腹腔压力监测-腹腔高压及腹间隔室综和征的诊治.ppt

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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,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,几个概念,腹腔内压力Intra-abdominal Pressure正常IAP:0-5 mm Hg,腹腔高压症Intra-abdominal HypertensionIAP12 mm Hg*,腹间隔室综合征Abdominal Compartment SyndromeIAP 20 mm Hg 出现一个或多个脏器功能衰竭,*Malbrain M L;Deeren D;De Potter,et al.Current

2、 opinion in Critical Care.2005,11(2):156-171.,IAH/ACS,IAP决定于,Definition of WSACS,WSACS Current opinion in Critical Care.2005,11(2):156-171.,正常值,WSACS：5-7mmHg,Intensive Care Med(2009)35:969976,正常值,Comparison of IAP among different weight groups,Intensive Care Med(2009)35:969976,7-14mmHg,IAH发病率,IAH 发生

3、率约 50%ACS病死率：40-100,IAP正常 67.9IAH 32.1%ACS 4.2%IAH中发生ACS 12.9,Malbrain ML,Chiumello D,Pelosi P,et al.CCM,2005,33(2):315-322,Malbrain,Intensive Care Medicine(2004):,The higher the IAP the poorer the survival rate,Malbrain ML,Chiumello D,Pelosi P,et al.CCM,2005,33(2):315-322,预测病人死亡率的独立危险因素年龄APACHE收入IC

4、U类型有无肝功能不全ICU期间发生IAH入院第一日IAP12mmHg APP(腹腔灌注压)=MAP-IAP,Malbrain ML,Chiumello D,Pelosi P,et al.CCM,2005,33(2):315-322,*Cheatham ML,White MW,Sagraves SG,et al.J Trauma 2000;49:621-626.,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,ACS and MODS,Malbrain ML,Deeren,D,De Potter,et al.Current

5、opinion in Critical Care.2005,11(2):156-171.,ACS：IAH+器官功能障碍,ACS and MODS,ACS and MODS,Malbrain ML,Chiumello D,Pelosi P,et al.CCM,2005,33(2):315-322,IAP越高器官衰竭的数目越多,ACS and MODS,循环系统,ACS and MODS,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,Alexander Schachtrupp,Juergen Graf,Chri

6、stian Tons,et al.J Trauma.003;55:734 740.,ACS and MODS 循环系统,CVP升高,心输出量(CO)下降,ACS and MODS 循环系统,ACS and MODS,循环系统IAH 增加对前负荷评估的难度CVP?PAWP?CO?,ACS and MODS,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。,Alexander Schachtrupp,Juergen Graf,Christian Tons,et al.J Trauma.2003;55:734 740.,ACS and MODS 呼吸系统,ACS

7、and MODS 呼吸系统,Malbrain ML.Currunt Opinion of Critical Care.2004,10(2):132-145,呼吸系统静态顺应性降低,有认为：IAP 25mmHg是肾衰最敏感、特异性最高的指标之一。,FG(肾脏滤过压)=MAP-2IAP,ACS and MODS 肾功能,少尿，Cr,BUN,CCr 肾素、醛固酮、ADH,ACS and MODS 肾功能,Alexander Schachtrupp,Juergen Graf,Christian Tons,et al.J Trauma.2003;55:734 740.,ACS and MODS 肾功能,

8、尿量减少,Circling the Drain,Intra-abdominal PressureMucosalBreakdown(Multi-System Organ Failure)Bacterial translocationAcidosis,Decreased O2 deliveryAnaerobic metabolism,Capillary leakFree radical formation,MSOF,腹腔压力（IAP）监测与EN,IAP（cmH2O）,天,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

9、后病人IAH，是预防术后伤口并发症的重要环节。,ACS and MODS,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,ACS and MODS,Deeren D,Leijs J,Van den Brande E,et al.Crit Care Med in press.,ACS and MODS 神经系统,颅内压(ICP)与IAP,Joseph DA,Dutton RP,Aarabi B,et al.Traum

10、a,2004,57(4):687-695.,腹腔减压术前后参数改变,Cheatham 62(Supplement1):268,可逆性：依赖监测早、发现早、处理早,Critical care med,2006,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,IAP监测方法,直接测压法,腹部或腹膜后手术中14-F PVC圆形引流管,E.Risin,The American Journal of Srugery,191(2006)235-237,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

11、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,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,Intensive care med,2007,膀胱内压力测定方法（transvesical catheter）Simple,quick,and inexpensiveKron first described modern IAP monitoring in 1984

12、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-ORIGINAL KRON TECHNIQUE,禁忌神经性膀胱膀胱损伤膀胱挛缩,Malbrain ML,Deeren D,De Potter,et al.Current opinion in Critical Care.2005,11(2):156-171.,经膀胱压力测定法,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,60ml注射器向膀胱内注入NS.50-100ml,每次测量前膀胱内液体

13、相等 传感器零点位置关闭注射器连接阀，读取平均压力 q 2-4 hours监测一次.无菌 操作,经膀胱压力测定法,经膀胱压力测定法,In mmHg(1 mmHg=1.36 cm H2O)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(to allow bladder detrusor muscle relaxation)无腹肌紧张情况下,经膀胱压力测定法,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,充盈盐水量对IAP的影响,Chiumello et al.Critical Care 2007,11.,N

14、=13,N=20adult,充盈盐水量对IAP的影响,一次注入盐水量最多不超过 25ml-World Society on Abdominal Compartment Syndrome(WSACS)recommends,注射后平衡时间的影响,Chiumello et al.Critical Care 2007,11.,注射盐水温度的影响,Chiumello et al.Critical Care 2007,11.,室温加热至体温,Zero reference point,N=132 supine position Three reference levels were studied:耻骨联合

15、（the symphysis pubis）胸骨中线（the phlebostatic axis:(or mid-chest reference level)髂前上嵴腋中线（the midaxillary line at the level of the iliac）,IAPphlebostatic(9.9 4.67 mmHg)*IAPpubis(8.4 4.60 mmHg)*IAPmidax(12.2 4.66 mmHg)p 0.0001,零点位置,2,3,胸骨中线Phlebostatic axis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-axillary line at il

16、iac crest最为精确可重复性好,1,Journal of Surgical Research 139,280285(2007),IAP in defferent HOB and BMI,P0.001HOB-74%BMI-25-36%,N=45,N=16P=0.001,HOB and IAP,Intensive Care Med(2008)34:16321637,HOB and IAP,HOB 3045on average is 4 and 9 mmHg higher,Intensive Care Med(2009)35:969976,HOB and IAP,HOB 的提高可以显著升高IA

17、P过高的 BMI对IAP影响更为显著,P2-P1=-g(h2-h1),Prone and IAP,Intensive Care Med(2009)35:969976,IAP,IAP,no effect on systemic blood flow,renal perfusion,ect.,Prone IAP unchanged Martejovc et al.Michelet et al.,PEEP and IAP,Intensive Care Med(2009)35:969976,If IAP12mmHg,PEEP and IAP?,PEEP and IAP,N=30IAP-Original

18、 method by Kron.5min interval5Kg to the patients bellyPEEP:010,CLINICS 2009;64(2):105-12,CLINICS 2009;64(2):105-12,PEEP and IAP,CLINICS 2009;64(2):105-12,PEEP and IAP,p=0.47,P0.001,CLINICS 2009;64(2):105-12,PEEP and IAP,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.,CLINICS 2009;64

19、(2):105-12,PEEP and IAP,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,IAH/ACS的临床分级,UBP35cmH2O,UBP 2635cmH2O,UBP 1625cmH2O,无临床器官功能损害表现,UBP 1015cmH2O,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,Burch JM,Moore EE,Moore FA,et al.Surg Clin North Am 1996;76:833-842.,University of Utah:I

20、AP Monitoring Protocol,IAP monitoring Q1-2 hours for first12 hours,IAP consistently12 mm Hg,IAP 12 to 15mm Hg,IAP 15-20 mm Hgwith no evidenceof organ dysfunction/ischemia(ACS),IAP 20 mm HgORAPP 50-60 mm Hg?Plus evidence of organ dysfunction/ischemia(ACS),Optimize Abdominal perfusion pressureCareful

21、fluid managementPressors,Reduce IAPmeasurements to Q4-6 hoursfor 24 hours,“Second Hit”pt.develops new indication for IAPmonitoring,IAP remains12 mm Hgdiscontinuemonitoring,Consider Medical Management Sedation/Neuromuscular blockade Paracentesis of free fluidOther options Gastric suction,catharticsRe

22、ctal tube/enemasContinuous filtrationColloids,Surgical Decompression,ACS治疗,ACS治疗,Balogh,Z,McKinley BA,Holcomb JB.Trauma,2003,54(5):848-861,Balogh,Zsolt MD;McKinley,Bruce A.PhD;Holcomb,John B.MD;Trauma,2003,54(5):848-861,不要等发现ACS的临床表现再在决定进行IAP测定By then the patient has one foot in the grave!You have lost your opportunity for medical therapy对所有所有高腹压风险病人进行及早、动态的腹压监测：视腹压测定为重要生命体征观察的一部分在严重高腹压发生前早期干预,Thank You!,