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Kokyu to Junkan Volume 55, Issue 9 （September 2007）

呼吸と循環 55巻9号（2007年9月発行）

Japanese English

研究

B型急性大動脈解離におけるクリニカルパスの妥当性についての検討―早期離床の効果 Clinical Pathway for Patients with Type B Acute Aortic Dissection: The effect of early rehabilitation 新野哲也 ¹ , 秦光賢 ¹ , 瀬在明 ¹ , 依田真隆 ¹ , 和久井真司 ¹ , 宇野沢聡 ¹ , 梅田有史 ¹ , 南和友 ¹ Tetsuya Niino ¹ , Mitsumasa Hata ¹ , Akira Sezai ¹ , Masataka Yoda ¹ , Shinji Wakui ¹ , Satoshi Unosawa ¹ , Tomofumi Umeda ¹ , Kazutomo Minami ¹ ¹日本大学医学部心臓血管外科 ¹Department of Cardiovascular Surgery, Nihon University School of Medicine キーワード：急性大動脈解離 , Stanford B型解離 , クリニカルパス , acute aortic dissection , Stanford type B , clinical pathway Keyword: 急性大動脈解離 , Stanford B型解離 , クリニカルパス , acute aortic dissection , Stanford type B , clinical pathway pp.1049-1054

発行日 2007年9月15日 Published Date 2007/9/15

DOI https://doi.org/10.11477/mf.1404100892

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要旨　B型急性大動脈解離の保存療法における急性期のクリニカルパスの妥当性について検討した．当科に入院した1996年1月から行っていた長期安静を主体とした保存療法を行った前期群(n＝90)と，2001年1月から導入したクリニカルパスに基づいて早期離床を目標に管理した後期群(n＝74)を比較検討した．肺炎合併率23.3 vs 2.7%，人工呼吸器装着率11.1 vs 5.4%，不穏合併率22.2 vs 5.4%であり，呼吸器合併症と長期臥床や絶飲食などによると思われる不穏は後期群で著明に低下し，ICU滞在期間も短縮した．早期手術回避率96.7 vs 98.6%，早期死亡率3.3vs 2.7%であり，大動脈径や偽腔径の増大はなく，破裂などの血管関連の合併症や死亡率には有意差を認めなかった．今回導入したB型急性大動脈解離に対するクリニカルパスは，肺炎や不穏などの合併症を予防し，入院期間の短縮に貢献するものと考えられた．

　During the last 12 years, 164 patients with type B acute aortic dissection without complication(rupture or organ ischemia) have been admitted to our institute. The patients were divided into two groups; Group CG consisted of 90 patients who had been treated with 7 days of bed rest and intravenous antihypertensive agents during the previous 5 years; Group CPG Consisted of 74 patients treated by early rehabilitation inaccordance with our clinical pathway. In our clinical pathway, the patient is supposed to receive oral medication from the first day after onset and should be taking short walks from the third day after onset. In both groups, systolic blood pressure was kept under 120 mmHg with careful observation of urine output. If urine output decreases, blood pressure is controlled to around 140 mmHg. The length of ICU stay was significantly longer in CG(6.1±5.5 days) than in CPG(2.6±2.5). Duration of the bed-rest period was also significantly longer in CG(11.2±6.3 days) than in CPG(2.7±2.2). The incidence of pneumonia and ICU syndrome was significantly higher in CG. The rate of requiring a respirator was also significantly higher in the CG group. The maximum diameter of the dissected aorta at the time of onset was similar in each group, and the diameter had not increased one month later. Hospital mortality was similar in both groups(CG; 3.3% vs CPG; 2.7%). Our clinical pathway for patients with type B acute aortic dissection in the acute phase was safe and effective.