臨牀透析 Vol.15 No.10(4-2)


特集名 多臓器不全と血液浄化法
題名 多臓器不全の示す症状と治療 (2) 重症感染症
発刊年月 1999年 09月
著者 今泉 均 札幌医科大学医学部救急集中治療部
著者 本田 亮一 札幌医科大学医学部救急集中治療部
著者 金子 正光 札幌医科大学医学部救急集中治療部
【 要旨 】 重症感染症である敗血症は多臓器不全の発症原因としてもっとも多い.また多臓器不全症例は免疫不全状態にあるため敗血症を併発しやすく,予後に悪影響を与える.敗血症・多臓器不全の病態には,種々のmediatorの過剰産生とそれによる組織酸素代謝の失調が関与するため,感染症のコントロールとmediator対策が必要である.感染症対策としては,感染巣に対する適切なドレナージ,感受性のある抗生物質や抗真菌薬の投与,炎症性サイトカインの産生を抑制させるためmethylprednisoloneや蛋白分解酵素阻害薬の投与, 誤嚥性肺炎やbacterial translocation予防のため腸洗浄が有効である.血液浄化法として,エンドトキシン除去を目的にエンドトキシン吸着療法が,臓器不全誘発物質などのmediator除去と体液,酸塩基平衡,電解質などの生体の恒常性維持を目的に持続的血液濾過透析が用いられている.しかし,カテーテル感染や血液浄化法によって部分的に除去される治療薬剤にも注意が必要である.
Theme Multiple Organ Failure and Blood Purification Therapy
Title Blood purification in patients with multiple organ failure due to sepsis
Author Hitoshi Imaizumi Department of Traumatology and Critical Care Medicine, Sapporo Medical University School of Medicine
Author Ryoichi Honda Department of Traumatology and Critical Care Medicine, Sapporo Medical University School of Medicine
Author Masamitsu Kaneko Department of Traumatology and Critical Care Medicine, Sapporo Medical University School of Medicine
[ Summary ] Sepsis is the most common cause of multiple organ failure (MOF). Sepsis is frequently complicated with MOF in patients with an immunosuppressive condition, causing severe deterioration in their condition. As the pathogenesis of sepsis/MOF derives from overproduction of various mediators and disorientation of tissue oxygen metabolism, the infection itself and the mediators must be controlled. Treatments for sepsis are as follows; drainage at the focus of infection; antibiotics sensitive to the bacteria; antifungal drugs sensitive to the fungus; methylprednisolone and protease inhibitors to reduce production and/or release of inflammatory cytokines, and enteral lavage to prevent silent aspiration pneumonia and bacterial translocation. Additionally there are methods of blood purification, such as endotoxin removal therapy and continuous hemodiafiltration (CHDF). Direct hemoperfusion with polymyxin-B immobilized fibers is indicated to remove endotoxins in patients with endotoxemia. CHDF is indicated to remove various mediators, which produce organ injury, and to maintain homeostasis of fluids, acid-base balance and electrolytes. However, catheter-related sepsis and therapeutic drugs, removed partially by blood purification, are possibilities which must be considerd.
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