腹腔内压力测定在危重患者中的应用.ppt

单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,腹内高压症与监测,腹内高压症和,ACS,1,腹内高压症的危险因素,2,腹内高压症的病理生理改变,3,腹内压监测的方法,4,概念和定义,腹内压,(IAP),隐藏在腹腔内的压力,.,腹腔内压力（,IAP,）主要由腹腔内脏器的静水压产生,.,正常时接近零,.,腹腔内高压,(IAH),腹内压持续或反复,12 mm Hg(,经常导致隐匿性缺血,),，无器官衰竭,腹腔间隔室综合征,(ACS),腹内压持续,20 mm Hg,，伴随新器官功能障碍或衰竭,Diagram,多器官衰竭,器官功能障碍,腹腔压力增高,正常生理状态,MODS,ACS,腹腔内高压症,正常腹内压,腹腔内高压的高危因素,Title,腹部手术后,向心性肥胖,腹腔内容物增加,脓毒症,肠腔内容物增加,毛细血管渗漏,腹腔内高压症的病理生理改变,呼吸,高通气阻力,低氧血症,高碳酸血症,循环,心脏顺应性降低，,CO,下降,下肢回心血量减少,CVP,增高,肾脏,肾血流减少,肾小球，肾小管功能障碍,肾功能衰竭,腹腔内高压症的病理生理改变,脑,ICP,增高,CPP,降低,肝脏,肝动脉，肝静脉，门静脉血流减少,肝功能障碍,胃肠道,动脉缺血，静脉淤血,肠道水肿，,细菌，毒素移位,什么是腹腔内高压的主要原因,?,液体,!,5,升多的液体从哪里进入到体内,?,脑,?,肺,?,皮肤,/,软组织,?,肠道,/,肠系膜,.,.,液体都在这里,!,这就是当腹腔内高压没有检测到，演变成腹腔间隔室综合征发生的状况。,Brain:,IAP elevation can directly contribute to ICP elevation.,Lungs:,IAP pushes diaphragms into chest,raising intrathoracic pressure causing an increase in barotrauma,hypercarbia and hypoxemia.This results in increased time on the ventilator with increases in VAP.,Intestines:,IAP compromises intestinal blood flow resulting in ischemia,necrosis and multisystem organ failure.,Heart:,Cardiac monitoring,including CVP and PCWP,are artificially elevated by IAP making them difficult to interpret in the IAH setting.,Kidneys:,Reduced kidney perfusion and urine production results in inability to mobilize fluids and increased rates of renal insufficiency/failure.,Vena Cava Compression:,IAP greater than 8-12 mm Hg results in reduced blood flow(preload)to the heart.,Most critically ill patients have a significant systemic inflammatory response(SIRS)that triggers the release of cytokines leading to capillary permeability and interstitial edema.Abdominal viscera are particularly vulnerable as tissue edema worsens with the third spacing of resuscitative fluid.As visceral edema worsens intra-abdominal pressure(IAP)increases.As IAP increases perfusion to abdominal organs decreases resulting in compromise to visceral blood flow and tissue ischemia.Tissue ischemia then perpetuates further cytokine release and worsening systemic inflammation thus initiating the,vicious cycle,.,Intra-Abdominal Hypertension(IAH)is defined as Intra-Abdominal Pressure(IAP)above 12 mm Hg.At which point significant tissue perfusion problems arise,which can lead to early organ dysfunction.An IAP level over 20 mm Hg typically causes organ failure and is called Abdominal Compartment Syndrome,As IAP exceeds 15 to 20 mm Hg capillary blood flow is dramatically reduced,leading to anaerobic metabolism,increased cytokine production and exacerbation of capillary permeability(worsening bowel edema).At IAP levels approaching 20 mm Hg venous return to the heart is impaired reducing cardiac output.Decreases in systemic blood flow(CO)compounds the insult of direct tissue ischemia perpetuating the,vicious cycle,.,Intra-Abdominal Pressure,Intra-Abdominal Hypertension,不测量腹内压的危险,晚监测,=,晚识别,晚识别,=,晚干预,晚干预,=,有限的治疗选择,有限的选择,=,不良结果,预期的，双盲实验,医师判断,结果,:,小于,50%,的时间医生能够确定何时腹内压升高,检测腹腔内高压，临床判断有多好,?,Kirkpatrick,Can J Surg 2000,腹内压监测的意义,对于,ICU,的危重病人，,IAH,是很常见的,IAH,不能被临床检查出来,.,检测,IAH,的唯一方法是测量腹内压。,IAH/ACS,的预后与干预时机密切相关,检测,/,干预延迟导致成本提高，病人的预后差,检测,/,干预延迟导致更高的死亡率,积极的非手术干预缩短住院时间、改善预后,腹腔内压力监测的方法,直接测压法,临床少用,测压方法,间接测压法,膀胱内压力测定最常用,腹腔内压测定方法,患者平卧位，在膀胱内置入,Foley,导尿管，排空膀胱内尿液，注入,25-50ml,无菌生理盐水，通过三通管与压力换能器相连，换能器以耻骨联合处为调零点，联接美国,DASH4000,监护仪，先行校零后，打开三通，在监护仪上读取压力值，单位为,mmHg,。,AbViser,腹内压监测系统,AbViser,腹内压监测系统,AutoValve,无需阻断和三通,一步操作节省医生时间,标准化的腹内压测量,always done the say way by each user,手术室兼容,数据协助医生完成剖腹手术,经验证的准确性，重复性和安全性,完整的腹内压监测系统,腹内压监测和干预的国际性推荐：,腹高压的评估方法,病人转入,ICU,之后应该评估发生,IAH/ACS,的风险，同时评估是否有新的器官衰竭或加重危险因素。,如果存在两个或两个以上风险因素，则应进行腹内压（,IAP,）监测。,如果存在腹高压（,IAH,），那么在病人危重期间应该定时进行腹内压（,IAP,）测量。,IAH Grading,Grade IAP 12-15mmHg,Grade IAP 16-20mmHg,Grade IAP 21-25mmHg,Grade IAP25mmHg,IAH/ACS,处理流程,腹内压持续,12mmHg,是：明确诊断腹高压,通知主管医护人员评估,IAP,。按照,IAH/ACS,流程处理,否：病人没有,IAH,继续观察病人。如果病人的情况恶化，再次测量腹内压,IAH/ACS,处理流程,下列治疗方案的选择（和成功）是和病人的,IAH/ACS,病因和临床情况紧密相关的。对于任何个体病人，干预实施前都应考虑干预措施是否合适。,干预应当以渐进形式应用，直到病人的腹内压（,IAP,）下降。,如果没有达到预期的治疗效果，治疗应当升级到流程的下一步,腹内压测量注意事项：,以毫米汞柱表示（,1mmHg=1.36 cm H2O,）,在呼气末期测量,在仰卧位操作,在髂骨处腋中线位校零,注射不超过,25ml,生理盐水,儿童 每公斤,1,毫升，最多,20,毫升,（膀胱测压技术）,灌注,30-60,秒后测量，使逼尿肌放松（膀胱测压技术）,在没有明显腹部肌肉收缩的情况下测量,可能的并发症,主要和导尿管相关并发症包括：,尿道损伤,尿路感染,堵塞,结石,脱落等,效益,腹内压监测技术是三级医院一般性项目；,消化胃肠压力测定,500,元,/24h,膀胱内静压监测包中标价：,760,元,Thank You!,qhbcxl,