薬や筋弛緩薬の使用がうつ病やPTSDの発症と関係しているというインパクトのある研究であった2)。このように、薬剤、輸血、輸液、人工呼吸器、血液浄化療法などの治療因子もPICSの発症との関連が言われており、PICSの予防に寄与する可能性がある。また治療以外にケア因子でも同様にPICSの発症との関連があると言われている。具体的に、喀痰の吸引や体位変換などが挙げられる。精神因子としては、せん妄、不眠、不穏、精神的ストレス、環境因子として、モニター音やアラーム音、ICUの閉め切った環境などがある。なおケア因子と精神因子にまたがる興味深いPICSの予防方法として、ICU日記がある。2010年にJonesらは多施設前向き研究で、家族もしくは医療従事者によりICU入院患者の日記帳を作ることでPTSDの発症が抑制出来ることを報告した3)。これは、ICU入院患者の状態が改善した場合にこの日記を読むことで自分の身に何が起こっていたのかを知り、また妄想と現実とのギャップを埋めることが出来るためだと言われている。このことが精神機能の回復を早めてPTSDの発症を防ぐことが出来る機序ではないかと推測される。
 このようにPICSの予防に重要な項目としてMarkらは、①ABCDEバンドルによるアプローチ、②ICU日記、③早期離床/理学療法、④認知療法、⑤その他(血糖コントロール、ステロイド投与)を挙げている4,5)。(表1参照)これらの事項を遵守することによりPICSを予防出来る可能性がある。
 ここまでPICSの予防の可能性を述べたが、未だエビデンズが乏しい分野であり今後のさらなる研究成果が期待される。また敗血症の治療の進歩に伴い、PICSの患者は今後さらに増えることが予想され、PICSの予防をおこなうことが当たり前の時代が来ることを切に望む。

 表1. PICS予防のためにおこなうべきこと

ABCDEバンドル

・鎮静薬や人工呼吸器のオン・オフを日々実践する

・せん妄のモニタリングと管理

・可能な範囲で安静度を上げる

ICU日記

・家族や医療従事者により実施

③早期離床/理学療法

④認知療法

⑤その他

・血糖コントロール

・ステロイドの使用がPTSDの発症を抑制させる可能性あり

(しかしながら現時点ではその理由だけでステロイドを使用すべきではない。)




参考文献
1. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med. 40:502-509, 2012
2. Nelson BJ, Weinert CR, Bury CL, et al. Intensive care unit drug use and subsequent quality of life in acute lung injury patients. Crit Care Med. 2000;28(11):3626-3630.
3. Jones C, Bäckman C, Capuzzo M, et al. Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial. Crit Care. 2010;14(5):R168.
4. Mark EM, Giora N, Theodore I. Post-intensive care syndrome (PICS). < http://www.uptodate.com/contents/post-intensive-care-syndrome-pics>
5. Pandharipande P, Banerjee A, McGrane S, et al. Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care. Crit Care 2010;14(3):157.







by kaigaiwataihenda | 2016-05-22 10:05 | 敗血症 | Comments(61)
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