75歳以上の後期高齢者におけるくも膜下出血後の脳血管攣縮期を中心とした周術期管理について（経胸壁心エコーの重要性）

Is Hyperdynamic Therapy Possible for Elderly Patients with Vasospasm Following Subarachnoid Hemorrhage?

Ⅰ．はじめに

　日本は超高齢社会を迎え，2008年には65歳以上の高齢者比率は21.8％にも達し，75歳以上の比率も10.2％と高率である¹³⁾．現在もなお高齢者比率は年間0.5～0.7％の割合で増加しており¹³⁾，とりわけ秋田県では高齢化の比率が高い．社会的には75歳以上が後期高齢者と分類され，保険診療の上での区別も行われている．このような状況下で高齢者脳卒中患者は当然増加し，比較的若い患者が多いくも膜下出血（SAH）においても高齢者の比率が高くなっている．高齢者SAHは一般的に若年者と比較して発症時のWFNS gradeが悪く，さらに入院中の合併症率も高いことから予後は悪いと言われている⁶⁾．これまでにSAH後の高血糖³⁾，不整脈⁴⁾，心筋トロポニンTの上昇¹⁰⁾が症候性脳血管攣縮や予後を増悪させるとの報告はあるが，心機能と合併症・予後に関して検討した報告は数少ない．この研究では当施設で経験したSAH患者に関し後ろ向きに検討し，特に75歳以上における後期高齢者に関して，脳血管攣縮期の管理を難しくすると思われる心機能と，心肺合併症を中心とした合併症の関連につき検討した．

　Background: Recently we have an increased number of elderly patients with subarachnoid hemorrhage (SAH) to be treated. Elderly patients are expected to have a worse cardiac function than that of younger patients. A question arises whether management for elderly patients in the vasospasm period can be performed as safely as it is for younger patients. The aim of this study is to examine the cardiac function of the elderly patients (≧75 y.o.) with SAH correlated with various complications in the vasospasm period.

　Materials: We retrospectively analyzed consecutive 356 patients with SAH encountered in our institute since 2000 to 2006. Seventy-three patients (20.5% of all) are 75 or more than 75 year-old. Their mean age is 80.4±4.43 (16 male, 57 female). Cardiac function was examined by trans-thoracic echocardiography (TTE) in 40 patients (54.8%).

　Result: Average value of their ejection fraction (EF) and rates of perioperative complications were not so different from those of the younger patients. But among patients of ≧75 y.o., certain patients in whom EF was under 0.6 significantly have experienced cardiopulmonary complications and longer hospitalization. In a multiple logistic analyses, only EF is significantly related with cardiopulmonary complications (P＝0.013).

　Conclusions: Among elderly SAH patients ≧75 year of age, some have experienced more cardiopulmonary complications than younger patients and have needed longer hospitalization. For such patients hyperdynamic therapy must be carefully carried out. TTE is effective to predispose and help eliminate their cardiopulmonary complications in the pre- and post-operative period.