《腹腔间隙综合征中》PPT课件.ppt

腹腔内高压与腹腔间隙综合症Intra AbdominalHypertension IAH AbdominalCompartmentSyndrome ACS Sillentkiller 你关注过他们的腹内压是多少呢 你曾经见过危重患者液体复苏后越来越肿胀吗 你见过ICU患者发生肾衰需要透析吗 你曾经见过患者发生多器官衰竭最后死亡吗 病例1 脓毒症儿童 5岁女孩因脓毒症入院治疗 补液 血管活性药物 抗生素24小时后症状加重 低血压 无尿 低氧 高碳酸血症 IAP 26腹腔减压术迅速缓解了肾 肺和血流动力学不稳定状态7天后关腹 存活出院 DeCou JPedSurg2000 病例2 肺栓塞 46岁肺栓塞男性使用肝素抗凝后 迅速进展 需要血管活性药物 大量补液 输血 后腹膜血肿 无尿 血压下降 通气困难IAP50mmHg腹腔减压后无尿 低血压及呼吸机支持程度均好转最后存活出院 Dabney IntensiveCareMed2001 病例3 胸部和盆腔创伤 54岁男性15英尺高坠落 肋骨 盆腔 腰椎骨折盆腔外固定 腰部制动2天后出现呼吸困难 插管机械通气肺部症状进展 出现低血压 需要大量补液及多巴胺和去甲肾上腺素肺动脉导管显示前负荷正常 但是出现无尿膀胱压力46cm减压初期心肺功能迅速改善 但是后期恶化 9天后死于MSOF Kopelman JTrauma2000 77岁男性卧床后误吸 转入ICU后插管 低血压一晚上给与10升的静脉补液 去甲肾1 0mg kg min 无尿 8小时35ml尿 血乳酸 4 6IAP 31mmHg 腹部平片 大小肠明显肿胀 超声未显示腹腔积液 外科会诊后予以剖腹减压1小时后 IAP12mmHg 尿量210ml 去甲肾撤用 Cheatham WSACS2006 病例4 误吸患者 由此可见 创伤并不是ACS唯一病因 IAH和ACS出现于多数ICU中 PICU MICU SICU CVICU NCC OR ER 临床监测IAP是必要的 能有助于判定IAH是否会导致器官功能衰竭仅关注IAP升高到一定的值将会导致诊断的延误 临床出现明显的ACS症状后才去测定IAP势必会使亚急性的临床事件变为急症 IAP监测能早期发现和早期干预IAH 以免发生ACS 定义 whatisit 病因病理生理流行病学对患者预后的影响监测 经膀胱测压治疗t犹他 Utah 大学的诊疗规范 Whatiscompartmentsyndrome 定义WCACS AntwerpBelgium2007 腹腔内压Intra abdominalPressure IAP 腹膜腔内的压力腹腔内高压Intra abdominalHypertension IAH IAP持续 12mmHg 通常伴随隐性缺血 不伴明显的器官功能障碍腹腔间隙综合征AbdominalCompartmentSyndrome ACS IAH 20mmHg 并且至少1个器官功能衰竭 腹腔内压力水平是如何定义的 压力 mmHg 定义0 5正常5 10大多ICU患者常见 12 GradeI 腹腔内高压16 20 GradeII 危险的IAH 建议开始非创伤性的干预 21 25 GradeIII 强烈提示ACS 剖腹减压伴随对腹腔内压力增高对器官功能的影响 对腹腔内高压的定义基准已经下调WSACS org 生理改变 危重急症 组织缺血 全身炎症反应 SIRS 毛细血管渗漏 组织水肿 包括肠壁和肠系膜 腹腔内高压 IAH 液体复苏 IAP升高的原因 严重的腹腔内 腹膜后病变缺血改变 SIRS需要液体复苏 24小时内大量补液后正出的量超过5000ml这么多液体到哪里去了呢 水在这儿呢 IAH ACS 病理生理改变 心血管系统 腹腔内压力增高导致 静脉回心血流量减少导致大静脉塌陷受压胸腔内压力 ITP 增高后产生多种负性心肌效应结果 心脏输出量减少全身血管阻力增加心脏负荷增加组织灌注降低 混合血血氧饱和度ScvO2降低CVP和PAWP升高 但并不能反应真正的右心室前负荷水平心脏供血不足心脏骤停 PEEP PIP吸气压峰值 腹内压 胸廓顺应性 胸膜腔压力 肺顺应性 气道阻力 心脏内压力 肺动脉导管 心室顺应性改变 瓣膜病变 导管尖端的压力 血管内容量 CVP PAOP CIinthepresenceofIntra abdominalHypertension r 0 33 r 0 33 CVP PAOP和心脏指数之间是无相关关系的 Cheatham Malbrain2005 Ridings etal1995 肺 IAP增加导致 膈肌抬高导致肺容量减少 胸廓顺应性变差 变得 僵硬 肺泡充气不良 组织间液增加 淋巴回流受阻 结果 胸内压增高气道峰压增加 潮气量减少间质水肿 肺充气不良 低氧血症 高碳酸血症机械通气相关性肺损伤 气压伤细胞因子释放 前炎症反应ARDS 病理生理改变 肺 IAH 正常 ITP 胃肠道 腹内压增高导致 肠系膜静脉和毛细血管受压 充血心输出到胃肠道血流量减少结果 肠道灌注减少 水肿和渗出增加缺血 坏死 细胞因子释放 中性粒细胞趋化聚集细菌易位SIRS发生发展腹腔内液体进一步增加 肾脏 腹腔内压力增加导致 肾静脉和实质受压心脏输出到肾脏血流量减少结果 肾血流量减少肾充血水肿肾小球滤过率降低 GFR 肾衰 少尿 无尿 正常腹部CT 下腔静脉 注意腹腔是椭圆的 而不是球形 正常肾脏 后腹膜血肿 注意 腹腔是圆的 而不是椭圆形了 肾脏受压 病人无尿 Pickhardt AJR1999 ACS时异常的腹部 肾脏受压 变得扁平的下腔静脉 中枢神经系统 腹腔内压力增高导致 胸内压增高上腔静脉压力增高导致回胸腔血流降低结果 中心静脉压增高颅内压增高大脑灌注压降低脑水肿 脑缺氧 脑损伤 Maryland休克创伤中心对颅内压顽固升高的患者均常规实施开腹减压手术 病理生理改变 腹腔内压力改变对其它压力指标的影响 IAP增高会导致ICP 颅内压 IJP 颈内静脉压 andCVP PAOP 肺动脉阻塞压 增高 15升袋置于腹壁 Citerio2001 IAHinneuropatients Joseph2004 腹腔减压治疗顽固性颅内高压17位经其它治疗 其中14位实施开颅减压手术 后仍顽固性ICP增高患者 平均ICP30mmHg 平均IAP27mmHg17位均行剖腹减压术100 ICP立即或数小时后下降 平均17mmHg11位ICP一直正常这11位均存活 并且无神经系统后遗症 goodneurologicoutcome 缺血时间与细胞存活的关系 不可逆的细胞凋亡或坏死 Rivers Earlygoaldirectedtherapyforsepsislecture 细胞氧需量的基线 无氧代谢 有氧代谢 时间紧迫的 黄金小时 分钟为单位 心脏骤停 5min 严重创伤 Thegoldenhour 急性心肌梗死 timeismuscle 90minDTB 休克 Brainattack 3hourtimewindow 严重的ICP升高 cranialcompartmentsyndrome 张力性气胸 心包填塞 thoraciccompartsyndrome 时间紧急的 6小时 小时为单位 脓毒性休克 Survivingsepsis totalbodyischemia IAH ACS Survivingfluidresuscitation totalbodyischemia 肢体缺血 栓塞 肢端间隔综合征 肠系膜缺血 主动脉栓塞 IAH ACS CirclingtheDrain Intra abdominalPressureMucosalBreakdown Multi SystemOrganFailure Bacterialtranslocation CellularApoptosis NecrosisAcidosis DecreasedO2deliveryAnaerobicmetabolism CapillaryleakFreeradicalformation MSOF ICU患者ACS的发病率 Malbrain IntensiveCareMedicine 2004 ThesedataareforALLICUpatients MUCHhigherifyouuseaprotocoltoselecthighriskpatients 脓毒症患者的发病率 Efstathiouetal IntensiveCareMed2005 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 incidenceofIAP 20mmHginsepticshockDaugherty 2007 ACS常见于ICU中需要大量液体复苏的患者 85 ofpatientswith5literspositivefluidbalancehadIAH30 hadIAP 20withorganfailure 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 50 时间临床医生能在IAP升高的时候第一时间发现 研究发现需要一些更常规通用的方法如经膀胱测压 Kirkpatrick CanJSurg2000 IAH能预测死亡IAH 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IAP 18mmHg 25cmH2O 25例手术后立即关腹 52 IAP 18mmHg39 死亡 45例腹腔 开放 22 IAP 18mmHg10 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 p 0 01 15天住院时间 IAH干预会影响患者结局吗 Cheatham2007 积极管理IAH ACS提高存活率吗 ActaClinicaBelgica引入managementprotocolin2005前后的比较 开腹率from28 to15 medicalmanagement 如果开腹减压 早期进行 不是发生ACS后 关腹天数从平均21天降至6天初次成功关腹率从1 3to2 3机械通气天数降低住院日从28天到18天存活率从51 到72 IAH干预会影响患者结局吗 DoesIAH ACSaffectpatientoutcome Points IAH ACSiscommonintheICUenvironment includingyours IAHandACSincreasemorbidity mortalityandICUlengthofstay Early protocoldriveninterventionsimproveoutcomeswithoutincreasingcostofcare shorterICUandhospitalLOS However ClinicalsignsofIAHareunreliableandonlyshowuplateintheclinicalcourse SOEarlymonitoring TRENDING detectionofIAHwithearlyinterventionisneededtoobtainoptimaloutcomes Intra AbdominalPressureMonitoring Intra AbdominalPressureMonitoring ThereferencestandardforintermittentIAPmeasurementisviathebladderwithamaximalinstillationvolumeof25mlsterilesaline WSACS org HomeMade PressureTransducerTechnique Home madeassembly Transducer2stopcocks160mlsyringe 1tubingwithsalinebagspike luerconnector1tubingwithluerbothends1needle angiocathClampforFoleyAssembledsterilely usedinproperfashion HomeMade PressureTransducerTechnique PROBLEMS Home made Nostandardization confidenceproblemwithdataSterilityissues CAUTInolongerreimbursedTimeconsuming thereforitsuseislateandinfrequentduetothehasslefactor i e notmonitoring waitingforACS Datareproducibilityerrors whatarethecosts morbidityofinaccurateordelayedinformation Other Needlestick Recurrentpenetrationofsterilesystem Leaks re zeroingproblems failuretotrend Fluid ColumnManometry Sedrak2002 Problems FailuretopayextremeattentiontodetailmayleadtoerrorsSiphoneffectleadstofalseelevationsInadequatevolumeofinfusionwillleadtofalselylowmeasurementsCAUTIRisk Needtoinfuseurinebackintopatient BladderPressureMonitoring Howtodoit Commerciallyavailabledevices FoleyManometer Bladdermanometer CiMon Gastric Spiegelberg Gastric AbViser Bladdertransduction IAPmonitor Bladdertransduction Advantages Simple Standardized Reproducible Timeefficient Sterile AbViser ReproducibilityStudy Inter observerScatterplot r 0 95 p 0 001 Kimball IntCareMed2007 Nursingdrivenstudywith89differentnursesparticipating Excellentintra andinter observerreproducibility CommonQuestions Howmuchfluidshouldbeinfusedintobladder Volumeofinfusion ml IAPMeasured mmHg Non compliantbladder Measuredpressureincreasesasvolumesexceed50mlofinfusion Compliantbladder Measuredpressurechangesverylittlewithhighervolumesoffluidinfusion WSACS Maxvolume25ml 1ml kginchildren CommonQuestion HowdoIrecognizeappropriateIAPtransductionontomymonitor Propertransductionclues Respiratoryvariationnoted subtleatlowpressures OscillationtestpositiveReproducibleoverseveralmeasurements Concern UTIcancausesepsis CAUTIisnotreimbursableInfectioncontrolstatements ClosedsystemisrequiredtoreduceUTIrisk bladderpressuremonitoringviolatesclosedsystemconcept Contraryconcern EverythingismedicineisbasedonriskbenefitanalysisWhatistheriskofUTIversustheriskofmissingIAH ACS Howdoweresolvethis Whatistheactualdata CommonQuestions WhatistheriskofUTIfromtransvesicularIAPmonitoring CommonQuestions WhatistheriskofUTIfromtransvesicularIAPmonitoring Myth Breakingthe closedsystem increasesriskofUTIWong GuidelinestopreventCAUTI AmJInfControl1983ResearchData Closedsealedsystems versus opensystems demonstratenodifferenceinCAUTIrisk Threeprospectiverandomizedcontrolledtrials level1evidence onenon randomizedAllstudiescomparedopen notconnected vsclosed pre connected tamperseal drainsystemDeGroot InfContHospEpid1988 203patients RCT CAUTIratesequalWille JHospInf 1993 183patientsRCT CAUTIratesequalLeone IntCareMed2003 311ICUpatients RCT CAUTIratesequalLeone IntCareMed2003 224ICUpatients CAUTIratesequal SowhatdoescauseCAUTI CommonQuestions WhatistheriskofUTIfromtransvesicularIAPmonitoring Maki Engineeringouttheriskofinfectionwithurinarycatheters EmergInfControl2001 Infectionsinwhichbiofilmdoesnotplayaroleareprobablycausedbymasstransportofintraluminalcontentsintothebladderbyretrograderefluxofmicrobeladenurinewhenacollectionsystemismanipulated Loop Cheatham Intravesicularpressuremonitoringdoesnotcauseurinarytractinfection IntCareMed2006ComparedICUpatientsgettingIAPmonitoringtothosewhodidnotgetIAPmonitoringCAUTIrate7 9versus6 5per1000cathdays P N S despitehigheracuityandmortalityintheIAPgroup CommonQuestions WhatistheriskofUTIfromtransvesicularIAPmonitoring Conclusions TransvesicularmonitoringofIAPprobablycarrieslittleriskofCAUTI FailuretomonitoranddetectIAH ACSdoescarryahighrisktopatientsoriskbenefitanalysissuggestsmonitoringneedstobedoneregardless Closedsystemmythmayhavesomemerit aseptictechnique butisnotdefendedbyevidencebasedmedicineandisover blown Obviouslyweneedtobecareful butnotparanoid Manipulationoftheurinarydraintubewithrepeateddumpingofoldurinebackintothepatientsbladderisprobablyamodifiableriskwecanimpact CommonQuestions WhatistheriskofUTIfromtransvesicularIAPmonitoring ManagementofIAHandACS IAH ACSManagement Relativelyeasy bedsidenursingcontrolinterventionsBedPosition Binders NO ConsiderfullyrecumbentwithreversetrendelenbergBalanceVAPissuesagainstIAHissues riskbenefitanalysis Sedation PaincontrolOftenallthatisneededFluids enoughbutnottoomuchBeawareofproblemswithhemodynamicdatainthefaceofIAHThinkaboutinfusionvolumes concentratingsomeofthedripsAbdominalperfusionpressure 50 60mmHg SimilartoCerebralperfusionpressureAPP MAP IAPNGT Cathartics Rectaltube enemasParalysis Balanceriskvs benefit IAH ACSManagement Positioning Vasquez 2007 IAH ACSManagement Paralysis DeWaele CritCareMed2003 UOP IAP IAH ACSManagement Colloids O Mara 2005 ProspectiverandomizedevaluationofIAPwithcrystalloidandcolloidresuscitationinburns31caseswith 25 burnplusinhalationor 40 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 BeawarethatdelayingcareuntilthiscomplicationoccursisVERYexpensive moreexpensivethelongeryouwait 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 10Xigris activatedproteinC 16Thrombolyticsorcardiaccath 37tPAforstroke 100tPAinsteadofstreptokinase 111 Costanalysis IAPmonitoringimpactonresourceutilization SummaryofCheathamandSundata Simplestandmostconservativecalculationis10to13daysreducedhospitalLOSwithfarhighersurvivalrate Assumelowendof 1000 2000 daysavings Save 10 000 20 000perpatientwithIAHwhohasearlymonitoringandprotocoldrivencare OpenupICUbedsoonerIncreasesurvival Costanalysis IAPmonitoringimpactonresourceutilization OthermoredifficulttoquantifycostsOpportunitycosts thinkwaitresswithatable LongerICULOSleadstoinabilitytoadmitanotherpatienttothatbed ICUchargesarefarhigherduringfirstfewdaysofadmission sointermsofbusiness longICULOSleadstolossesintermsofnewpatientbilling MortalitycostsHigherdeathratewithouttreatmentleadstolossofthatpersonfromproductivelifeinsociety Whatistheeconomicvalueofahumanlife Whatisareasonablecosttosaveonelife Summary IsIAPmonitoringandinterventioncosteffective IAHisverycommoninfluidresuscitatedpatientsIAHcannotbeclinicallydetectedIAH ACSoutcomeistimedependent Delayeddetection interventionconsumesmoreresourcesDelayeddetection interventionresultsinhighermortality Aggressiveinterventionleadstoreducedcostswithbetteroutcomes So Conclusion IsIAPmonitoringandinterventioncosteffective Thecostofmonitoringintra abdominalpressure earlyandoften isfaroutweighedbythesavingsincliniciantime organfunction hospitaldaysandliv