腹腔高压症及腹腔压力监测在危重病人中的应用演示文稿

腹腔高压症及腹腔压力监测在危重病人中的应用演示文稿现在是1页\一共有52页\编辑于星期五（优选）腹腔高压症及腹腔压力监测在危重病人中的应用现在是2页\一共有52页\编辑于星期五ResultsfromtheInternationalConferenceofExpertsonIntra-AbdominalHypertension(IAH)andAbdominalCompartmentSyndrome(ACS)DEFINITIONSIntensiveCareMedicine2006;32:1722-1732现在是3页\一共有52页\编辑于星期五INTRODUCTIONTOTHEDEFINITIONSIntra-abdominalhypertension(IAH)andabdominalcompartmentsyndrome(ACS)havebeenincreasinglyrecognizedinthecriticallyillascausesofsignificantmorbidityandmortality.Thevarietyofpreviousdefinitionshasledtoconfusionanddifficultyincomparingonestudytoanother.AninternationalgroupofcriticalcarespecialistsconvenedtostandardizedefinitionsforbothIAHandACSaswellasestablishstandardsforthemeasurementofintra-abdominalpressure(IAP).现在是4页\一共有52页\编辑于星期五WHATISINTRA-ABDOMINALPRESSURE?ElevatedIAPisacommonfindingintheICUIAPincreasesanddecreaseswithrespirationIAPisdirectlyaffectedby:SolidorganorhollowvisceravolumeSpaceoccupyinglesionsAscites,blood,fluid,tumorsConditionsthatlimitexpansionoftheabdominalwallBurneschars,third-spaceedema现在是5页\一共有52页\编辑于星期五WHATISABDOMINALPERFUSIONPRESSURE?“Abdominalperfusionpressure(APP)=meanarterialpressure(MAP)minusintra-abdominalpressure(IAP)=MAP-IAP.”ThecriticalIAPthatleadstoorganfailurevariesbypatientAsinglethresholdIAPcannotbegloballyappliedtoallpatientsAnalogoustocerebralperfusionpressure,APPassessesnotonlytheseverityofIAP,butalsotherelativeadequacyofabdominalbloodflowAPPissuperiortoIAP,arterialpH,basedeficit,andarteriallactateinpredictingorganfailureandpatientoutcomeFailuretomaintainAPP>60mmHgbyday3predictssurvival现在是6页\一共有52页\编辑于星期五HOWSHOULDIAPBEMEASURED?“IAPshouldbeexpressedinmmHgandmeasuredatend-expirationinthecompletesupinepositionafterensuringthatabdominalmusclecontractionsareabsentandwiththetransducerzeroedatthelevelofthemidaxillaryline.”PhysicalexamisinaccurateinpredictingIAPSensitivity40-61%Positivepredictivevalue45-76%IAPmeasurementsareessentialtothediagnosis ofelevatedIAPandthemanagementofIAHAvarietyoftechniquesmaybeusedtomeasureIAP现在是7页\一共有52页\编辑于星期五WHATISTHEREFERENCESTANDARDFORIAP?“ThereferencestandardforintermittentIAPmeasurementisviathebladderwithamaximalinstillationvolumeof25mlsterilesaline.”现在是8页\一共有52页\编辑于星期五WHATISNORMALIAP?“NormalIAPisapproximately5-7mmHgincriticallyilladults.”Normaladult0-5mmHgTypicalICUpatient5-7mmHgPost-laparotomypatient10-15mmHgPatientwithsepticshock15-25mmHgPatientwithacuteabdomen25-40mmHg现在是9页\一共有52页\编辑于星期五WHATISINTRA-ABDOMINALHYPERTENSION?“IAHisdefinedbyasustainedorrepeatedpathologicalelevationinIAP≥12mmHg.”ThedefinitionofIAHhasvariedovertheyearswiththresholdsashighas40mmHgbeingpreviouslyadvocated.MostcliniciansarethereforeconcernedonlywhenIAPexceeds20-25mmHgThisiswellabovetheIAPthatcancauseorgandysfunctionandfailureFailuretointervenewhenIAPrisesabove25mmHgisassociatedwithpooreroutcome现在是10页\一共有52页\编辑于星期五HOWISIAHGRADED?“IAHisgradedasfollows:GradeI IAP12-15mmHgGradeII IAP16-20mmHgGradeIII IAP21-25mmHgGradeIV IAP>25mmHg.”TheIAHgradeshavebeenreviseddownwardasthedetrimentalimpactofelevatedIAPonend-organfunctionhasbeenrecognized现在是11页\一共有52页\编辑于星期五WHATISABDOMINALCOMPARTMENTSYNDROME?“ACSisdefinedasasustainedIAP>20mmHg(withorwithoutanAPP<60mmHg)thatisassociatedwithneworgandysfunction/failure.”ACS=IAH+organdysfunctionThemostcommonorgandysfunction/failure(s)are:MetabolicacidosisdespiteresuscitationOliguriadespitevolumerepletionElevatedpeakairwaypressuresHypercarbiarefractorytoincreasedventilationHypoxemiarefractorytooxygenandPEEPIntracranialhypertension现在是12页\一共有52页\编辑于星期五WHATISPRIMARYACS?“PrimaryACSisaconditionassociatedwithinjuryordiseaseintheabdominopelvicregionthatfrequentlyrequiresearlysurgicalorinterventionalradiologicalintervention.” TraumaticInjury Ascites/Fluid AbdominalTumor现在是13页\一共有52页\编辑于星期五WHATISSECONDARYACS?“SecondaryACSreferstoconditionsthatdonotoriginatefromtheabdominopelvicregion.” Sepsis/ Burns Massive CapillaryLeak Resuscitation现在是14页\一共有52页\编辑于星期五WHATISRECURRENTACS?“RecurrentACSreferstotheconditioninwhichACSredevelopsfollowingprevioussurgicalormedicaltreatmentofprimaryorsecondaryACS.”Followingdamagecontrollaparotomyandatemporaryabdominalclosure(TAC),apatient’sIAHrecurred(IAP24mmHg,APP46mmHg)accompaniedbydecreasedurinaryoutput.RevisionoftheTACallowedtheedematousvisceratodecompressresultinginresolutionoftheIAH(IAP13mmHg,APP67mmHg)andrestorationofadequaterenalfunction.现在是15页\一共有52页\编辑于星期五腹腔内压力

(Intra-abdominalPressure,IAP)腹腔高压症

(Intra-abdominalHypertension,IAH)IAP≥12mmHg*腹间隔室综合征

(AbdominalCompartmentSyndrome,ACS)IAP>=20mmHg*出现一个或多个脏器功能衰竭*MalbrainML;DeerenD;DePotter,etal..CurrentopinioninCriticalCare.2005,11(2):156-171.现在是16页\一共有52页\编辑于星期五IAH/ACS 表现特征性变化腹胀心输出量（CO）下降肺顺应性下降，气道峰压(Ppeak)急剧升高少尿或无尿现在是17页\一共有52页\编辑于星期五病因及流行病学ACS病因急性慢性腹部因素非腹部因素现在是18页\一共有52页\编辑于星期五病因及流行病学ThehighertheIAP,thepoorerthesurvivalrateMalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322现在是19页\一共有52页\编辑于星期五预测病人死亡率的独立危险因素年龄APACHEⅡ收入ICU类型有无肝功能不全ICU期间发生IAH入院第一日IAP≥12mmHgAPP(腹腔灌注压)=MAP-IAPMalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322病因及流行病学*CheathamML,WhiteMW,SagravesSG,etal.JTrauma2000;49:621-626.现在是20页\一共有52页\编辑于星期五病因及流行病学IAH独立预测因素（independentpredictors）肝功能不全腹部手术液体复苏肠麻痹

--高度警惕IAH的发生！MalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322现在是21页\一共有52页\编辑于星期五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现在是22页\一共有52页\编辑于星期五

膀胱内压力测定方法（urinarybladderpressure,UBP）Kron等在1984年提出并推广应用。原理：膀胱内有50—100ml液体时膀胱壁会象膈肌一样反映IAP的变化。IAP监测方法现在是23页\一共有52页\编辑于星期五IAP监测方法股静脉/下腔静脉压力测定方法经股静脉（或下腔静脉）插管测定下腔静脉压力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股静脉及下腔静脉血流与IAP呈负相关性改变，即虽着IAP增高而降低现在是24页\一共有52页\编辑于星期五IAP监测方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。现在是25页\一共有52页\编辑于星期五IAP监测方法患者取仰卧位，适当镇静与肌松，镇静与肌松的程度以能消除腹肌收缩为标准，留置导尿，排空膀胱内尿液。将导尿管与连有500ml生理盐水的输液皮条连接，往导尿管内持续滴注注射约25ml生理盐水。将输液皮条拔出生理盐水袋，静置30–60秒，在以腋中线为0点，测量皮条内液体高度，读取呼气末数值，即为腹内压值。现在是26页\一共有52页\编辑于星期五现在是27页\一共有52页\编辑于星期五现在是28页\一共有52页\编辑于星期五循环系统

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、狭窄现在是29页\一共有52页\编辑于星期五ACSandMODS循环系统IAP为20～25mmHg时，出现CO/CI明显下降，HR增快，BP降低，CVP仍升高IAH增加对前负荷评估的难度CVP?CO?现在是30页\一共有52页\编辑于星期五AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.003;55:734–740.ACSandMODS

–

循环系统CVP升高心输出量(CO)下降现在是31页\一共有52页\编辑于星期五AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS

–

循环系统胸腔内血流量(ITBV)降低总循环血量(TCBV)降低现在是32页\一共有52页\编辑于星期五AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS

–

循环系统CO与ITBVCO与CVP现在是33页\一共有52页\编辑于星期五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。膈肌抬高IAP↑机械性压迫胸腔内容量减少肺脏扩张受限肺脏的血管床阻力↑肺不张肺泡水肿现在是34页\一共有52页\编辑于星期五ACSandMODS呼吸系统呼吸系统总静态顺应性↓PV曲线变平并右移IAP升高时，IAP与PV曲线下拐点呈正相关关系。肺中性粒细胞激活，肺脏炎性渗出增加肺泡水肿及压缩性肺不张MalbrainML,DeerenD,NieuwendijkR,etal.IntensiveCareMed2003;29:S85.现在是35页\一共有52页\编辑于星期五AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS

–

呼吸系统血管外肺水增加气道峰压升高现在是36页\一共有52页\编辑于星期五ACSandMODS

主动脉和肾动脉受压，肾脏毛细血管网阻力升高，肾静脉回流受阻输尿管受压IAP↑机械性压迫肾动脉的灌注血量减少，肾皮质的血流分流到髓质，致使肾小球的有效滤过率下降，尿的生成减少肾功能FG(肾脏滤过压)=MAP-2IAP现在是37页\一共有52页\编辑于星期五ACSandMODS肾功能少尿，Cr,BUN↑,CCr↓

肾素、醛固酮、ADH↑现在是38页\一共有52页\编辑于星期五AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS–

肾功能尿量减少现在是39页\一共有52页\编辑于星期五ACSandMODS-

肾功能Balogh,Z,McKinleyBA,HolcombJB.Trauma,2003,54(5)

:848-861现在是40页\一共有52页\编辑于星期五ACSandMODS-

肾功能LindströmP,WadströmJ,OllerstamA,etal.NephrologyDialysisTransplantation,2003,18(11):2269-2277.现在是41页\一共有52页\编辑于星期五胃肠道

大量动物实验证实小肠血流量与IAH有关，IAP升至10mmHg，胃肠道灌注减少→细菌移位内脏受压，内脏缺血。研究显示IAH刺激促炎介质的释放门静脉及中心静脉细胞因子水平显著升高肠道喂养困难FriedlanderMH,SimonRJ,IvaturyR,et