腹腔压力监测---腹腔高压及腹间隔室综和征的诊治.ppt

Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,首都医科大学附属北京同仁医院,ICU,腹腔高压及腹间隔室综和征的诊治,概要,IAH/ACS,的治疗,IAP,监测的影响因素,IAP,的监测方法,IAH/ACS,对脏器功能的影响,腹腔高压的相关概念,几个概念,IAP,IAH,ACS,腹腔内压力,Intra-abdominal Pressure,正常,IAP:0-5 mm Hg,腹腔高压症,Intra-abdominal,Hypertension,IAP12 mm Hg*,腹间隔室综合征,Abdominal Compartment Syndrome,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,IAP,决定于,脏器容积,占位性损伤,出血 积液 肿瘤,腹壁顺应性,Definition of WSACS,WSACS,Current opinion in Critical Care.2005,11(2):156-171.,正常值,Patient population,Number,IAP(mean SD),Sugerman,UC,5,5.1 1.2,Sanchez,S-NS,27,5.0 2.9,Chionh,S-NS,58,7.0(0.73.2),Lambert,ELS,4,0.0 1.5,Arfvidsson,GS,4,6.2 1.2,WSACS,：,5-7mmHg,Intensive Care Med(2009)35:969976,正常值,Comparison of IAP among different weight groups,Intensive Care Med(2009)35:969976,7-14mmHg,IAH,发病率,IAH,发生率约,50%,ACS,病死率：,40-100,IAP,正常,67.9,IAH 32.1%,ACS 4.2%,IAH,中发生,ACS 12.9,Malbrain,ML,Chiumello,D,Pelosi P,et al.CCM,2005,33(2):315-322,IAP,Total,Prevalence,MICU,Prevalence,SICU,Prevalence,IAP12,58.8%,54.5%,65%,IAP15,28.9%,29.8%,27.5%,IAP20,Plus organ failure,8.2%,10.5%,5.0%,Malbrain,Intensive Care Medicine(2004):,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,*,Cheatham ML,White MW,Sagraves,SG,et al,.J Trauma 2000;49:621-626.,概要,IAH/ACS,的治疗,IAP,监测的影响因素,IAP,的监测方法,IAH/ACS,对脏器功能的影响,腹腔高压的相关概念,ACS and MODS,Malbrain,ML,Deeren,D,De Potter,et al.Current opinion in Critical Care.2005,11(2):156-171.,ACS,：,IAH+,器官功能障碍,ACS and MODS,ACS,IAP-MODS-DEATH,呼吸,循环肾脏,t,颅脑,胃肠,其它,ACS and MODS,Malbrain,ML,Chiumello,D,Pelosi P,et al.CCM,2005,33(2):315-322,IAP,越高,器官衰竭的数目越多,ACS and MODS,腹胀,CO,Ppeak,肺顺应性,少尿,无尿,ACS,IAP,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,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,ACS and MODS,循环系统,ACS and MODS,循环系统,IAH,增加对前负荷评估的难度,CVP?,PAWP?,CO?,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。,膈肌抬高,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。,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。,肺不张,肺泡水肿,Alexander,Schachtrupp,Juergen,Graf,Christian Tons,et al.J Trauma.2003;55:734 740.,ACS and MODS,呼吸系统,血管外肺水增加,气道峰压升高,ACS and MODS,呼吸系统,Malbrain,ML.,Currunt,Opinion of Critical Care.2004,10(2):132-145,呼吸系统静态顺应性降低,有认为：,IAP 25mmHg,是肾衰最敏感、特异性最高的指标之一。,FG(,肾脏滤过压,)=MAP-,2,IAP,ACS and MODS,肾功能,少尿，,Cr,BUN,CCr,肾素、醛固酮、,ADH,ACS and MODS,肾功能,Alexander,Schachtrupp,Juergen,Graf,Christian Tons,et al.J Trauma.2003;55:734 740.,ACS and MODS,肾功能,尿量减少,Circling the Drain,Intra-abdominal Pressure,Mucosal,Breakdown,(Multi-System Organ Failure),Bacterial translocation,Acidosis,Decreased O2 delivery,Anaerobic metabolism,Capillary leak,Free radical formation,MSOF,腹腔压力（,IAP,）,监测与,EN,0,5,10,15,20,25,30,35,40,45,1,3,5,7,9,11,13,15,17,19,21,23,25,27,TPN,EN+PN,IAP,（,cmH2O,）,天,腹壁,腹腔内压力的增高直接压迫腹壁组织，使腹壁组织的血液供应减少造成腹壁的缺血和水肿。,IAH,病人伤口并发症发生明显增加。,有效控制术后病人,IAH,，是预防术后伤口并发症的重要环节。,ACS and MODS,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,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 and MODS,神经系统,颅内压,(ICP),与,IAP,Joseph DA,Dutton RP,Aarabi,B,et al.Trauma,2004,57(4):687-695.,腹腔减压术前后参数改变,IAH/ACS,减压手术后生存率,2006,71%,2005,65%,2004,54%,2003,57%,2002,51,Cheatham&,Safcsak,Acta,Clinica,Belgica,2007;62(Supplement1):268,可逆性：依赖,监测早、发现早、处理早,Critical care med,2006,概要,IAH/ACS,的治疗,IAP,监测的影响因素,IAP,的监测方法,IAH/ACS,对脏器功能的影响,腹腔高压的相关概念,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,测,压,直接测压法,腹部或腹膜后手术中,14-F PVC,圆形引流管,E.,Risin,The American Journal of,Srugery,191(2006)235-237,下腔静脉压力测定方法,经股静脉插管测定下腔静脉压力,放置股静脉导管，导管尖端位置应达到肾血管水平，测量方法同中心静脉压测定,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,导管相关性感染,经胃测压法,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,带气囊导管，注入气体,3ml,胃腔内自身液体影响，,EN,影响，胃壁较厚，影响测量结果,研究少,Waele,Intensive care med,2007,膀胱内压力测定方法,（,transvesical,catheter,）,Simple,quick,and inexpensive,Kron,first described modern IAP,monitoring in 1984,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。,经膀胱测压法,-,ORIGINAL KRON TECHNIQUE,禁忌,神经性膀胱,膀胱损伤,膀胱挛缩,Malbrain,ML,Deeren,D,De Potter,et al.Current opinion in Critical Care.2005,11(2):156-171.,经膀胱压力测定法,留置,Foley,尿管，平卧位,回路连接,NS,袋,(,无需肝素,),连接测压管：,2-way-,连接,18,号针头,3-way,连接,Y,型管,测压前保证尿液引流通畅，膀胱排空，夹闭尿管,60ml,注射器向膀胱内注入,NS.50-100ml,每次测量前膀胱内液体相等,传感器零点位置,关闭注射器连接阀，读取平均压力,q 2-4 hours,监测一次,.,无菌 操作,经膀胱压力测定法,经膀胱压力测定法,In mmHg,(1 mmHg=1.36 cm H2O),平卧位,呼气末测量,腋中线为零点,注意事项,30-60,秒平衡时间,(to allow bladder,detrusor,muscle relaxation),无腹肌紧张情况下,经膀胱压力测定法,概要,IAH/ACS,的治疗,IAP,监测的影响因素,IAP,的监测方法,IAH/ACS,对脏器功能的影响,腹腔高压的相关概念,充盈盐水量对,IAP,的影响,Chiumello,et al.Critical Care 2007,11.,N=13,N=20,adult,充盈盐水量对,IAP,的影响,一次注入盐水量最多不超过,25ml,-,World Society on Abdominal Compartment Syndrome(WSACS)recommends,注射后平衡时间的影响,Chiumello,et al.Critical Care 2007,11.,*,*,注射即刻,注射后,5min,胃内压力,注射盐水温度的影响,Chiumello,et al.Critical Care 2007,11.,室温,加热至体温,Zero reference point,N=132 supine position,Three reference levels were studied:,耻骨联合（,the,symphysis,pubis,）,胸骨中线（,the,phlebostatic,axis:,(or,mid-chest reference level),髂前上嵴腋中线（,the,midaxillary,line at the level of the iliac,）,IAPphlebostatic(9.9 4.67 mmHg),*,IAPpubis,(8.4 4.60,mmHg),*,IAPmidax,(12.2 4.66 mmHg),p,0.0001,零点位置,2,3,耻骨联合,Symphysis,pubis,测量,IAP,的传统位置,胸骨中线,Phlebostatic,axis,精确性较差,血流动力学监测的传统位置,髂前上嵴腋中线,Mid-,axillary,line at iliac crest,最为精确,可重复性好,1,Journal of Surgical Research,139,280285(2007),IAP in,defferent,HOB and BMI,P12mmHg,PEEP and IAP?,PEEP and IAP,N=30,IAP-Original method by,Kron,.,5min interval,5Kg to the patients belly,PEEP:010,CLINICS 2009;64(2):105-12,Mild IAH,IAH 10%,0.001,0.001,0.005,0.001,0.165,0.001,P,值,CLINICS 2009;64(2):105-12,PEEP and IAP,IAH 10%,PEEP 15,IAH 10%,0.001,0.001,0.001,0.165,P,值,CLINICS 2009;64(2):105-12,PEEP and IAP,IAH 10%,0.001,0.005,0.001,0.001,P,值,p=0.47,P0.001,CLINICS 2009;64(2):105-12,PEEP and IAP,IAH,可使气道平台压升高,.,对于应用,PEEP,的机械通气病人，平台压并不能单独作为,IAP,升高的理想指标,但对这些病人应该监测,IAP.,CLINICS 2009;64(2):105-12,PEEP and IAP,概要,IAH/ACS,的治疗,IAP,监测的影响因素,IAP,的监测方法,IAH/ACS,对脏器功能的影响,腹腔高压的相关概念,IAH/ACS,的临床分级,UBP35cmH2O,UBP 2635cmH2O,UBP 1625cmH2O,级,级,级,级,无临床器官功能损害表现,UBP 1015cmH2O,出现临床器官功能损害表现,多数患者出现器官损害表现,、,级患者应进行手术治疗。,均出现器官损害表现,Burch JM,Moore EE,Moore FA,et al,.,Surg,Clin,North Am 1996;76:833-842.,University of Utah:IAP Monitoring Protocol,IAP monitoring Q1-2 hours for first,12 hours,IAP,consistently,20 mm Hg,OR,APP 50-60 mm Hg?,Plus evidence of,organ dysfunction/,ischemia(ACS),Optimize Abdominal perfusion pressure,Careful fluid management,Pressors,Reduce IAP,measurements,to Q4-6 hours,for 24 hours,“Second Hit”pt.,develops new,indication for IAP,monitoring,IAP remains,12 mm Hg,discontinue,monitoring,Consider Medical Management,Sedation/Neuromuscular blockade,Paracentesis of free fluid,Other options,Gastric suction,cathartics,Rectal tube/enemas,Continuous filtration,Colloids,Surgical,Decompression,ACS,治疗,腹腔减压术,B,E,C,D,A,胃肠减压,胃肠动力药物,CRRT,灌肠导泻,引流腹腔积液,ACS,治疗,Balogh,Z,McKinley BA,Holcomb JB.Trauma,2003,54(5):848-861,Balogh,Zsolt,MD;McKinley,Bruce A.PhD;Holcomb,John B.MD;Trauma,2003,54(5):848-861,不要等发现,ACS,的临床表现再在决定进行,IAP,测定,By then the patient has one foot in the grave!,You have lost your opportunity for medical therapy,对所有所有高腹压风险病人进行,及早、动态,的腹压监测：,视腹压测定为重要生命体征观察的一部分,在严重高腹压发生前早期干预,Thank You!,