腹腔高压症及腹腔压力监测在危重病人中的应用[1].ppt

1、腹腔高压症及腹腔压力监测,彭 沪,背景,19世纪后期，Eddy 1890年，Heinricius 1951年，Baggot 1984年，Kron,Results from the International Conference of Experts on Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome (ACS),DEFINITIONS Intensive Care Medicine 2006; 32:1722-1732 ,INTRODUCTION TO THE DEFINI

2、TIONS,Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill as causes of significant morbidity and mortality. The variety of previous definitions has led to confusion and difficulty in comparing one study to another. An in

3、ternational group of critical care specialists convened to standardize definitions for both IAH and ACS as well as establish standards for the measurement of intra-abdominal pressure (IAP). ,WHAT IS INTRA-ABDOMINAL PRESSURE?,Elevated IAP is a common finding in the ICU IAP increases and

4、decreases with respiration IAP is directly affected by: Solid organ or hollow viscera volume Space occupying lesions Ascites, blood, fluid, tumors Conditions that limit expansion of the abdominal wall Burn eschars, third-space edema,,WHAT IS ABDOMINAL PERFUSION PRESSURE?,“Abdominal perf

5、usion pressure (APP) = mean arterial pressure (MAP) minus intra-abdominal pressure (IAP) = MAP - IAP.” The critical IAP that leads to organ failure varies by patient A single threshold IAP cannot be globally applied to all patients Analogous to cerebral perfusion pressure, APP assesses not only the

6、severity of IAP, but also the relative adequacy of abdominal blood flow APP is superior to IAP, arterial pH, base deficit, and arterial lactate in predicting organ failure and patient outcome Failure to maintain APP 60 mmHg by day 3 predicts survival,,HOW SHOULD IAP BE MEASURED?,“IAP sh

7、ould be expressed in mmHg and measured at end-expiration in the complete supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the midaxillary line.” Physical exam is inaccurate in predicting IAP Sensitivity 40-61% Positive predic

8、tive value 45-76% IAP measurements are essential to the diagnosis of elevated IAP and the management of IAH A variety of techniques may be used to measure IAP,,WHAT IS THE REFERENCE STANDARD FOR IAP?,“The reference standard for intermittent IAP measurement is via the bladder with a maxi

9、mal instillation volume of 25ml sterile saline.”,,WHAT IS NORMAL IAP?,“Normal IAP is approximately 5-7 mmHg in critically ill adults.”,,WHAT IS INTRA-ABDOMINAL HYPERTENSION?,“IAH is defined by a sustained or repeated pathological elevation in IAP 12mmHg.” The definition of

10、IAH has varied over the years with thresholds as high as 40 mmHg being previously advocated. Most clinicians are therefore concerned only when IAP exceeds 20-25 mmHg This is well above the IAP that can cause organ dysfunction and failure Failure to intervene when IAP rises above 25 mmHg is associate

11、d with poorer outcome,,HOW IS IAH GRADED?,“IAH is graded as follows: Grade IIAP 12 - 15 mmHg Grade IIIAP 16 - 20 mmHg Grade III IAP 21 - 25 mmHg Grade IV IAP 25mmHg.” The IAH grades have been revised downward as the detrimental impact of elevated IAP on end-organ function has been recog

12、nized,,WHAT IS ABDOMINAL COMPARTMENT SYNDROME?,“ACS is defined as a sustained IAP 20mmHg (with or without an APP 60mmHg) that is associated with new organ dysfunction/ failure.” ACS = IAH + organ dysfunction The most common organ dysfunction / failure(s) are: Metabolic acidosis despite

13、resuscitation Oliguria despite volume repletion Elevated peak airway pressures Hypercarbia refractory to increased ventilation Hypoxemia refractory to oxygen and PEEP Intracranial hypertension,,WHAT IS PRIMARY ACS?,“Primary ACS is a condition associated with injury or disease in the abd

14、ominopelvic region that frequently requires early surgical or interventional radiological intervention.”,Traumatic InjuryAscites / Fluid Abdominal Tumor,,WHAT IS SECONDARY ACS?,“Secondary ACS refers to conditions that do not originate from the abdominopelvic region.”,Sepsis / Burns Mass

15、ive Capillary Leak Resuscitation,,WHAT IS RECURRENT ACS?,“Recurrent ACS refers to the condition in which ACS redevelops following previous surgical or medical treatment of primary or secondary ACS.” Following damage control laparotomy and a temporary abdominal closure (TAC), a patients

16、IAH recurred (IAP 24 mmHg, APP 46 mmHg) accompanied by decreased urinary output. Revision of the TAC allowed the edematous viscera to decompress resulting in resolution of the IAH (IAP 13 mmHg, APP 67 mmHg) and restoration of adequate renal function.,,腹腔内压力 (Intra-abdominal Pressure, IA

17、P ) 腹腔高压症 (Intra-abdominal Hypertension, IAH ) IAP12 mm Hg * 腹间隔室综合征 (Abdominal Compartment Syndrome, ACS ) IAP =20 mm Hg * 出现一个或多个脏器功能衰竭,*Malbrain M L; Deeren D; De Potter, et al. .Current opinion in Critical Care. 2005,11(2):156-171 .,IAH/ACS 表现,特征性变化 腹胀 心输出量（CO）下降 肺顺应性下降，气道峰压(Ppeak)急剧升高 少尿或无尿,病因及

18、流行病学,病因及流行病学,The higher the IAP, the poorer the survival rate,Malbrain ML, Chiumello D, Pelosi P, et al. CCM, 2005, 33(2) :315-322,预测病人死亡率的独立危险因素 年龄 APACHE 收入ICU类型 有无肝功能不全 ICU期间发生IAH 入院第一日IAP12mmHg APP(腹腔灌注压)=MAP-IAP,Malbrain ML, Chiumello D, Pelosi P, et al. CCM, 2005, 33(2) :315-322,病因及流行病学,*Cheat

19、ham ML, White MW, Sagraves SG, et al. J Trauma 2000; 49:621-626.,病因及流行病学,IAH独立预测因素（independent predictors） 肝功能不全 腹部手术 液体复苏 肠麻痹 -高度警惕IAH的发生！,Malbrain ML, Chiumello D, Pelosi P, et al. CCM, 2005, 33(2) :315-322,IAP监测方法,腹腔压力测定,经 膀 胱 测 压 法,间接测压法,直接测压法,下 腔 静 脉 压,经 胃 测 压 法,经 直 肠 测 压 法,穿 刺 直 接 测 压,经 腹 引 管

20、测 压,膀胱内压力测定方法 （urinary bladder pressure, UBP） Kron等在1984年提出并推广应用。 原理：膀胱内有50100ml液体时膀胱壁会象膈肌一样反映IAP的变化。,IAP监测方法,IAP监测方法,股静脉/下腔静脉压力测定方法 经股静脉（或下腔静脉）插管测定下腔静脉压力 与腹内压力变化以及经腹腔直接测定、经膀胱压力测定结果有较好的相关性 股静脉及下腔静脉血流与IAP呈负相关性改变，即虽着IAP增高而降低,IAP监测方法,胃内压力测定方法 经鼻胃管向胃内注入50-100ml生理盐水，连接传感器或压力计，以腋中线为零点进行测量。,IAP监测方法,患者取仰卧位，

21、适当镇静与肌松，镇静与肌松的程度以能消除腹肌收缩为标准，留置导尿，排空膀胱内尿液。 将导尿管与连有500ml生理盐水的输液皮条连接，往导尿管内持续滴注注射约25ml生理盐水。 将输液皮条拔出生理盐水袋，静置30 60秒，在以腋中线为0点，测量皮条内液体高度，读取呼气末数值，即为腹内压值。 ,循环系统,ACS and MODS,胸腔内压力 静脉回心血量 外周血管阻力,IAP 机械性压迫,心输出量,下腔静脉、门静脉和腹膜后静脉血流减少 膈肌升高，下腔静脉发生扭曲、狭窄,ACS and MODS,循环系统 IAP为2025mmHg时，出现CO/CI明显下降，HR增快， BP

22、降低，CVP仍升高 IAH 增加对前负荷评估的难度 CVP? CO?,Alexander Schachtrupp, Juergen Graf, Christian Tons, et al. J Trauma. 003;55:734 740.,ACS and MODS 循环系统,CVP升高,心输出量(CO)下降,Alexander Schachtrupp, Juergen Graf, Christian Tons, et al. J Trauma. 2003;55:734 740.,ACS and MODS 循环系统,胸腔内血流量(ITBV)降低,总循环血量(TCBV)降低,Alexander

23、Schachtrupp, Juergen Graf, Christian Tons, et al. J Trauma. 2003;55:734 740.,ACS and MODS 循环系统,CO 与 ITBV,CO 与 CVP,ACS and MODS,呼吸系统 最早和显著的临床表现。 Ppeak升高，肺顺应性下降，P/F下降，高碳酸血症。,ACS and MODS,呼吸系统 呼吸系统总静态顺应性 PV 曲线变平并右移 IAP 升高时，IAP与PV曲线下拐点呈正相关关系。 肺中性粒细胞激活，肺脏炎性渗出增加 肺泡水肿及压缩性肺不张,Malbrain ML, Deeren D, Nieuwend

24、ijk R, et al. Intensive Care Med 2003; 29:S85.,Alexander Schachtrupp, Juergen Graf, Christian Tons, et al. J Trauma. 2003;55:734 740.,ACS and MODS 呼吸系统,ACS and MODS,主动脉和肾动脉受压， 肾脏毛细血管网阻力升高， 肾静脉回流受阻 输尿管受压,IAP 机械性压迫,肾动脉的灌注血量减少， 肾皮质的血流分流到髓质， 致使肾小球的有效滤过率下降，尿的生成减少,肾功能 FG(肾脏滤过压)=MAP-2IAP,ACS and MODS,肾功能 少

25、尿，Cr, BUN, CCr 肾素、醛固酮、ADH,Alexander Schachtrupp, Juergen Graf, Christian Tons, et al. J Trauma. 2003;55:734 740.,ACS and MODS 肾功能,尿量减少,ACS and MODS -肾功能,Balogh, Z, McKinley BA, Holcomb JB. Trauma, 2003, 54(5):848-861,ACS and MODS -肾功能,Lindstrm P, Wadstrm J, Ollerstam A, et al. Nephrology Dialysis Tr

26、ansplantation, 2003, 18(11):2269-2277.,胃肠道 大量动物实验证实小肠血流量与IAH有关，IAP 升至10 mmHg，胃肠道灌注减少细菌移位 内脏受压，内脏缺血。 研究显示IAH刺激促炎介质的释放 门静脉及中心静脉细胞因子水平显著升高 肠道喂养困难,Friedlander MH, Simon RJ, Ivatury R, et al. J Trauma 1998; 45:433-489.,ACS and MODS,腹腔压力（IAP）监测与EN,神经系统 IAP25mmHg时出现 ICP-颅内压力升高，与IAP成正相关。 CPP-脑灌注压降低，CPP=MAP-ICP 胸腔内压和CVP增高使脑组织静脉血回流受阻，颅内血管床扩大所致 CPP下降，颅内损害加重 头部创伤病人应谨慎使用腹腔镜诊治，并应监测IAP,ACS and MODS,Deeren D, Leijs J, Van den Brande E, et al. Crit Care Med in press.,ACS a