{
  "articleContentId": "b44b43fd-9fc7-4de5-9c57-bd354e21e612",
  "articleId": "ff7a0f40-b9fc-4e6b-9878-b0ed4802e143",
  "blocks": [
    {
      "blockId": "article03/lead",
      "kind": "paragraph",
      "text": "出血が始まっても、血圧はすぐには下がらないことがあります。頻脈、動脈収縮、静脈収縮が循環を支えるからです。この記事では、自律神経が担う代償を一つずつ手で加えながら、「血圧は正常」という報告の裏で何が失われているのかを確かめます。"
    },
    {
      "blockId": "article03/divider/0",
      "kind": "divider"
    },
    {
      "blockId": "article03/h2/hook",
      "kind": "heading",
      "level": 2,
      "text": "「血圧は保たれています」"
    },
    {
      "blockId": "article03/p/hook-1",
      "kind": "paragraph",
      "text": "術後2時間。ドレーンからの出血が続く患者について、研修医が報告します。「心拍数110 /minですが、血圧は112/92 mmHgで保たれています」"
    },
    {
      "blockId": "article03/p/hook-2",
      "kind": "paragraph",
      "text": "本当に「保たれている」のでしょうか。安心はできません。脈圧は20 mmHgしかなく、拡張期血圧は92 mmHgと高めです。この組み合わせだけで、出血していないとは言えません。"
    },
    {
      "blockId": "article03/p/quick-answer",
      "kind": "paragraph",
      "text": "先に結論を示します。出血が始まっても、動脈収縮、静脈収縮、頻脈が働けば、平均血圧はしばらく保たれます。血圧は循環の余裕そのものではなく、代償を使ったあとの出力です。脈圧、拡張期血圧、心拍数、末梢灌流、出血量を合わせて読みます。"
    },
    {
      "blockId": "article03/p/model-intro",
      "kind": "paragraph",
      "text": "このシミュレーターには圧受容体反射がありません。この記事では、その制約を教材として使います。自律神経が自動で行う代償を一つずつ手で加え、何が血圧を支えているのかを分解します。"
    },
    {
      "blockId": "article03/h2/outcomes",
      "kind": "heading",
      "level": 2,
      "text": "読み終えたときにできること"
    },
    {
      "blockId": "article03/p/outcomes",
      "kind": "paragraph",
      "text": "1. 反射のない出血と代償された出血で、血圧の見え方が違う理由を説明できる。\n2. 正常範囲の血圧だけで出血を否定せず、脈圧、拡張期血圧、心拍数を次の観察へつなげられる。\n3. 代償には上限があり、追加出血で再び心拍出量と血圧が下がる理由を説明できる。"
    },
    {
      "blockId": "article03/h2/model",
      "kind": "heading",
      "level": 2,
      "text": "出血は、静脈側から心拍出量を減らす"
    },
    {
      "blockId": "article03/p/causal-chain-1",
      "kind": "paragraph",
      "text": "出血で最初に減るのは、血管壁を押して圧を生むstressed volumeです。そこから、平均循環充満圧、静脈還流、前負荷、1回拍出量、心拍出量が順に低下します。"
    },
    {
      "blockId": "article03/p/causal-chain-2",
      "kind": "paragraph",
      "text": "出血 → stressed volume低下 → 充満圧低下 → 静脈還流低下 → 前負荷低下 → 1回拍出量低下 → 心拍出量・血圧低下"
    },
    {
      "blockId": "article03/accordion/cards",
      "blocks": [
        {
          "blockId": "article03/accordion/cards/p1",
          "kind": "paragraph",
          "text": "1つ目は動脈収縮です。少なくなった流量から圧を作ります。2つ目は静脈収縮です。unstressed volumeの一部をstressed volumeへ移し、静脈還流を支えます。3つ目は頻脈です。1拍あたりの減少を回数で補います。"
        },
        {
          "blockId": "article03/accordion/cards/p2",
          "kind": "paragraph",
          "text": "この3つは無限には使えません。代償とは、有限の予備を使って出血の影響を隠すことです。なお、この記事のシミュレーションでは心拍数を一定にし、動脈収縮と静脈収縮だけを手動で加えます。"
        }
      ],
      "kind": "accordion",
      "title": "もう一歩：体が使う3つの代償"
    },
    {
      "blockId": "article03/divider/1",
      "kind": "divider"
    },
    {
      "blockId": "article03/h2/experiment-1",
      "kind": "heading",
      "level": 2,
      "text": "動かして確かめる①：反射がなければ、出血は血圧に出る"
    },
    {
      "blockId": "article03/p/experiment-1-intro",
      "kind": "paragraph",
      "text": "まず、代償を加えずに総循環血液量を5,600 mLから4,800 mLへ減らします。シミュレーションを開く前に予測してください。"
    },
    {
      "blockId": "article03/quiz/experiment-1",
      "choices": [
        {
          "choiceId": "experiment-1/map",
          "label": "平均動脈圧"
        },
        {
          "choiceId": "experiment-1/ra",
          "label": "平均右房圧"
        },
        {
          "choiceId": "experiment-1/sbp",
          "label": "収縮期血圧"
        }
      ],
      "correctChoiceId": "experiment-1/ra",
      "explanation": "平均右房圧は3.33から1.93 mmHgへ約42%低下しました。出血の影響は静脈側から始まります。",
      "kind": "quiz",
      "question": "800 mL減らしたとき、割合として最も大きく低下するのはどれでしょうか？"
    },
    {
      "blockId": "block/authoring/a1039111-0011-4011-8011-000000000011",
      "kind": "experiment",
      "placement": {
        "briefing": {
          "controls": [
            {
              "binding": {
                "application": "absolute",
                "mode": "fixed",
                "scenarioIds": [
                  "scenario/article03/hemorrhage/loss-800"
                ]
              },
              "controlId": "hemodynamics.total-blood-volume-ml",
              "label": "総循環血液量",
              "order": 0,
              "presentation": {
                "kind": "buttons",
                "options": [
                  {
                    "label": "基準 5,600",
                    "value": 5600
                  },
                  {
                    "label": "−400 mL",
                    "value": 5200
                  },
                  {
                    "label": "−800 mL",
                    "value": 4800
                  }
                ]
              },
              "sourcePaneId": "controls-loss"
            }
          ],
          "defaultTitle": "反射のない出血：5,600 mL → 4,800 mL",
          "graphs": [
            {
              "emphasis": "primary",
              "order": 0,
              "paneId": "graph-arterial-pressure"
            }
          ],
          "outputs": [
            {
              "label": "収縮期血圧",
              "order": 0,
              "outputId": "hemodynamics.pressure.systolic.Ao",
              "scenarioId": "scenario/article03/hemorrhage/baseline",
              "sourcePaneId": "outputs-baseline"
            },
            {
              "label": "拡張期血圧",
              "order": 1,
              "outputId": "hemodynamics.pressure.diastolic.Ao",
              "scenarioId": "scenario/article03/hemorrhage/baseline",
              "sourcePaneId": "outputs-baseline"
            },
            {
              "label": "平均動脈圧",
              "order": 2,
              "outputId": "hemodynamics.pressure.mean.Ao",
              "scenarioId": "scenario/article03/hemorrhage/baseline",
              "sourcePaneId": "outputs-baseline"
            },
            {
              "label": "脈圧",
              "order": 3,
              "outputId": "hemodynamics.pressure.pulse.Ao",
              "scenarioId": "scenario/article03/hemorrhage/baseline",
              "sourcePaneId": "outputs-baseline"
            },
            {
              "label": "平均右房圧",
              "order": 4,
              "outputId": "hemodynamics.pressure.mean.RA",
              "scenarioId": "scenario/article03/hemorrhage/baseline",
              "sourcePaneId": "outputs-baseline"
            },
            {
              "label": "1回拍出量",
              "order": 5,
              "outputId": "hemodynamics.stroke-volume.LV-extrema",
              "scenarioId": "scenario/article03/hemorrhage/baseline",
              "sourcePaneId": "outputs-baseline"
            },
            {
              "label": "心拍出量",
              "order": 6,
              "outputId": "hemodynamics.output.native-left",
              "scenarioId": "scenario/article03/hemorrhage/baseline",
              "sourcePaneId": "outputs-baseline"
            },
            {
              "label": "収縮期血圧",
              "order": 7,
              "outputId": "hemodynamics.pressure.systolic.Ao",
              "scenarioId": "scenario/article03/hemorrhage/loss-800",
              "sourcePaneId": "outputs-loss"
            },
            {
              "label": "拡張期血圧",
              "order": 8,
              "outputId": "hemodynamics.pressure.diastolic.Ao",
              "scenarioId": "scenario/article03/hemorrhage/loss-800",
              "sourcePaneId": "outputs-loss"
            },
            {
              "label": "平均動脈圧",
              "order": 9,
              "outputId": "hemodynamics.pressure.mean.Ao",
              "scenarioId": "scenario/article03/hemorrhage/loss-800",
              "sourcePaneId": "outputs-loss"
            },
            {
              "label": "脈圧",
              "order": 10,
              "outputId": "hemodynamics.pressure.pulse.Ao",
              "scenarioId": "scenario/article03/hemorrhage/loss-800",
              "sourcePaneId": "outputs-loss"
            },
            {
              "label": "平均右房圧",
              "order": 11,
              "outputId": "hemodynamics.pressure.mean.RA",
              "scenarioId": "scenario/article03/hemorrhage/loss-800",
              "sourcePaneId": "outputs-loss"
            },
            {
              "label": "1回拍出量",
              "order": 12,
              "outputId": "hemodynamics.stroke-volume.LV-extrema",
              "scenarioId": "scenario/article03/hemorrhage/loss-800",
              "sourcePaneId": "outputs-loss"
            },
            {
              "label": "心拍出量",
              "order": 13,
              "outputId": "hemodynamics.output.native-left",
              "scenarioId": "scenario/article03/hemorrhage/loss-800",
              "sourcePaneId": "outputs-loss"
            }
          ],
          "scenarioScope": {
            "initialFocusScenarioId": "scenario/article03/hemorrhage/loss-800",
            "visibleScenarioIds": [
              "scenario/article03/hemorrhage/baseline",
              "scenario/article03/hemorrhage/loss-800"
            ]
          }
        },
        "caption": null,
        "placementId": "placement/authoring/a1039111-0011-4011-8011-000000000011",
        "schemaId": "circleheart-studio-experiment-placement-v2",
        "snapshotId": "4fe07d22-10a8-46d0-b04b-7099e37597ab",
        "titleOverride": null
      }
    },
    {
      "blockId": "article03/p/experiment-1-result-1",
      "kind": "paragraph",
      "text": "30秒後、平均右房圧は3.33から1.93 mmHgへ約42%低下しました。平均動脈圧は88.4から69.5 mmHgへ約21%、収縮期血圧は109.3から88.2 mmHgへ約19%低下しています。"
    },
    {
      "blockId": "article03/p/experiment-1-result-2",
      "kind": "paragraph",
      "text": "1回拍出量は90.7から72.1 mLへ、心拍出量は5.44から4.32 L/minへ低下しました。圧受容体反射のないモデルでは、出血は血圧にもはっきり現れます。"
    },
    {
      "blockId": "article03/accordion/experiment-1-evidence",
      "blocks": [
        {
          "blockId": "article03/accordion/experiment-1-evidence/p1",
          "kind": "paragraph",
          "text": "ここで示した値は、教育用モデルを30秒進めた結果です。患者で同じ800 mLを失ったときに同じ数値になる、という意味ではありません。この実験で確かめたのは、出血の影響が静脈側から始まるという因果の向きです。"
        }
      ],
      "kind": "accordion",
      "title": "数値の読み方：モデル出力と患者の事実を分ける"
    },
    {
      "blockId": "article03/divider/2",
      "kind": "divider"
    },
    {
      "blockId": "article03/h2/experiment-2",
      "kind": "heading",
      "level": 2,
      "text": "動かして確かめる②：血圧を支えて、出血を隠す"
    },
    {
      "blockId": "article03/p/experiment-2-intro",
      "kind": "paragraph",
      "text": "次は総循環血液量4,800 mLのまま、体血管抵抗を1.00から1.25へ上げます。その後、静脈トーヌスを0.15から1.00へ上げます。"
    },
    {
      "blockId": "article03/quiz/experiment-2",
      "choices": [
        {
          "choiceId": "experiment-2/restore",
          "label": "平均血圧と一緒に大きく戻る"
        },
        {
          "choiceId": "experiment-2/widen",
          "label": "さらに大きく開く"
        },
        {
          "choiceId": "experiment-2/narrow",
          "label": "狭いまま、あまり変わらない"
        }
      ],
      "correctChoiceId": "experiment-2/narrow",
      "explanation": "平均動脈圧は69.5から78.6 mmHgへ戻りましたが、脈圧は25.0から26.2 mmHgでした。",
      "kind": "quiz",
      "question": "動脈を収縮させて平均血圧を戻したとき、脈圧はどうなるでしょうか？"
    },
    {
      "blockId": "block/authoring/a1039102-0002-4002-8002-000000000002",
      "kind": "experiment",
      "placement": {
        "briefing": {
          "controls": [
            {
              "binding": {
                "application": "absolute",
                "mode": "fixed",
                "scenarioIds": [
                  "scenario/article03/compensation/full"
                ]
              },
              "controlId": "hemodynamics.systemic-resistance",
              "label": "体血管抵抗",
              "order": 0,
              "presentation": {
                "kind": "buttons",
                "options": [
                  {
                    "label": "基準",
                    "value": 1
                  },
                  {
                    "label": "収縮",
                    "value": 1.25
                  }
                ]
              },
              "sourcePaneId": "controls-compensation"
            },
            {
              "binding": {
                "application": "absolute",
                "mode": "fixed",
                "scenarioIds": [
                  "scenario/article03/compensation/full"
                ]
              },
              "controlId": "hemodynamics.venous-tone",
              "label": "静脈トーヌス",
              "order": 1,
              "presentation": {
                "kind": "buttons",
                "options": [
                  {
                    "label": "基準",
                    "value": 0.15
                  },
                  {
                    "label": "中間",
                    "value": 0.6
                  },
                  {
                    "label": "最大",
                    "value": 1
                  }
                ]
              },
              "sourcePaneId": "controls-compensation"
            }
          ],
          "defaultTitle": "代償を分解する：動脈収縮と静脈収縮",
          "graphs": [
            {
              "emphasis": "primary",
              "order": 0,
              "paneId": "graph-arterial-pressure"
            }
          ],
          "outputs": [
            {
              "label": "収縮期血圧",
              "order": 0,
              "outputId": "hemodynamics.pressure.systolic.Ao",
              "scenarioId": "scenario/article03/compensation/hemorrhage",
              "sourcePaneId": "outputs-hemorrhage"
            },
            {
              "label": "拡張期血圧",
              "order": 1,
              "outputId": "hemodynamics.pressure.diastolic.Ao",
              "scenarioId": "scenario/article03/compensation/hemorrhage",
              "sourcePaneId": "outputs-hemorrhage"
            },
            {
              "label": "平均動脈圧",
              "order": 2,
              "outputId": "hemodynamics.pressure.mean.Ao",
              "scenarioId": "scenario/article03/compensation/hemorrhage",
              "sourcePaneId": "outputs-hemorrhage"
            },
            {
              "label": "脈圧",
              "order": 3,
              "outputId": "hemodynamics.pressure.pulse.Ao",
              "scenarioId": "scenario/article03/compensation/hemorrhage",
              "sourcePaneId": "outputs-hemorrhage"
            },
            {
              "label": "平均右房圧",
              "order": 4,
              "outputId": "hemodynamics.pressure.mean.RA",
              "scenarioId": "scenario/article03/compensation/hemorrhage",
              "sourcePaneId": "outputs-hemorrhage"
            },
            {
              "label": "1回拍出量",
              "order": 5,
              "outputId": "hemodynamics.stroke-volume.LV-extrema",
              "scenarioId": "scenario/article03/compensation/hemorrhage",
              "sourcePaneId": "outputs-hemorrhage"
            },
            {
              "label": "心拍出量",
              "order": 6,
              "outputId": "hemodynamics.output.native-left",
              "scenarioId": "scenario/article03/compensation/hemorrhage",
              "sourcePaneId": "outputs-hemorrhage"
            },
            {
              "label": "収縮期血圧",
              "order": 7,
              "outputId": "hemodynamics.pressure.systolic.Ao",
              "scenarioId": "scenario/article03/compensation/arterial",
              "sourcePaneId": "outputs-arterial"
            },
            {
              "label": "拡張期血圧",
              "order": 8,
              "outputId": "hemodynamics.pressure.diastolic.Ao",
              "scenarioId": "scenario/article03/compensation/arterial",
              "sourcePaneId": "outputs-arterial"
            },
            {
              "label": "平均動脈圧",
              "order": 9,
              "outputId": "hemodynamics.pressure.mean.Ao",
              "scenarioId": "scenario/article03/compensation/arterial",
              "sourcePaneId": "outputs-arterial"
            },
            {
              "label": "脈圧",
              "order": 10,
              "outputId": "hemodynamics.pressure.pulse.Ao",
              "scenarioId": "scenario/article03/compensation/arterial",
              "sourcePaneId": "outputs-arterial"
            },
            {
              "label": "平均右房圧",
              "order": 11,
              "outputId": "hemodynamics.pressure.mean.RA",
              "scenarioId": "scenario/article03/compensation/arterial",
              "sourcePaneId": "outputs-arterial"
            },
            {
              "label": "1回拍出量",
              "order": 12,
              "outputId": "hemodynamics.stroke-volume.LV-extrema",
              "scenarioId": "scenario/article03/compensation/arterial",
              "sourcePaneId": "outputs-arterial"
            },
            {
              "label": "心拍出量",
              "order": 13,
              "outputId": "hemodynamics.output.native-left",
              "scenarioId": "scenario/article03/compensation/arterial",
              "sourcePaneId": "outputs-arterial"
            },
            {
              "label": "収縮期血圧",
              "order": 14,
              "outputId": "hemodynamics.pressure.systolic.Ao",
              "scenarioId": "scenario/article03/compensation/full",
              "sourcePaneId": "outputs-full"
            },
            {
              "label": "拡張期血圧",
              "order": 15,
              "outputId": "hemodynamics.pressure.diastolic.Ao",
              "scenarioId": "scenario/article03/compensation/full",
              "sourcePaneId": "outputs-full"
            },
            {
              "label": "平均動脈圧",
              "order": 16,
              "outputId": "hemodynamics.pressure.mean.Ao",
              "scenarioId": "scenario/article03/compensation/full",
              "sourcePaneId": "outputs-full"
            },
            {
              "label": "脈圧",
              "order": 17,
              "outputId": "hemodynamics.pressure.pulse.Ao",
              "scenarioId": "scenario/article03/compensation/full",
              "sourcePaneId": "outputs-full"
            },
            {
              "label": "平均右房圧",
              "order": 18,
              "outputId": "hemodynamics.pressure.mean.RA",
              "scenarioId": "scenario/article03/compensation/full",
              "sourcePaneId": "outputs-full"
            },
            {
              "label": "1回拍出量",
              "order": 19,
              "outputId": "hemodynamics.stroke-volume.LV-extrema",
              "scenarioId": "scenario/article03/compensation/full",
              "sourcePaneId": "outputs-full"
            },
            {
              "label": "心拍出量",
              "order": 20,
              "outputId": "hemodynamics.output.native-left",
              "scenarioId": "scenario/article03/compensation/full",
              "sourcePaneId": "outputs-full"
            }
          ],
          "scenarioScope": {
            "initialFocusScenarioId": "scenario/article03/compensation/full",
            "visibleScenarioIds": [
              "scenario/article03/compensation/hemorrhage",
              "scenario/article03/compensation/arterial",
              "scenario/article03/compensation/full"
            ]
          }
        },
        "caption": null,
        "placementId": "placement/authoring/a1039102-0002-4002-8002-000000000002",
        "schemaId": "circleheart-studio-experiment-placement-v2",
        "snapshotId": "5cd9b516-cb43-49ce-a8a9-87e67491dc56",
        "titleOverride": null
      }
    },
    {
      "blockId": "article03/p/experiment-2-result-1",
      "kind": "paragraph",
      "text": "体血管抵抗を上げると、平均動脈圧は69.5から78.6 mmHgへ戻りました。一方、脈圧は25.0から26.2 mmHgで、1回拍出量は72.1から69.2 mLへわずかに低下しました。"
    },
    {
      "blockId": "article03/p/experiment-2-result-2",
      "kind": "paragraph",
      "text": "動脈収縮は、少ない流量から圧を作る代償です。心拍出量を元に戻したわけではありません。だから平均血圧だけを見れば改善していても、拍の成分は痩せたままです。"
    },
    {
      "blockId": "article03/p/experiment-2-result-3",
      "kind": "paragraph",
      "text": "続いて静脈トーヌスを最大まで上げると、平均右房圧は1.85から3.12 mmHgへ戻りました。1回拍出量は69.2から86.3 mLへ、心拍出量は4.15から5.18 L/minへ増えます。平均動脈圧は98.8 mmHgまで上がりました。"
    },
    {
      "blockId": "article03/accordion/experiment-2-mechanism",
      "blocks": [
        {
          "blockId": "article03/accordion/experiment-2-mechanism/p1",
          "kind": "paragraph",
          "text": "血液は増えていません。容量血管にあった血液が、静脈収縮によって圧を生む側へ再配分されました。総循環血液量は4,800 mLのままです。"
        },
        {
          "blockId": "article03/accordion/experiment-2-mechanism/p2",
          "kind": "paragraph",
          "text": "冒頭の112/92 mmHgのように、狭い脈圧、高めの拡張期血圧、頻脈は、代償された出血で見られうる組み合わせです。ただし、この組み合わせだけで出血とは診断できません。"
        }
      ],
      "kind": "accordion",
      "title": "発展：静脈収縮は「内因性の輸液」なのか"
    },
    {
      "blockId": "article03/divider/3",
      "kind": "divider"
    },
    {
      "blockId": "article03/h2/experiment-3",
      "kind": "heading",
      "level": 2,
      "text": "動かして確かめる③：追加できる代償がないとき"
    },
    {
      "blockId": "article03/p/experiment-3-intro",
      "kind": "paragraph",
      "text": "体血管抵抗と静脈トーヌスを最大にしたまま、総循環血液量を4,800 mLから4,500 mLへさらに減らします。"
    },
    {
      "blockId": "article03/quiz/experiment-3",
      "choices": [
        {
          "choiceId": "experiment-3/same",
          "label": "血圧も心拍出量もほぼ変わらない"
        },
        {
          "choiceId": "experiment-3/down",
          "label": "平均血圧と心拍出量が再び低下する"
        },
        {
          "choiceId": "experiment-3/more-tone",
          "label": "静脈収縮がさらに強くなり、すぐ元へ戻る"
        }
      ],
      "correctChoiceId": "experiment-3/down",
      "explanation": "平均動脈圧は98.8から91.6 mmHgへ、心拍出量は5.18から4.82 L/minへ低下しました。",
      "kind": "quiz",
      "question": "追加できる代償がない状態で300 mL失うと、何が起こるでしょうか？"
    },
    {
      "blockId": "block/authoring/a1039103-0003-4003-8003-000000000003",
      "kind": "experiment",
      "placement": {
        "briefing": {
          "controls": [
            {
              "binding": {
                "application": "absolute",
                "mode": "fixed",
                "scenarioIds": [
                  "scenario/article03/exhaustion/further-loss"
                ]
              },
              "controlId": "hemodynamics.total-blood-volume-ml",
              "label": "総循環血液量",
              "order": 0,
              "presentation": {
                "kind": "buttons",
                "options": [
                  {
                    "label": "4,800",
                    "value": 4800
                  },
                  {
                    "label": "4,500",
                    "value": 4500
                  },
                  {
                    "label": "4,200",
                    "value": 4200
                  }
                ]
              },
              "sourcePaneId": "controls-further-loss"
            }
          ],
          "defaultTitle": "代償を使い切ったあと：さらに300 mL減る",
          "graphs": [
            {
              "emphasis": "primary",
              "order": 0,
              "paneId": "graph-arterial-pressure"
            }
          ],
          "outputs": [
            {
              "label": "収縮期血圧",
              "order": 0,
              "outputId": "hemodynamics.pressure.systolic.Ao",
              "scenarioId": "scenario/article03/exhaustion/compensated",
              "sourcePaneId": "outputs-compensated"
            },
            {
              "label": "拡張期血圧",
              "order": 1,
              "outputId": "hemodynamics.pressure.diastolic.Ao",
              "scenarioId": "scenario/article03/exhaustion/compensated",
              "sourcePaneId": "outputs-compensated"
            },
            {
              "label": "平均動脈圧",
              "order": 2,
              "outputId": "hemodynamics.pressure.mean.Ao",
              "scenarioId": "scenario/article03/exhaustion/compensated",
              "sourcePaneId": "outputs-compensated"
            },
            {
              "label": "脈圧",
              "order": 3,
              "outputId": "hemodynamics.pressure.pulse.Ao",
              "scenarioId": "scenario/article03/exhaustion/compensated",
              "sourcePaneId": "outputs-compensated"
            },
            {
              "label": "平均右房圧",
              "order": 4,
              "outputId": "hemodynamics.pressure.mean.RA",
              "scenarioId": "scenario/article03/exhaustion/compensated",
              "sourcePaneId": "outputs-compensated"
            },
            {
              "label": "1回拍出量",
              "order": 5,
              "outputId": "hemodynamics.stroke-volume.LV-extrema",
              "scenarioId": "scenario/article03/exhaustion/compensated",
              "sourcePaneId": "outputs-compensated"
            },
            {
              "label": "心拍出量",
              "order": 6,
              "outputId": "hemodynamics.output.native-left",
              "scenarioId": "scenario/article03/exhaustion/compensated",
              "sourcePaneId": "outputs-compensated"
            },
            {
              "label": "収縮期血圧",
              "order": 7,
              "outputId": "hemodynamics.pressure.systolic.Ao",
              "scenarioId": "scenario/article03/exhaustion/further-loss",
              "sourcePaneId": "outputs-further-loss"
            },
            {
              "label": "拡張期血圧",
              "order": 8,
              "outputId": "hemodynamics.pressure.diastolic.Ao",
              "scenarioId": "scenario/article03/exhaustion/further-loss",
              "sourcePaneId": "outputs-further-loss"
            },
            {
              "label": "平均動脈圧",
              "order": 9,
              "outputId": "hemodynamics.pressure.mean.Ao",
              "scenarioId": "scenario/article03/exhaustion/further-loss",
              "sourcePaneId": "outputs-further-loss"
            },
            {
              "label": "脈圧",
              "order": 10,
              "outputId": "hemodynamics.pressure.pulse.Ao",
              "scenarioId": "scenario/article03/exhaustion/further-loss",
              "sourcePaneId": "outputs-further-loss"
            },
            {
              "label": "平均右房圧",
              "order": 11,
              "outputId": "hemodynamics.pressure.mean.RA",
              "scenarioId": "scenario/article03/exhaustion/further-loss",
              "sourcePaneId": "outputs-further-loss"
            },
            {
              "label": "1回拍出量",
              "order": 12,
              "outputId": "hemodynamics.stroke-volume.LV-extrema",
              "scenarioId": "scenario/article03/exhaustion/further-loss",
              "sourcePaneId": "outputs-further-loss"
            },
            {
              "label": "心拍出量",
              "order": 13,
              "outputId": "hemodynamics.output.native-left",
              "scenarioId": "scenario/article03/exhaustion/further-loss",
              "sourcePaneId": "outputs-further-loss"
            }
          ],
          "scenarioScope": {
            "initialFocusScenarioId": "scenario/article03/exhaustion/further-loss",
            "visibleScenarioIds": [
              "scenario/article03/exhaustion/compensated",
              "scenario/article03/exhaustion/further-loss"
            ]
          }
        },
        "caption": null,
        "placementId": "placement/authoring/a1039103-0003-4003-8003-000000000003",
        "schemaId": "circleheart-studio-experiment-placement-v2",
        "snapshotId": "2390f3cd-3be3-4302-a126-7bb48d99b731",
        "titleOverride": null
      }
    },
    {
      "blockId": "article03/p/experiment-3-result-1",
      "kind": "paragraph",
      "text": "モデルでは平均動脈圧が98.8から91.6 mmHgへ、心拍出量が5.18から4.82 L/minへ低下しました。収縮期血圧は120.3から112.6 mmHgです。"
    },
    {
      "blockId": "article03/p/experiment-3-result-2",
      "kind": "paragraph",
      "text": "この結果を「ある点から必ず突然崩れる」と一般化してはいけません。今回のモデル出力が示すのは、動かせるcontrolを上限まで使ったあとでは、追加出血に対して同じ代償を上積みできず、圧と流量が再び下がるということです。"
    },
    {
      "blockId": "article03/p/experiment-3-result-3",
      "kind": "paragraph",
      "text": "臨床では代償反応が連続的に変わり、出血速度、麻酔、薬剤、心機能、年齢によって経過が異なります。血圧低下を待って出血を認識するのでは遅い場合があります。"
    },
    {
      "blockId": "article03/h2/clinical",
      "kind": "heading",
      "level": 2,
      "text": "臨床では「代償の指紋」を探す"
    },
    {
      "blockId": "article03/p/clinical-pattern",
      "kind": "paragraph",
      "text": "・脈圧が狭い：1回拍出量が少ない可能性を考える。\n・拡張期血圧が高め：末梢血管収縮が働いている可能性を考える。\n・心拍数が速い：回数で心拍出量を補っている可能性を考える。\n・末梢冷感、毛細血管再充満遅延、意識変化、乏尿：圧だけでは見えない灌流を確認する。\n・ドレーン、創部、画像、Hbの推移：出血の根拠を直接探す。"
    },
    {
      "blockId": "article03/p/clinical-caution",
      "kind": "paragraph",
      "text": "これらは出血の診断基準ではありません。心拍数110 /min、血圧112/92 mmHgという情報だけで結論を出さず、出血量、診察、経時変化を確認するための手がかりです。"
    },
    {
      "blockId": "article03/h2/transfer",
      "kind": "heading",
      "level": 2,
      "text": "転移課題：全身麻酔中なら、どう見えるか"
    },
    {
      "blockId": "article03/quiz/transfer",
      "choices": [
        {
          "choiceId": "transfer/early",
          "label": "早く現れうる"
        },
        {
          "choiceId": "transfer/late",
          "label": "遅く現れる"
        },
        {
          "choiceId": "transfer/same",
          "label": "必ず同じ"
        }
      ],
      "correctChoiceId": "transfer/early",
      "explanation": "覚醒時なら使えた動脈収縮と静脈収縮の余地が小さくなるためです。ただし導入後低血圧の原因は出血だけではありません。",
      "kind": "quiz",
      "question": "動脈・静脈トーヌスを下げうる全身麻酔中では、同じ出血が血圧に現れるのは覚醒時より早いでしょうか？"
    },
    {
      "blockId": "article03/accordion/transfer",
      "blocks": [
        {
          "blockId": "article03/accordion/transfer/p1",
          "kind": "paragraph",
          "text": "覚醒中に代償で隠れていた循環血液量不足が、麻酔導入後に顕在化することがあります。一方、薬剤性血管拡張、心筋抑制、陽圧換気でも血圧は下がります。経過、診察、出血の直接所見を合わせて鑑別します。"
        }
      ],
      "kind": "accordion",
      "title": "臨床への接続：麻酔導入後低血圧を一因だけで説明しない"
    },
    {
      "blockId": "article03/accordion/limitations",
      "blocks": [
        {
          "blockId": "article03/accordion/limitations/p1",
          "kind": "paragraph",
          "text": "このモデルには圧受容体反射がなく、出血に応じた頻脈や自動的な血管収縮は起きません。記事では動脈収縮と静脈収縮を手動で加えました。心拍数は一定です。"
        },
        {
          "blockId": "article03/accordion/limitations/p2",
          "kind": "paragraph",
          "text": "ヘモグロビン濃度、酸素運搬、乳酸、凝固、出血速度、組織ごとの血流再配分は含まれません。表示値は教育用モデルの出力であり、患者のショック分類、輸液・輸血の閾値、治療効果を予測するものではありません。"
        }
      ],
      "kind": "accordion",
      "title": "このシミュレーションの限界"
    },
    {
      "blockId": "article03/h2/summary",
      "kind": "heading",
      "level": 2,
      "text": "3つだけ思い出す"
    },
    {
      "blockId": "article03/p/summary",
      "kind": "paragraph",
      "text": "1. 出血の影響はstressed volumeと静脈還流の低下から始まる。\n2. 動脈収縮と静脈収縮は血圧を支えられるが、循環血液量を元に戻したわけではない。\n3. 正常範囲の血圧だけでは出血を否定できない。代償の所見と灌流、出血の直接所見を合わせて読む。"
    },
    {
      "blockId": "article03/quiz/retrieval-1",
      "choices": [
        {
          "choiceId": "retrieval-1/flow",
          "label": "圧を作っても、少ない1回拍出量は戻っていなかったから"
        },
        {
          "choiceId": "retrieval-1/blood",
          "label": "循環血液量がさらに減ったから"
        },
        {
          "choiceId": "retrieval-1/hr",
          "label": "心拍数が上がったから"
        }
      ],
      "correctChoiceId": "retrieval-1/flow",
      "explanation": "動脈収縮は少ない流量から圧を作りますが、心拍出量や1回拍出量を直接回復させる介入ではありません。",
      "kind": "quiz",
      "question": "体血管抵抗を上げたあとも脈圧が狭かったのはなぜでしょうか？"
    },
    {
      "blockId": "article03/quiz/retrieval-2",
      "choices": [
        {
          "choiceId": "retrieval-2/tachy",
          "label": "頻脈"
        },
        {
          "choiceId": "retrieval-2/narrow",
          "label": "脈圧狭小"
        },
        {
          "choiceId": "retrieval-2/cold",
          "label": "末梢冷感"
        }
      ],
      "correctChoiceId": "retrieval-2/tachy",
      "explanation": "頻脈が出にくいため、心拍数が正常だから大丈夫とは判断できません。",
      "kind": "quiz",
      "question": "β遮断薬を使用している患者では、どの代償所見が目立ちにくくなるでしょうか？"
    },
    {
      "blockId": "article03/h2/links",
      "kind": "heading",
      "level": 2,
      "text": "前提を確認する"
    },
    {
      "blockId": "article03/link/article01",
      "description": "平均血圧と脈圧を分けて、血圧の2つの成分を読みます。",
      "href": "/ja/articles/e9c99f89-bf71-4294-9178-485ac684a906",
      "kind": "link",
      "label": "血圧はどうやって決まるのか"
    },
    {
      "blockId": "article03/link/article02",
      "description": "stressed volume、静脈還流、Starling曲線から前負荷をたどります。",
      "href": "/ja/articles/9736c56b-82a4-4e71-afde-f990896c6f4d",
      "kind": "link",
      "label": "輸液で血圧が上がるのはなぜか"
    }
  ],
  "locale": "ja",
  "publicSlug": "article-ff7a0f40-b9fc-4e6b-9878-b0ed4802e143",
  "publishedAt": "2026-08-13T00:06:48.634569Z",
  "schemaId": "circleheart-studio-published-article-v1",
  "title": "出血のとき体で何が起きているか——「血圧は正常です」に騙されないために",
  "updatedAt": "2026-08-13T00:06:48.634569Z"
}