腹腔高壓癥及腹腔壓力監(jiān)測在危重病人中的應(yīng)用1

腹腔高壓癥及腹腔壓力監(jiān)測在危重病人中的應(yīng)用[1]第一頁，共58頁。腹腔高壓癥及腹腔壓力監(jiān)測彭滬第二頁，共58頁。背景19世紀(jì)后期，Eddy1890年，Heinricius1951年，Baggot1984年，Kron第三頁，共58頁。ResultsfromtheInternationalConferenceofExpertsonIntra-AbdominalHypertension(IAH)andAbdominalCompartmentSyndrome(ACS)DEFINITIONSIntensiveCareMedicine2006;32:1722-1732第四頁，共58頁。INTRODUCTIONTOTHEDEFINITIONSIntra-abdominalhypertension(IAH)andabdominalcompartmentsyndrome(ACS)havebeenincreasinglyrecognizedinthecriticallyillascausesofsignificantmorbidityandmortality.Thevarietyofpreviousdefinitionshasledtoconfusionanddifficultyincomparingonestudytoanother.AninternationalgroupofcriticalcarespecialistsconvenedtostandardizedefinitionsforbothIAHandACSaswellasestablishstandardsforthemeasurementofintra-abdominalpressure(IAP).第五頁，共58頁。WHATISINTRA-ABDOMINALPRESSURE?ElevatedIAPisacommonfindingintheICUIAPincreasesanddecreaseswithrespirationIAPisdirectlyaffectedby:SolidorganorhollowvisceravolumeSpaceoccupyinglesionsAscites,blood,fluid,tumorsConditionsthatlimitexpansionoftheabdominalwallBurneschars,third-spaceedema第六頁，共58頁。WHATISABDOMINALPERFUSIONPRESSURE?“Abdominalperfusionpressure(APP)=meanarterialpressure(MAP)minusintra-abdominalpressure(IAP)=MAP-IAP.”ThecriticalIAPthatleadstoorganfailurevariesbypatientAsinglethresholdIAPcannotbegloballyappliedtoallpatientsAnalogoustocerebralperfusionpressure,APPassessesnotonlytheseverityofIAP,butalsotherelativeadequacyofabdominalbloodflowAPPissuperiortoIAP,arterialpH,basedeficit,andarteriallactateinpredictingorganfailureandpatientoutcomeFailuretomaintainAPP>60mmHgbyday3predictssurvival第七頁，共58頁。HOWSHOULDIAPBEMEASURED?“IAPshouldbeexpressedinmmHgandmeasuredatend-expirationinthecompletesupinepositionafterensuringthatabdominalmusclecontractionsareabsentandwiththetransducerzeroedatthelevelofthemidaxillaryline.”PhysicalexamisinaccurateinpredictingIAPSensitivity40-61%Positivepredictivevalue45-76%IAPmeasurementsareessentialtothediagnosis ofelevatedIAPandthemanagementofIAHAvarietyoftechniquesmaybeusedtomeasureIAP第八頁，共58頁。WHATISTHEREFERENCESTANDARDFORIAP?“ThereferencestandardforintermittentIAPmeasurementisviathebladderwithamaximalinstillationvolumeof25mlsterilesaline.”第九頁，共58頁。WHATISNORMALIAP?“NormalIAPisapproximately5-7mmHgincriticallyilladults.”Normaladult0-5mmHgTypicalICUpatient5-7mmHgPost-laparotomypatient10-15mmHgPatientwithsepticshock15-25mmHgPatientwithacuteabdomen25-40mmHg第十頁，共58頁。WHATISINTRA-ABDOMINALHYPERTENSION?“IAHisdefinedbyasustainedorrepeatedpathologicalelevationinIAP≥12mmHg.”ThedefinitionofIAHhasvariedovertheyearswiththresholdsashighas40mmHgbeingpreviouslyadvocated.MostcliniciansarethereforeconcernedonlywhenIAPexceeds20-25mmHgThisiswellabovetheIAPthatcancauseorgandysfunctionandfailureFailuretointervenewhenIAPrisesabove25mmHgisassociatedwithpooreroutcome第十一頁，共58頁。HOWISIAHGRADED?“IAHisgradedasfollows:GradeI IAP12-15mmHgGradeII IAP16-20mmHgGradeIII IAP21-25mmHgGradeIV IAP>25mmHg.”TheIAHgradeshavebeenreviseddownwardasthedetrimentalimpactofelevatedIAPonend-organfunctionhasbeenrecognized第十二頁，共58頁。WHATISABDOMINALCOMPARTMENTSYNDROME?“ACSisdefinedasasustainedIAP>20mmHg(withorwithoutanAPP<60mmHg)thatisassociatedwithneworgandysfunction/failure.”ACS=IAH+organdysfunctionThemostcommonorgandysfunction/failure(s)are:MetabolicacidosisdespiteresuscitationOliguriadespitevolumerepletionElevatedpeakairwaypressuresHypercarbiarefractorytoincreasedventilationHypoxemiarefractorytooxygenandPEEPIntracranialhypertension第十三頁，共58頁。WHATISPRIMARYACS?“PrimaryACSisaconditionassociatedwithinjuryordiseaseintheabdominopelvicregionthatfrequentlyrequiresearlysurgicalorinterventionalradiologicalintervention.” TraumaticInjury Ascites/Fluid AbdominalTumor第十四頁，共58頁。WHATISSECONDARYACS?“SecondaryACSreferstoconditionsthatdonotoriginatefromtheabdominopelvicregion.” Sepsis/ Burns Massive CapillaryLeak Resuscitation第十五頁，共58頁。WHATISRECURRENTACS?“RecurrentACSreferstotheconditioninwhichACSredevelopsfollowingprevioussurgicalormedicaltreatmentofprimaryorsecondaryACS.”Followingdamagecontrollaparotomyandatemporaryabdominalclosure(TAC),apatient’sIAHrecurred(IAP24mmHg,APP46mmHg)accompaniedbydecreasedurinaryoutput.RevisionoftheTACallowedtheedematousvisceratodecompressresultinginresolutionoftheIAH(IAP13mmHg,APP67mmHg)andrestorationofadequaterenalfunction.第十六頁，共58頁。腹腔內(nèi)壓力

(Intra-abdominalPressure,IAP)腹腔高壓癥

(Intra-abdominalHypertension,IAH)IAP≥12mmHg*腹間隔室綜合征

(AbdominalCompartmentSyndrome,ACS)IAP>=20mmHg*出現(xiàn)一個或多個臟器功能衰竭*MalbrainML;DeerenD;DePotter,etal..CurrentopinioninCriticalCare.2005,11(2):156-171.第十七頁，共58頁。IAH/ACS 表現(xiàn)特征性變化腹脹心輸出量（CO）下降肺順應(yīng)性下降，氣道峰壓(Ppeak)急劇升高少尿或無尿第十八頁，共58頁。病因及流行病學(xué)ACS病因急性慢性腹部因素非腹部因素第十九頁，共58頁。病因及流行病學(xué)ThehighertheIAP,thepoorerthesurvivalrateMalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322第二十頁，共58頁。預(yù)測病人死亡率的獨立危險因素年齡APACHEⅡ收入ICU類型有無肝功能不全ICU期間發(fā)生IAH入院第一日IAP≥12mmHgAPP(腹腔灌注壓)=MAP-IAPMalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322病因及流行病學(xué)*CheathamML,WhiteMW,SagravesSG,etal.JTrauma2000;49:621-626.第二十一頁，共58頁。病因及流行病學(xué)IAH獨立預(yù)測因素（independentpredictors）肝功能不全腹部手術(shù)液體復(fù)蘇腸麻痹

--高度警惕IAH的發(fā)生！MalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322第二十二頁，共58頁。IAP監(jiān)測方法腹腔壓力測定經(jīng)膀胱測壓法間接測壓法直接測壓法下腔靜脈壓經(jīng)胃測壓法經(jīng)直腸測壓法穿刺直接測壓經(jīng)腹引管測壓第二十三頁，共58頁。

膀胱內(nèi)壓力測定方法（urinarybladderpressure,UBP）Kron等在1984年提出并推廣應(yīng)用。原理：膀胱內(nèi)有50—100ml液體時膀胱壁會象膈肌一樣反映IAP的變化。IAP監(jiān)測方法第二十四頁，共58頁。IAP監(jiān)測方法股靜脈/下腔靜脈壓力測定方法經(jīng)股靜脈（或下腔靜脈）插管測定下腔靜脈壓力與腹內(nèi)壓力變化以及經(jīng)腹腔直接測定、經(jīng)膀胱壓力測定結(jié)果有較好的相關(guān)性股靜脈及下腔靜脈血流與IAP呈負相關(guān)性改變，即雖著IAP增高而降低第二十五頁，共58頁。IAP監(jiān)測方法胃內(nèi)壓力測定方法經(jīng)鼻胃管向胃內(nèi)注入50-100ml生理鹽水，連接傳感器或壓力計，以腋中線為零點進行測量。第二十六頁，共58頁。IAP監(jiān)測方法患者取仰臥位，適當(dāng)鎮(zhèn)靜與肌松，鎮(zhèn)靜與肌松的程度以能消除腹肌收縮為標(biāo)準(zhǔn)，留置導(dǎo)尿，排空膀胱內(nèi)尿液。將導(dǎo)尿管與連有500ml生理鹽水的輸液皮條連接，往導(dǎo)尿管內(nèi)持續(xù)滴注注射約25ml生理鹽水。將輸液皮條拔出生理鹽水袋，靜置30–60秒，在以腋中線為0點，測量皮條內(nèi)液體高度，讀取呼氣末數(shù)值，即為腹內(nèi)壓值。第二十七頁，共58頁。第二十八頁，共58頁。第二十九頁，共58頁。循環(huán)系統(tǒng)

ACSandMODS胸腔內(nèi)壓力↑靜脈回心血量↓外周血管阻力↑IAP↑機械性壓迫心輸出量↓下腔靜脈、門靜脈和腹膜后靜脈血流減少膈肌升高，下腔靜脈發(fā)生扭曲、狹窄第三十頁，共58頁。ACSandMODS循環(huán)系統(tǒng)IAP為20～25mmHg時，出現(xiàn)CO/CI明顯下降，HR增快，BP降低，CVP仍升高IAH增加對前負荷評估的難度CVP?CO?第三十一頁，共58頁。AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.003;55:734–740.ACSandMODS–

循環(huán)系統(tǒng)CVP升高心輸出量(CO)下降第三十二頁，共58頁。AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS

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循環(huán)系統(tǒng)胸腔內(nèi)血流量(ITBV)降低總循環(huán)血量(TCBV)降低第三十三頁，共58頁。AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS

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循環(huán)系統(tǒng)CO與ITBVCO與CVP第三十四頁，共58頁。ACSandMODS

呼吸系統(tǒng)最早和顯著的臨床表現(xiàn)。Ppeak升高，肺順應(yīng)性下降，P/F下降，高碳酸血癥。膈肌抬高IAP↑機械性壓迫胸腔內(nèi)容量減少肺臟擴張受限肺臟的血管床阻力↑肺不張肺泡水腫第三十五頁，共58頁。ACSandMODS呼吸系統(tǒng)呼吸系統(tǒng)總靜態(tài)順應(yīng)性↓PV曲線變平并右移IAP升高時，IAP與PV曲線下拐點呈正相關(guān)關(guān)系。肺中性粒細胞激活，肺臟炎性滲出增加肺泡水腫及壓縮性肺不張MalbrainML,DeerenD,NieuwendijkR,etal.IntensiveCareMed2003;29:S85.第三十六頁，共58頁。AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS

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呼吸系統(tǒng)血管外肺水增加氣道峰壓升高第三十七頁，共58頁。ACSandMODS

主動脈和腎動脈受壓，腎臟毛細血管網(wǎng)阻力升高，腎靜脈回流受阻輸尿管受壓IAP↑機械性壓迫腎動脈的灌注血量減少，腎皮質(zhì)的血流分流到髓質(zhì)，致使腎小球的有效濾過率下降，尿的生成減少腎功能FG(腎臟濾過壓)=MAP-2IAP第三十八頁，共58頁。ACSandMODS腎功能少尿，Cr,BUN↑,CCr↓

腎素、醛固酮、ADH↑第三十九頁，共58頁。AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS–

腎功能尿量減少第四十頁，共58頁。ACSandMODS-

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

:848-861第四十一頁，共58頁。ACSandMODS-

腎功能Lindstr?mP,Wadstr?mJ,OllerstamA,etal.NephrologyDialysisTransplantation,2003,18(11):2269-2277.第四十二頁，共58頁。胃腸道

大量動物實驗證實小腸血流量與IAH有關(guān)，IAP升至10mmHg，胃腸道灌注減少→細菌移位內(nèi)臟受壓，內(nèi)臟缺血。研究顯示IAH刺激促炎介質(zhì)的釋放門靜脈及中心靜脈細胞因子水平顯著升高腸道喂養(yǎng)困難FriedlanderMH,SimonRJ,IvaturyR,etal.JTrauma1998;45:433-489.ACSandMODS

第四十三頁，共58頁。腹腔壓力（IAP）監(jiān)測與EN05101520253035404513579111315171921232527TPNEN+PN第四十四頁，共58頁。神經(jīng)系統(tǒng)

IAP>25mmHg時出現(xiàn)ICP-顱內(nèi)壓力升高，與IAP成正相關(guān)。CPP-腦灌注壓降低，CPP=MAP-ICP胸腔內(nèi)壓和CVP增高使腦組織靜脈血回流受阻，顱內(nèi)血管床擴大所致CPP下降，顱內(nèi)損害加重頭部創(chuàng)傷病人應(yīng)謹(jǐn)慎使用腹腔鏡診治，并應(yīng)監(jiān)測IAPACSandMODS

第四十五頁，共58頁。DeerenD,LeijsJ,VandenBrandeE,etal.CritCareMedinpress.ACSandMODS

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神經(jīng)系統(tǒng)顱內(nèi)壓(ICP)與IAP第四十六頁，共58頁。JosephDA,DuttonRP,AarabiB,etal.Trauma,2004,57(4):687-695.腹腔減壓術(shù)前后參數(shù)改變第四十七頁，共58頁。外科重癥病人IAP改變的臨床觀察***U