腹腔内压力测定在危重患者中的应用

腹腔内压力测定在危重患者中的应用概念和定义腹内压(IAP)隐藏在腹腔内得压力、腹腔内压力(IAP)主要由腹腔内脏器得静水压产生、正常时接近零、腹腔内高压(IAH)腹内压持续或反复

>12mmHg(经常导致隐匿性缺血),无器官衰竭腹腔间隔室综合征

(ACS)腹内压持续>20mmHg,伴随新器官功能障碍或衰竭Diagram多器官衰竭器官功能障碍腹腔压力增高正常生理状态MODSACS腹腔内高压症正常腹内压腹腔内高压得高危因素Title腹部手术后向心性肥胖腹腔内容物增加脓毒症肠腔内容物增加毛细血管渗漏腹腔内高压症得高危因素1急性呼吸衰竭，腹部手术，尤其是有张力关腹时严重创伤/烧伤俯卧姿势，床头抬高＞30°体质指数(BMI)高，向心型肥胖2胃轻瘫肠梗阻结肠假性梗阻3腹腔积血/气腹腹水/肝功能障碍4大量液体复苏（＞5升/24小时）胰腺炎少尿脓毒症严重创伤/烧伤开腹探查术ICU得危重病人容易患腹腔内高压!腹主动脉瘤腹部手术腹水肠梗阻烧伤腹内高压症缺血胰腺炎腹膜炎外伤脓毒症/全身炎症反应综合征腹腔内高压症得病理生理改变呼吸高通气阻力低氧血症高碳酸血症循环心脏顺应性降低，CO下降下肢回心血量减少CVP增高肾脏肾血流减少肾小球，肾小管功能障碍肾功能衰竭腹腔内高压症得病理生理改变脑ICP增高CPP降低肝脏肝动脉，肝静脉，门静脉血流减少肝功能障碍胃肠道动脉缺血，静脉淤血肠道水肿，细菌，毒素移位什么就是腹腔内高压得主要原因?

液体!5升多得液体从哪里进入到体内?

脑?

肺?

皮肤/软组织?

肠道/肠系膜……、、液体都在这里!!这就就是当腹腔内高压没有检测到,演变成腹腔间隔室综合征发生得状况。Brain:IAPelevationcandirectlycontributetoICPelevation.Lungs:IAPpushesdiaphragmsintochest,raisingintrathoracicpressurecausinganincreaseinbarotrauma,hypercarbiaandhypoxemia.ThisresultsinincreasedtimeontheventilatorwithincreasesinVAP.Intestines:IAPcompromisesintestinalbloodflowresultinginischemia,necrosisandmultisystemorganfailure.Heart:Cardiacmonitoring,includingCVPandPCWP,areartificiallyelevatedbyIAPmakingthemdifficulttointerpretintheIAHsetting.Kidneys:Reducedkidneyperfusionandurineproductionresultsininabilitytomobilizefluidsandincreasedratesofrenalinsufficiency/failure.VenaCavaCompression:IAPgreaterthan8-12mmHgresultsinreducedbloodflow(preload)totheheart.Mostcriticallyillpatientshaveasignificantsystemicinflammatoryresponse(SIRS)thattriggersthereleaseofcytokinesleadingtocapillarypermeabilityandinterstitialedema.Abdominalvisceraareparticularlyvulnerableastissueedemaworsenswiththethirdspacingofresuscitativefluid.Asvisceraledemaworsensintra-abdominalpressure(IAP)increases.AsIAPincreasesperfusiontoabdominalorgansdecreasesresultingincompromisetovisceralbloodflowandtissueischemia.Tissueischemiathenperpetuatesfurthercytokinereleaseandworseningsystemicinflammationthusinitiatingtheviciouscycle.Intra-AbdominalHypertension(IAH)isdefinedasIntra-AbdominalPressure(IAP)above12mmHg.Atwhichpointsignificanttissueperfusionproblemsarise,whichcanleadtoearlyorgandysfunction.AnIAPlevelover20mmHgtypicallycausesorganfailureandiscalledAbdominalCompartmentSyndromeAsIAPexceeds15to20mmHgcapillarybloodflowisdramaticallyreduced,leadingtoanaerobicmetabolism,increasedcytokineproductionandexacerbationofcapillarypermeability(worseningboweledema).AtIAPlevelsapproaching20mmHgvenousreturntotheheartisimpairedreducingcardiacoutput.Decreasesinsystemicbloodflow(CO)compoundstheinsultofdirecttissueischemiaperpetuatingtheviciouscycle.Intra-AbdominalPressureIntra-AbdominalHypertension大家学习辛苦了，还是要坚持继续保持安静不测量腹内压得危险晚监测 =晚识别晚识别 =晚干预晚干预 =有限得治疗选择有限得选择=不良结果预期得,双盲实验–医师判断

结果:小于50%得时间医生能够确定何时腹内压升高检测腹腔内高压,临床判断有多好?

Kirkpatrick,CanJSurg2000腹内压监测得意义对于ICU得危重病人,IAH就是很常见得IAH不能被临床检查出来、检测IAH得唯一方法就是测量腹内压。IAH/ACS得预后与干预时机密切相关检测/干预延迟导致成本提高,病人得预后差检测/干预延迟导致更高得死亡率积极得非手术干预缩短住院时间、改善预后腹腔内压力监测得方法直接测压法临床少用测压方法间接测压法

膀胱内压力测定最常用腹腔内压测定方法患者平卧位,在膀胱内置入Foley导尿管,排空膀胱内尿液,注入25-50ml无菌生理盐水,通过三通管与压力换能器相连,换能器以耻骨联合处为调零点,联接美国DASH4000监护仪,先行校零后,打开三通,在监护仪上读取压力值,单位为mmHg。AbViser腹内压监测系统AbViser腹内压监测系统AutoValve®无需阻断和三通一步操作节省医生时间标准化得腹内压测量–alwaysdonethesaywaybyeachuser手术室兼容–数据协助医生完成剖腹手术经验证得准确性,重复性和安全性完整得腹内压监测系统腹内压监测和干预得国际性推荐:腹高压得评估方法病人转入ICU之后应该评估发生IAH/ACS得风险,同时评估就是否有新得