腹腔间隙综合征中文.ppt

腹腔内高压与腹腔间隙综合症Intra-AbdominalHypertension(IAH)31supp11:S183Abs703,*ThesedataareforALLsepsispatients.MUCHhigherifyoulookonlyatmajorfluidresuscitation.,休克和液体复苏患者的发病率？,Requeira,2007:脓毒性休克患者ACS的发病率.51%incidenceofIAP20mmHginsepticshockDaugherty,2007:ACS常见于ICU中需要大量液体复苏的患者.85%ofpatientswith5literspositivefluidbalancehadIAH30%hadIAP20withorganfailure(abdominalcompartmentsyndrome),临床判断IAP升高的措施究竟有多少用处呢?,随机-双盲的研究结果:12死亡率38.8%无IAH-死亡率:22.2%,Malbrain,CritCareMed,2005,内外危重ICU患者,IAH/ACS会影响患者结局吗?,Al-Bahrani,2008:重症胰腺炎患者腹内高压的临床相关性.18例重症胰腺炎7(39%)例IAP15(均超过20)mmHg:45%死亡率平均ICU住院时间21days,IAH/ACS会影响患者结局吗?,IAH干预会影响患者结局吗?,Ivatury,JTrauma,1998:损伤控制后的ACS.70例检测IAP18mmHg(25cmH2O)25例手术后立即关腹:52%IAP18mmHg39%死亡-45例腹腔“开放”:22%IAP18mmHg10.6%死亡,Sun,2006:爆发性胰腺炎持续腹腔引流与传统治疗.110例爆发性胰腺炎-RCT对照组:常规ICU治疗实验组:常规治疗再加上IAP监测(第一天平均21mmHg)持续腹腔内引流(drain1800cconday1)结局:对照组-20.7%死亡,28天住院时间实验组-10.0%死亡(p25%burnplusinhalationor40%burnwithoutinhalationRandomizedtosalinevsplasmaResultspostresuscitation:CrystalloidIAPmean26.5mmHgPlasmaIAPmean10.6mmHg,IAH/ACSManagement:Hemofiltration,Oda,2005:ManagementofIAHinpatientswithsevereacutepancreatitisusingcontinuoushemofiltration.17casesofseverepancreatitisandIAHTreatedwithhemofiltrationwhenIAP+15mm,PRIORtodevelopingrenalinsufficiency(maintainedadequateserumoncoticpressurewithalbumin)Results:Interleukin(IL-6)cytokinelevelscutinhalfReducedvascularpermeabilityandinterstitialedemaMeanIAPvaluedroppedfrom15mmtolessthan10mm16of17patientsdischargedalivewithoutcomplication,IAH/ACSManagement:Paracentesis,MultiplecaseseriesreportingsuccessfultreatmentofIAHandACS:Latenser2002:BurnpatientmanagementReckard2005:PeripancreaticfluidfilledmassSharp2002:PediatricblunttraumaEtzion2004:MalignantascitestherapySun2006:Pancreatitis(prospectiveRCT)Cutdeathsinhalf,cuthospitalLOSby13days,IAH/ACSManagement,DecompressiveLaparotomy:ErronthesideofearlyvslateinterventionLessboweledemaorcelldamage,betterchanceofearlyclosureandearlyrecovery.BeawarethatdelayingcareuntilthiscomplicationoccursisVERYexpensivemoreexpensivethelongeryouwait:Vanderbiltcostsforopenabdomen(Vogel2007):Sameadmissionclosure-$150,000Failuretocloseoninitialadmission$250,000(estimatenearlyasmuchovernextyearbytimeventralherniafinallyrepaired).,IAH/ACSManagement:DecompressiveLaparotomy,RigidAbdomeninACS,Postdecompressivelaparotomy,DecompressiveLaparotomy,DelayinabdominaldecompressionmayleadtointestinalischemiaDecompressEarly!,DecompressiveLaparotomy,Post-operativedressing,Severaldayspost-op,Nosuchthingasan“OpenAbdomen”intheICU,“OpenAbdomen”Vac-pacdressingplacedinOR.Now6hourspost-op:MAP=70HR=114IAP=24UOP100cc/hourPIP=30cmH2O,Nosuchthingasan“OpenAbdomen”intheICU,24hoursintoICUstay:WorsenedboweledemaHowever:MAP=79IAP=12Lactate=1.9,Noteexpansionofviscera,SurgicalManagementofCompartmentSyndromes,CompartmentCraniumChestPericardiumLimb,PathophysiologyICPelevationTensionpneumothoraxCardiactamponadeExtremitycompartmentsyndrome,SurgicalManagementCraniotomy,etc.ChesttubePericardiocentesisFasciotomy,CompartmentSyndromesversusHypertension,Abdominalcompartmentsyndrome=EmergentSurgicalDisease.Intra-abdominalhypertension=UrgentMedicalDisease.,Costanalysis,IsIAPmonitoringandinterventioncosteffective?,Costanalysis,CompartmentsyndromeriskcomparisonTheCranium:Fall,hithead,LOC,vomitingbutalertIsitworththecostofaheadCT?(StandardofCare)Incidenceislessthan5%positiveLessthan0.5%needanyinterventionTheAbdomen:ICUpatientwithmajorfluidresuscitation(5literspositiveat24hours)IsitworththecostofmeasuringtheirIAP?IncidenceofIAHis85%30%willhaveACS,Costanalysis:Timedependentcriticalcareinterventionsvs.livessaved,Numberneededtotreattosaveonelife:IAH/ACSaggressiveprotocol:3-10EGDTforsepsis:6-8Lowvolumeventilation:10XigrisactivatedproteinC:16Thrombolyticsorcardiaccath:37tPAforstroke:100tPAinsteadofstreptokinase:111,Costanalysis:IAPmonitoringimpactonresourceutilization.,SummaryofCheathamandSundata:Simplestandmostconservativecalculationis10to13daysreducedhospitalLOSwithfarhighersurvivalrate.Assumelowendof$1000-$2000/daysavings:Save$10,000-$20,000perpatientwithIAHwhohasearlymonitoringandprotocoldrivencare.OpenupICUbedsoonerIncreasesurvival,Costanalysis:IAPmonitoringimpactonresourceutilization.,OthermoredifficulttoquantifycostsOpportunitycosts(thinkwaitresswithatable)LongerICULOSleadstoinabilitytoadmitanotherpatienttothatbed.ICUchargesarefarhigherduringfirstfewdaysofadmissionsointermsofbusiness,longICULOSleadstolossesintermsofnewpatientbilling.MortalitycostsHigherdeathratewithouttreatmentleadstolossofthatpersonfromproductivelifeinsociety.Whatistheeconomicvalueofahumanlife?Whatisareasonablecosttosaveonelife?,Summary:IsIAPmonitoringandinterventioncosteffective?,IAHisverycommoninfluidresuscitatedpatientsIAHcannotbeclinicallydetectedIAH/ACSoutcomeistimedependent.Delayeddetection/interventionconsumesmoreresourcesDelayeddetection/interventionresultsinhighermortality.Aggressiveinterventionleadstoreducedcostswithbetteroutcomes.So.,Conclusion-IsIAPmonitoringandinterventioncosteffective?,Thecostofmonitoringintra-abdominalpressure-earlyandoften-isfaroutweighedbythesavingsincliniciantime,organfunction,hospitaldaysandlivessaved.,IAHmonitoringandinterventionprotocol,WSACSIAH/ACSG2007,Assessmentalgorithm,Managementalgorithm,IAPmonitoringalgorithm,EntrycriteriadefinedintableNurseisempoweredtoenteranypatientfulfillingthesecriteria,IAPMonitoring&InterventionProtocol,IAPmonitoringQ2hoursforfirst24-48hours,IAPconsistently20-25mmHgorevidenceoforgandysfunction/ischemia(ACS),CarefulfluidmanagementCorrectCVPforIAPAdjustbedposition?OptimizeAPP?ConcentratedripsSedate,ReduceIAPmeasurementstoQ4-6hoursfor24hours,“SecondHit”pt.developsnewindicationforIAPmonitoring,IAPremains12mmHgdiscontinuemonitoring,MedicalManagementSedation/paincontrolEmptyGItractGastricsuction,catharticsRectaltube/enemasNeuromuscularblockadeColloids/diureticsParacentesis/PercutaneousdrainCVVHplusColloids,Surgicalconsult:ConsiderSurgicalDecompression,FinalThought,DoNOTwaitforsig