腹腔压力监测---腹腔高压及腹间隔室综和征的诊治ppt课件

.,1,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,2,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,3,几个概念,腹腔内压力Intra-abdominalPressure正常IAP:0-5mmHg,腹腔高压症Intra-abdominalHypertensionIAP12mmHg*,腹间隔室综合征AbdominalCompartmentSyndromeIAP20mmHg出现一个或多个脏器功能衰竭,*MalbrainML;DeerenD;DePotter,etal.CurrentopinioninCriticalCare.2005,11(2):156-171.,4,5,IAH/ACS,IAP决定于,6,DefinitionofWSACS,WSACSCurrentopinioninCriticalCare.2005,11(2):156-171.,7,正常值,WSACS：5-7mmHg,IntensiveCareMed(2009)35:969976,8,正常值,ComparisonofIAPamongdifferentweightgroups,IntensiveCareMed(2009)35:969976,7-14mmHg,9,IAH发病率,IAH发生率约50%ACS病死率：40-100,IAP正常67.9IAH32.1%ACS4.2%IAH中发生ACS12.9,MalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322,10,Malbrain,IntensiveCareMedicine(2004):,11,ThehighertheIAPthepoorerthesurvivalrate,MalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322,12,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IAP12mmHgAPP(腹腔灌注压)=MAP-IAP,MalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322,*CheathamML,WhiteMW,SagravesSG,etal.JTrauma2000;49:621-626.,13,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,14,ACSandMODS,MalbrainML,Deeren,D,DePotter,etal.CurrentopinioninCriticalCare.2005,11(2):156-171.,ACS：IAH+器官功能障碍,15,ACSandMODS,16,ACSandMODS,MalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322,IAP越高器官衰竭的数目越多,17,ACSandMODS,18,循环系统,ACSandMODS,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,19,AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.003;55:734740.,ACSandMODS循环系统,CVP升高,心输出量(CO)下降,20,ACSandMODS循环系统,21,ACSandMODS,循环系统IAH增加对前负荷评估的难度CVP?PAWP?CO?,22,ACSandMODS,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。,23,AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734740.,ACSandMODS呼吸系统,24,ACSandMODS呼吸系统,MalbrainML.CurruntOpinionofCriticalCare.2004,10(2):132-145,呼吸系统静态顺应性降低,25,有认为：IAP25mmHg是肾衰最敏感、特异性最高的指标之一。,FG(肾脏滤过压)=MAP-2IAP,ACSandMODS肾功能,26,少尿，Cr,BUN,CCr肾素、醛固酮、ADH,ACSandMODS肾功能,27,AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734740.,ACSandMODS肾功能,尿量减少,28,CirclingtheDrain,Intra-abdominalPressureMucosalBreakdown(Multi-SystemOrganFailure)BacterialtranslocationAcidosis,DecreasedO2deliveryAnaerobicmetabolism,CapillaryleakFreeradicalformation,MSOF,29,腹腔压力（IAP）监测与EN,IAP（cmH2O）,天,30,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。,ACSandMODS,31,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,ACSandMODS,32,DeerenD,LeijsJ,VandenBrandeE,etal.CritCareMedinpress.,ACSandMODS神经系统,颅内压(ICP)与IAP,33,JosephDA,DuttonRP,AarabiB,etal.Trauma,2004,57(4):687-695.,腹腔减压术前后参数改变,34,Cheatham62(Supplement1):268,35,可逆性：依赖监测早、发现早、处理早,Criticalcaremed,2006,36,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,37,IAP监测方法,38,39,直接测压法,腹部或腹膜后手术中14-FPVC圆形引流管,E.Risin,TheAmericanJournalofSrugery,191(2006)235-237,40,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,41,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,Intensivecaremed,2007,42,膀胱内压力测定方法（transvesicalcatheter）Simple,quick,andinexpensiveKronfirstdescribedmodernIAPmonitoringin1984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-ORIGINALKRONTECHNIQUE,43,禁忌神经性膀胱膀胱损伤膀胱挛缩,MalbrainML,DeerenD,DePotter,etal.CurrentopinioninCriticalCare.2005,11(2):156-171.,经膀胱压力测定法,44,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,45,60ml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q2-4hours监测一次.无菌操作,经膀胱压力测定法,46,经膀胱压力测定法,InmmHg(1mmHg=1.36cmH2O)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(toallowbladderdetrusormusclerelaxation)无腹肌紧张情况下,47,经膀胱压力测定法,48,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,49,充盈盐水量对IAP的影响,Chiumelloetal.CriticalCare2007,11.,N=13,50,N=20adult,51,充盈盐水量对IAP的影响,一次注入盐水量最多不超过25ml-WorldSocietyonAbdominalCompartmentSyndrome(WSACS)recommends,52,注射后平衡时间的影响,Chiumelloetal.CriticalCare2007,11.,53,注射盐水温度的影响,Chiumelloetal.CriticalCare2007,11.,室温加热至体温,54,Zeroreferencepoint,55,N=132supinepositionThreereferencelevelswerestudied:耻骨联合（thesymphysispubis）胸骨中线（thephlebostaticaxis:(ormid-chestreferencelevel)髂前上嵴腋中线（themidaxillarylineattheleveloftheiliac）,56,IAPphlebostatic(9.94.67mmHg)*IAPpubis(8.44.60mmHg)*IAPmidax(12.24.66mmHg)p0.0001,57,零点位置,2,3,胸骨中线Phlebostaticaxis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-axillarylineatiliaccrest最为精确可重复性好,1,58,JournalofSurgicalResearch139,280285(2007),IAPindefferentHOBandBMI,P12mmHg,PEEPandIAP?,65,PEEPandIAP,N=30IAP-OriginalmethodbyKron.5mininterval5KgtothepatientsbellyPEEP:010,CLINICS2009;64(2):105-12,66,CLINICS2009;64(2):105-12,PEEPandIAP,67,CLINICS2009;64(2):105-12,PEEPandIAP,68,p=0.47,P0.001,CLINICS2009;64(2):105-12,PEEPandIAP,69,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.,CLINICS2009;64(2):105-12,PEEPandIAP,70,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,71,IAH/ACS的临床分级,UBP35cmH2O,UBP2635cmH2O,UBP1625cmH2O,无临床器官功能损害表现,UBP1015cmH2O,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,BurchJM,MooreEE,MooreFA,etal.SurgClinNorthAm1996;76:833-842.,72,73,74,UniversityofUtah:IAPMonitoringProtocol,IAPmonitoringQ1-2hoursforfirst12hours,IAPconsistently20mmHgORAPP50-60mmHg?Plusevidenceoforgandysfunction/ischemia(ACS),OptimizeAbdominalperfusionpressureCarefulfluidmanagementPressors,ReduceIAPmeasurementstoQ4-6hoursfor24hours,“SecondHit”pt.developsnewindicationforIAPmonitoring,IAPremains12mmHgdiscontinuemonitoring,ConsiderMedicalManagementSedation/NeuromuscularblockadeParacentesisoffreefluidOtheroptionsGastricsuction,catharticsRectaltube/enemasContinuousfiltrationColloids,SurgicalDecompression,75,ACS治疗,76,ACS治疗,Balogh,Z,McKinleyBA,Ho