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Blood purification has been applied conventionally as an artificial kidney or artificial liver in the management of patients with multiple organ failure (MOF), and most blood purifications have been performed intermittently. Recent advances in medical engineering made it possible to perform such blood purifications continuously (i. e., 24 hours a day, 7 days a week if necessary) even in critically ill patients. This modality is referred to as continuous renal replacement therapy (CRRT) or continuous blood purification (CBP). Among many kinds of CBP, continuous hemodiafiltration (CHDF) is most useful for management of MOF, as it can be performed without serious or hazardous side effects, and improvement can be expected with it. Recently, CHDF and polymyxin B immobilized endotoxin adsorption columns were used for the prevention or treatment of MOF, with the expectation that such therapy can be effective as a countermeasure against the pathophysiologic causes of MOF. Our data and that of others clearly indicate that continuous blood purification, such as with CHDF and endotoxin adsorption, can remove or decrease the blood levels of humoral mediators, including proinflammatory cytokines, and can improve tissue oxygenation, especially oxygen consumption (VO2) among critically ill patients including those with MOF. Blood purification is also useful in the careful management of fluid, electrolytes, and acid-base balance and for the removal of metabolic wastes. Blood purification is now considered to be one of the basic therapeutic tools of critical care, equal to nutritional support with total parenteral nutrition and respiratory support without a ventilator.

We investigated hemodynamic and respiratory changes in 19 postoperative patients who had undergone thromboendarterectomy for chronic pulmonary thromboembolism (CPTE) between 1986 and 1993 and were managed in our ICU. The postoperative hemodynamic and respiratory studies revealed reduced mean pulmonary arterial pressure (mean PAP), increased cardiac index (CI), and a resultant significant reduction in pulmonary vascular resistance (PVR) compared to their preoperative values. However, arterial oxygen tension (PaO2) deteriorated and the respiratory index (RI) increased on the admission to ICU. We classified these patients into two groups according to the duration of ventilatory support: group A required 5 or more days for weaning from the ventilator and group B were weaned from the ventilator within 5 days. The percent changes in mean PAP and PVR were greater in group A than in group B. The deteriorations in respiratory condition observed during the immediate postoperative period were supposed due to the ventilation-perfusion imbalance following the sudden reliease of mechanical obstruction caused by the removal of the thromboemboli. However, the patients' postoperative respiratory condition gradually improved in both groups and the difference had vanished by the 7th postoperative day. The preoperative hemodynamic findings, especially PVR, were worse in the non-survivors than that in the survivors, indicating that the preoperative PVR is a determinant factor of outcome.

目的:肝細胞ミトコンドリア機能を表し,肝のエネルギー代謝動態を示す動脈血中ケトン体比(arterial ketone body ratio,以下AKBRと略す)は,肝移植や肝切除等の肝臓外科,救急・集中治療領域において,肝障害の重症度を知る指標として広く用いられている。本研究は,劇症肝炎の診断基準および肝機能評価法としてのAKBRおよびケトン体量の有用性と問題点について検討することを目的とした。対象および方法:1987.9～1992.9の間に当施設において治療した劇症肝炎26例(急性型14例,亜急性型12例)を対象とした。ICU入室から退室までの間,連日動脈採血し,acetoacetate (ACAC), β-hydroxybutyrate (BOHB)を測定し,AKBR (ACAC/BOHB),ケトン体量(ACAC+BOHB)を算出した。結果:ICU入室時の急性型,亜急性型のAKBRは,それぞれ0.39±0.22, 0.94±0.31で急性型が有意に低値であった(p