腹腔高压症及腹腔压力监测在危重病人中的应用1

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1、腹腔高压症及腹腔压力监测腹腔高压症及腹腔压力监测 彭彭 沪沪背景背景 19世纪后期，世纪后期，Eddy 1890年，年，Heinricius 1951年，年，Baggot 1984年，年，KronResults from the International Conference of Experts on Intra-Abdominal Hypertension(IAH)and Abdominal Compartment Syndrome(ACS)DEFINITIONS Intensive Care Medicine 2006;32:1722-1732 www.wsacs.orgINTRODU

2、CTION TO THE DEFINITIONS Intra-abdominal hypertension(IAH)and abdominal compartment syndrome(ACS)have been increasingly recognized in the critically ill as causes of significant morbidity and mortality.The variety of previous definitions has led to confusion and difficulty in comparing one study to

3、another.An international group of critical care specialists convened to standardize definitions for both IAH and ACS as well as establish standards for the measurement of intra-abdominal pressure(IAP).www.wsacs.orgWHAT IS INTRA-ABDOMINAL PRESSURE?Elevated IAP is a common finding in the ICU IAP incre

4、ases and decreases with respiration IAP is directly affected by:1.Solid organ or hollow viscera volume2.Space occupying lesions Ascites,blood,fluid,tumors3.Conditions that limit expansion of the abdominal wall Burn eschars,third-space edemaWHAT IS ABDOMINAL PERFUSION PRESSURE?“Abdominal perfusion pr

5、essure(APP)=mean arterial pressure(MAP)minus intra-abdominal pressure(IAP)=MAP-IAP.”The critical IAP that leads to organ failure varies by patient A single threshold IAP cannot be globally applied to all patients Analogous to cerebral perfusion pressure,APP assesses not only the severity of IAP,but

6、also the relative adequacy of abdominal blood flow APP is superior to IAP,arterial pH,base deficit,and arterial lactate in predicting organ failure and patient outcome Failure to maintain APP 60 mmHg by day 3 predicts survivalHOW SHOULD IAP BE MEASURED?“IAP should be expressed in mmHg and measured a

7、t end-expiration in the complete supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the midaxillary line.”Physical exam is inaccurate in predicting IAP Sensitivity 40-61%Positive predictive value 45-76%IAP measurements are esse

8、ntial to the diagnosis of elevated IAP and the management of IAH A variety of techniques may be used to measure IAPWHAT IS THE REFERENCE STANDARD FOR IAP?“The reference standard for intermittent IAP measurement is via the bladder with a maximal instillation volume of 25ml sterile saline.”WHAT IS NOR

9、MAL IAP?“Normal IAP is approximately 5-7 mmHg in critically ill adults.”Normal adult0-5 mmHgTypical ICU patient5-7 mmHgPost-laparotomy patient10-15 mmHgPatient with septic shock15-25 mmHgPatient with acute abdomen25-40 mmHgWHAT IS INTRA-ABDOMINAL HYPERTENSION?“IAH is defined by a sustained or repeat

10、ed pathological elevation in IAP 12mmHg.”The definition of IAH has varied over the years with thresholds as high as 40 mmHg being previously advocated.Most clinicians are therefore concerned only when IAP exceeds 20-25 mmHg This is well above the IAP that can cause organ dysfunction and failure Fail

11、ure to intervene when IAP rises above 25 mmHg is associated with poorer outcomeHOW IS IAH GRADED?“IAH is graded as follows:Grade I IAP 12-15 mmHg Grade IIIAP 16-20 mmHg Grade III IAP 21-25 mmHg Grade IV IAP 25mmHg.”The IAH grades have been revised downward as the detrimental impact of elevated IAP o

12、n end-organ function has been recognizedWHAT IS ABDOMINAL COMPARTMENT SYNDROME?“ACS is defined as a sustained IAP 20mmHg(with or without an APP=20 mm Hg*出现一个或多个脏器功能衰竭出现一个或多个脏器功能衰竭*Malbrain M L;Deeren D;De Potter,et al.Current opinion in Critical Care.2005,11(2):156-171.IAH/ACS 表现表现 特征性变化特征性变化 腹胀腹胀 心

13、输出量（心输出量（CO）下降）下降 肺顺应性下降，气道峰压肺顺应性下降，气道峰压(Ppeak)急剧急剧升高升高 少尿或无尿少尿或无尿 病因及流行病学病因及流行病学ACS病因病因急性急性慢性慢性腹部因素腹部因素非腹部因素非腹部因素病因及流行病学病因及流行病学 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预测病人死亡率的独立危险因素 年龄年龄 APACHE 收入收入ICU类型类型 有无肝功能不全有

14、无肝功能不全 ICU期间发生期间发生IAH 入院第一日入院第一日IAP12mmHg APP(腹腔灌注压腹腔灌注压)=MAP-IAPMalbrain ML,Chiumello D,Pelosi P,et al.CCM,2005,33(2):315-322 病因及流行病学病因及流行病学*Cheatham ML,White MW,Sagraves SG,et al.J Trauma 2000;49:621-626.病因及流行病学病因及流行病学 IAH独立预测因素（独立预测因素（independent predictors）肝功能不全肝功能不全 腹部手术腹部手术 液体复苏液体复苏 肠麻痹肠麻痹-高度警

15、惕高度警惕IAH的发生！的发生！Malbrain ML,Chiumello D,Pelosi P,et al.CCM,2005,33(2):315-322 IAP监测方法监测方法腹腔压力测定腹腔压力测定经经膀膀胱胱测测压压法法间接测压法间接测压法直接测压法直接测压法下下腔腔静静脉脉压压经经胃胃测测压压法法经经直直肠肠测测压压法法穿穿刺刺直直接接测测压压经经腹腹引引管管测测压压 膀胱内压力测定方法膀胱内压力测定方法（urinary bladder pressure,UBP）Kron等在等在1984年提出并推广应用。年提出并推广应用。原理：膀胱内有原理：膀胱内有50100ml液体时膀胱壁会液体时膀

16、胱壁会象膈肌一样反映象膈肌一样反映IAP的变化。的变化。IAP监测方法监测方法 IAP监测方法监测方法 股静脉股静脉/下腔静脉压力测定方法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测定结果有较好的相关性 股静脉及下腔静脉血流与股静脉及下腔静脉血流与IAP呈负相关性改变，即虽呈负相关性改变，即虽着着IAP增高而降低增高而降低IAP监测方法监测方法 胃内压力测定方法胃内压力测定方法 经鼻胃管向胃内注入经鼻胃管向胃内注入50-

17、100ml生理盐水，生理盐水，连接传感器或压力计，以腋中线为零点进连接传感器或压力计，以腋中线为零点进行测量。行测量。IAP监测方法监测方法 www.wsacs.org 循环系统循环系统 ACS and MODS胸腔内压力胸腔内压力静脉回心血量静脉回心血量外周血管阻力外周血管阻力IAP机械性压迫机械性压迫心输出量心输出量下腔静脉、门静脉和下腔静脉、门静脉和腹膜后静脉血流减少腹膜后静脉血流减少膈肌升高，下腔静脉膈肌升高，下腔静脉发生扭曲、狭窄发生扭曲、狭窄ACS and MODS 循环系统循环系统 IAP为为2025mmHg时，出现时，出现CO/CI明显下降，明显下降，HR增快，增快，BP降低，

18、降低，CVP仍升高仍升高 IAH 增加对前负荷评估的难度增加对前负荷评估的难度 CVP?CO?Alexander Schachtrupp,Juergen Graf,Christian Tons,et al.J Trauma.003;55:734 740.ACS and MODS 循环系统循环系统CVP升高升高心输出量心输出量(CO)下降下降Alexander Schachtrupp,Juergen Graf,Christian Tons,et al.J Trauma.2003;55:734 740.ACS and MODS 循环系统循环系统胸腔内血流量胸腔内血流量(ITBV)降低降低总循环血量

19、总循环血量(TCBV)降低降低Alexander Schachtrupp,Juergen Graf,Christian Tons,et al.J Trauma.2003;55:734 740.ACS and MODS 循环系统循环系统CO 与与 ITBVCO 与与 CVPACS and MODS 呼吸系统呼吸系统 最早和显著的临床表现。最早和显著的临床表现。Ppeak升高，肺顺应性下降，升高，肺顺应性下降，P/F下降，高碳酸血症。下降，高碳酸血症。膈肌抬高膈肌抬高IAP机械性压迫机械性压迫胸腔内容量减少胸腔内容量减少肺脏扩张受限肺脏扩张受限肺脏的血管床阻力肺脏的血管床阻力肺不张肺不张肺泡水肿肺

20、泡水肿ACS and MODS 呼吸系统呼吸系统 呼吸系统总静态顺应性呼吸系统总静态顺应性 PV 曲线变平并右移曲线变平并右移 IAP 升高时，升高时，IAP与与PV曲线下拐点呈正相关曲线下拐点呈正相关关系。关系。肺中性粒细胞激活，肺脏炎性渗出增加肺中性粒细胞激活，肺脏炎性渗出增加 肺泡水肿及压缩性肺不张肺泡水肿及压缩性肺不张 Malbrain ML,Deeren D,Nieuwendijk R,et al.Intensive Care Med 2003;29:S85.Alexander Schachtrupp,Juergen Graf,Christian Tons,et al.J Traum

21、a.2003;55:734 740.ACS and MODS 呼吸系统呼吸系统血管外肺水增加血管外肺水增加气道峰压升高气道峰压升高ACS and MODS 主动脉和肾动脉受压，主动脉和肾动脉受压，肾脏毛细血管网阻力升高，肾脏毛细血管网阻力升高，肾静脉回流受阻肾静脉回流受阻输尿管受压输尿管受压IAP机械性压迫机械性压迫肾动脉的灌注血量减少，肾动脉的灌注血量减少，肾皮质的血流分流到髓质，肾皮质的血流分流到髓质，致使肾小球的有效滤过率下致使肾小球的有效滤过率下降，尿的生成减少降，尿的生成减少肾功能肾功能FG(肾脏滤过压肾脏滤过压)=MAP-2 IAPACS and MODS 肾功能肾功能 少尿，少尿

22、，Cr,BUN,CCr 肾素、醛固酮、肾素、醛固酮、ADHAlexander Schachtrupp,Juergen Graf,Christian Tons,et al.J Trauma.2003;55:734 740.ACS and MODS 肾功能肾功能尿量减少尿量减少ACS and MODS-肾功能肾功能Balogh,Z,McKinley BA,Holcomb JB.Trauma,2003,54(5):848-861 ACS and MODS-肾功能肾功能Lindstrm P,Wadstrm J,Ollerstam A,et al.Nephrology Dialysis Transpla

23、ntation,2003,18(11):2269-2277.胃肠道胃肠道 大量动物实验证实小肠血流量与大量动物实验证实小肠血流量与IAH有关，有关，IAP 升升至至10 mmHg，胃肠道灌注减少，胃肠道灌注减少细菌移位细菌移位 内脏受压，内脏缺血。内脏受压，内脏缺血。研究显示研究显示IAH刺激促炎介质的释放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门静脉及中心静脉细胞因子水平显著升高 肠道喂养困难肠道喂养困难Friedlander MH,Simon RJ,Ivatury R,et al.J Trauma 1998;45:433-489.ACS and MODS 0 05 5101

24、015152020252530303535404045451 13 35 57 79 91111 1313 1515 1717 1919 2121 2323 2525 2727TPNEN+PN 神经系统神经系统 IAP25mmHg时出现时出现 ICP-颅内压力升高，与颅内压力升高，与IAP成正相关。成正相关。CPP-脑灌注压降低，脑灌注压降低，CPP=MAP-ICP 胸腔内压和胸腔内压和CVP增高使脑组织静脉血回流受阻，增高使脑组织静脉血回流受阻，颅内血管床扩大所致颅内血管床扩大所致 CPP下降，颅内损害加重下降，颅内损害加重 头部创伤病人应谨慎使用腹腔镜诊治，并应监测头部创伤病人应谨慎使用腹

25、腔镜诊治，并应监测IAPACS and MODS Deeren D,Leijs J,Van den Brande E,et al.Crit Care Med in press.ACS and MODS 神经系统神经系统颅内压颅内压(ICP)与与IAP Joseph DA,Dutton RP,Aarabi B,et al.Trauma,2004,57(4):687-695.腹腔减压术前后参数改变腹腔减压术前后参数改变外科重症病人外科重症病人IAP改变的临床观察改变的临床观察*UBP25cmH2O为为IAH组，组，UBP25cmH2O为对照组为对照组*与与IAH相关的临床情况相关的临床情况外科重症

26、病人外科重症病人IAP改变的临床观察改变的临床观察外科重症病人外科重症病人IAP改变的临床观察改变的临床观察*IAHIAH组组对照组对照组*p=0.000r=0.812外科重症病人外科重症病人IAP改变的临床观察改变的临床观察p=0.042r=-0.283外科重症病人外科重症病人IAP改变的临床观察改变的临床观察外科重症病人外科重症病人IAP改变的临床观察改变的临床观察10101515202025253030353540405 51515252535354545UBP（c mH2O）UBP（c mH2O）RR(bpm)RR(bpm)p=0.000r=0.7495 510101515202025

27、2530303535404010102020303040405050UBP（c mH2O）UBP（c mH2O）Ppeak(cmH2O)Ppeak(cmH2O)p=0.000r=0.641505010010015015020020025025030030035035010102020303040405050UBP(cmH2O)UBP(cmH2O)P/FP/Fp=0.000r=-0.625外科重症病人外科重症病人IAP改变的临床观察改变的临床观察IAH/ACS的临床分级：的临床分级：级，级，UBP在在1015cmH2O，无临床器，无临床器 官功能损害表现；官功能损害表现；级，级，UBP为为162

28、5cmH2O，出现临床，出现临床 器官功能损害表现；器官功能损害表现；级，级，UBP为为2635cmH2O，多数患者，多数患者 出现器官损害表现；出现器官损害表现；级，级，UBP35cmH2O。*、级患者应进行手术治疗。级患者应进行手术治疗。Burch JM,Moore EE,Moore FA,et al.Surg Clin North Am 1996;76:833-842.治疗治疗 保守治疗保守治疗 胃肠减压胃肠减压 胃肠动力药物胃肠动力药物 利尿剂或与利尿剂或与20白蛋白联合应用白蛋白联合应用 CHVF 镇静镇静 腹腔减压术腹腔减压术认识认识IAH/ACS的重要意义的重要意义 IAH/AC

29、SIAH/ACS是一种由是一种由IAPIAP增高导致多器官功能损害的增高导致多器官功能损害的临床征候群，临床征候群，IAPIAP越高死亡率越高。越高死亡率越高。对对IAPIAP进行准确的动态测量，经膀胱测压法简便易进行准确的动态测量，经膀胱测压法简便易行、重复性好，可作为行、重复性好，可作为IAHIAH监测的重要指标。监测的重要指标。MalbrainMalbrain 等建议病人临床情况恶化时监测等建议病人临床情况恶化时监测IAPIAP。DaughertyDaugherty日液体平衡日液体平衡5L5L，应行，应行IAPIAP监测。监测。IAP20cmHIAP20cmH2 2O O并伴有其他病理生理学改变（如并伴有其他病理生理学改变（如PpeakPpeak和和/或少尿等）时，应行腹腔减压性手术或少尿等）时，应行腹腔减压性手术治疗。治疗。Intra-abdominal hypertension in the critically ill:it is time to pay attention!