東京慈恵会医科大学 麻酔科学講座variables) control)group) ) n=10) intervention)...
TRANSCRIPT
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JAMA. 2018 Jul 24;320(4):368-378.
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BackgroundICU 50%
ICU-AW ICU-AW
ICU-AW
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BackgroundICU
ICU-AW ICU
Cycle ergometer
2 ICU
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Schweickert WD, et al. Lancet 2009;373:1874-82.
2009 Schweickert
Background
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2009 Schweickert
2009 12 21 http://www.jseptic.com/journal/jreview_014.ppt.
http://www.jseptic.com/journal/jreview_014.ppt.%E3%82%88
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• 18• 72 24
• 2 Barthel Index 70
Methods
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Barthel Index
ADL
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•• CPA• 6 50
••• trial
Methods
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– 1 1– 10
→ → →→ → →
– ADL
– 1 1–
Methods
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– ―–– 1 3 8.3mmoL/L 149.4mg/dL
CVII
Methods
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24– Barthel Index score– ADL–– ICU-AW–
Methods
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Results
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JAMA. 2018 Jul 24;320(4):368-378.
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Methods
20 medical-surgical ICU2014 7 2016 6
(6 2016 11 24 )1)182) ICU 723)ICU 484)ICU 15
Barthel index > 55 ( )
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1)2) ICU
3) ICD4) 725)6)7)8) DVT 489)10)11)12)
Methods
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ICU VS
4 6
Methods
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ICU
SchweickertROM
1550
Methods
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MOTOmed letto2
https://www.mobilefrance.fr/galeries-photos-motomed-letto2-g5.html
http://www.medicalexpo.com/prod/cefarcompex/product-67974-434989.html
Rehab400
Methods
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Primary Outcome-ICU MRC (0-60)
Secondary Outcome- ICU
L12-3MHz linear array transducer
Methods
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Medical Research Council(MRC) scale
::
0
1
2
3
4
5
600
Kleyweg RP, et al. Muscle Nerve. ;14(11):1103-9.
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Stevens RD, et al. Crit Care Med 2009; 37[Suppl.]:S299 –S308
1 2 3or4 5 .12
3 24 2 MRC score 48MRC score 4
45
ICU-AW
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3
1
2009 Seymour
Thorax. 2009 May;64(5):418-23.
Clin Nutr. 2017 Dec;36(6):1710-1715.
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Secondary Outcome-ICU ICU mobility scale-ICU CAM-ICU- Katz Index ICU ICU
Barthel Index ADL
- 28ICU ICU
28
Methods
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Secondary Outcome-QOL SF-36
ICU
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Methods
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CAM-ICU
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MOS 36-Item Short-Form Health Survey
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Sample Size
SchweickertMRC 4
1 5% 90%150
Methods
CIDP IVIG
J Neurol Neurosurg Psychiatry. 2010 Nov;81(11):1194-9.
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Statistical Analysis
ICU 0
ICU MICE (Mul4variate Imputa4on by Chained Equa4ons)
Primary OutcomeMann-Whitney test
Methods
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Statistical Analysis
95%CI
6
R
Methods
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Results498 314
159 155
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Results
2
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ICU MRC 2
Primary OutcomeResults
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Secondary Outcome
2
Results
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Secondary Outcome
2
Results
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( 7 4.4% 9 (5.8%))
Per protocol
Results
Per protocol
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Results
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Discussionprimary outcome secondary outcome
cycling exercise
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Discussion
ICU 30cycling
exercise ICU7
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DiscussionICU
ICU
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MRC
MRC
Discussion
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ConclusionICU
ICU
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MRC
Limitation
ICU-AW MRC
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BMJ Open. 2018 May 5;8(5):e019998.
ICU
ICU
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MRC Outcome RCT
BMJ Open. 2018 May 5;8(5):e019998.
ICU
52[25 - 58]VS 48[0 - 58] (p=0.38)
50.4 7.5 VS 45.2 13.2 (p=0.10)
51.9 10.5 VS 47.3 13.6 (p=0.24)
Early rehabilitation VS Control
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ICU-AW Outcome RCT
BMJ Open. 2018 May 5;8(5):e019998.
ICU
7/25(28%) VS 10/20(50%) (p=0.13)
15/49(31%) VS 27/55(49%) (p=0.09)
Early rehabilitation VS Control
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MRC
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Crit Care Med. 2015 Apr;43(4):897-905.
2015
4
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2009 Seymour
Thorax. 2009 May;64(5):418-23.
COPD
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JAMA. 2013 Oct 16;310(15):1591-600.
-18 48 ICU 7
--
-ICU 1 3 7 10
DNA-
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P = 0.03
P = 0.31Day1 to day7 change Decrease rate [95% CI]
RFCSA -10.3% [-6.1 to -14.5] fiberCSA -17.5%
[-5.8 to -29.3] change in protein:DNA ratio -29.5% [-13.4 to -45.6]
ICU
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0.035%/hour[0.023-0.047]
0.039%/hour[0.029-0.048]
0.076%/hour[0.032-0.120]
0.065%/ hour[0.049-0.080]
P=0.03
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P = 0.025
P = 0.019
Am J Respir Crit Care Med. 2017 Jan 1;195(1):136-138.
Day1 to day7 change Decrease rate [95% CI] Thickness -4.6%
[-14.19 to 4.95] fiberCSA -16.4%
[-32.0 to -0.74] change in protein:DNA ratio -30.9% [-51.2 to -10.6]
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Crit Care Med. 2018 Sep;46(9):1436-1443.
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ICU 72
Methods
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•••••• CPA• ICU 7
Methods
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–– 1 2 (7/7day)– 30 (MOTOmed Letto2)
–– (5/7day)
Methods
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Primary Outcome-- ubiquitin-proteasome pathway (UPP) autophagy- Akt-mTOR pathway
Secondary Outcome--MRC
Methods
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Results
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Variables)Control)group) )
n=10)
Intervention)
group)n=9)p"value#
Indirect)calorimetry) 70%)(7)) 56%)(5)) 0.65)
Measured)REE)by)indirect)calorimetry)
(kcal/24h))1823±437)(n=7)) 1960±724)(n=5)) 0.69)
Theoretical)REE)(kcal/24h)*) 1549±171)(n=3)) 1535±343)(n=4)) 0.91)
Prescribed)REE)(kcal/24h)†) 1652±376) 1692±621) 0.94)
Administered)nutritional)support)
(kcal/24h))1239±357) 1414±816) 0.54)
Difference)administeredPprescribed) )
nutritional)support)(%))P24±21) P20±27) 0.73)
) ) Day)1)(%)) P47±31) P28±32) 0.58)
) ) Day)2)(%)) P10±33) P18±23) 0.60)
) ) Day)3)(%)) P16±28) P28±33) 0.38)
) ) Day)4)(%)) P27±27) P11±33) 0.30)
) ) Day)5)(%)) P23±34) P13±28) 0.53)
) ) Day)6)(%)) P25±35) P3±33) 0.20)
) ) Day)7)(%)) P22±32) P7±32) 0.33)
Administered)proteins)(g/kg/day)) 0.91±0.30) 1.05±0.57) 0.52)
Nitrogen)balance~) P4.53±4.74)(n=8)) P2.55±2.63)(n=8)) 0.46)
Insulin)dose)at)Biopsy)1)(Ul/h)) 1.45±1.96) 0.72±0.76) 0.31)
Insulin)dose)at)Biopsy)2)(Ul/h)) 1.56±1.99) 1.15±1.22) 0.66)
Glycaemia)at)Biopsy)1)(mmol/l)) 7.21±1.58) 8.17±1.59) 0.21)
Glycaemia)at)Biopsy)2)(mmol/l)) 7.88±1.70) 7.88±2.48) 0.99)
Nutritional)route)
) ) ) Only)parenteral) P) P) )
) ) ) Parenteral)and)oral) P) 11%)(1)) )
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Results
Autophagy
lysosomal-associated membrane protein (LAMP) 2. LAMP2/p62 colocalization
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Autophagy
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MRC
Results
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Conclusion
Autophagy
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Lancet Respir Med. 2013 Oct;1(8):621-9.
ICU 48
autophagy
cycle
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8 1 autophagy
ICU-AW
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2018 JAMA Fossat