腹腔間隙綜合征中文課件

1、腹腔內高壓與腹腔間隙綜合癥Intra-Abdominal Hypertension (IAH)&Abdominal CompartmentSyndrome (ACS)Sillent killer!你關注過他們的腹內壓是多少呢?你曾經(jīng)見過危重患者液體復蘇后越來越腫脹嗎？你見過ICU患者發(fā)生 腎衰 需要透析嗎？你曾經(jīng)見過患者發(fā)生多器官衰竭 最后死亡嗎?病例1: 膿毒癥兒童5 歲女孩因膿毒癥入院治療: 補液、 血管活性藥物、 抗生素24小時后癥狀加重：低血壓、無尿、低氧、高碳酸血癥。IAP = 26 腹腔減壓術迅速緩解了腎、肺和血流動力學不穩(wěn)定狀態(tài)7 天后關腹、存活出院DeCou, J Ped Su

2、rg 2000病例2:肺栓塞46 歲肺栓塞男性使用肝素抗凝后：迅速進展, 需要血管活性藥物、大量補液、輸血（后腹膜血腫）無尿、血壓下降、通氣困難IAP 50 mm Hg腹腔減壓后無尿、低血壓及呼吸機支持程度均好轉最后存活出院Dabney, Intensive Care Med 2001病例3: 胸部和盆腔創(chuàng)傷54 歲男性15英尺高墜落 肋骨、盆腔、腰椎骨折盆腔外固定、腰部制動2 天后出現(xiàn)呼吸困難、插管機械通氣肺部癥狀進展，出現(xiàn)低血壓，需要大量補液及多巴胺和去甲腎上腺素肺動脈導管顯示前負荷正常，但是出現(xiàn)無尿膀胱壓力 46 cm 減壓初期心肺功能迅速改善，但是后期惡化，9天后死于MSOF.Kope

3、lman, J Trauma 200077 歲男性臥床后誤吸. 轉入 ICU 后插管，低血壓一晚上給與10 升的靜脈補液,去甲腎 1.0 mg/kg/min. 無尿 (8小時35 ml 尿). 血乳酸 = 4.6IAP = 31 mm Hg. 腹部平片 大小腸明顯腫脹，超聲未顯示腹腔積液.外科會診后予以剖腹減壓1 小時后: IAP 12 mm Hg, 尿量210 ml, 去甲腎撤用Cheatham, WSACS 2006病例4: 誤吸患者由此可見創(chuàng)傷并不是ACS 唯一病因:IAH 和ACS 出現(xiàn)于多數(shù)ICU中 (PICU, MICU, SICU, CVICU, NCC, OR, ER).臨床監(jiān)

4、測IAP 是必要的: 能有助于判定IAH是否會導致器官功能衰竭 僅關注 IAP升高到一定的值將會導致診斷的延誤:臨床出現(xiàn)明顯的ACS癥狀后才去測定 IAP勢必會使 亞急性的臨床事件變?yōu)榧卑Y. IAP 監(jiān)測 能早期發(fā)現(xiàn)和早期干預 IAH ，以免發(fā)生 ACS .定義 what is it? 病因病理生理流行病學對患者預后的影響監(jiān)測:經(jīng)膀胱測壓治療t猶他 （Utah）大學的診療規(guī)范What is compartment syndrome?定義WCACS, Antwerp Belgium 2007腹腔內壓Intra-abdominal Pressure (IAP): 腹膜腔內的壓力 腹腔內高壓Intr

5、a-abdominal Hypertension (IAH): IAP持續(xù) 12 mm Hg (通常伴隨隱性缺血) ，不伴明顯的器官功能障礙腹腔間隙綜合征Abdominal Compartment Syndrome (ACS): IAH 20 mm Hg ，并且至少1個器官功能衰竭腹腔內壓力水平是如何定義的?壓力 (mm Hg) 定義 0-5 正常 5-10 大多 ICU患者常見 12(Grade I) 腹腔內高壓 16-20 (Grade II) 危險的 IAH - 建議開始非創(chuàng)傷性的 干預 21-25 (Grade III) 強烈提示ACS- 剖腹減壓伴隨對腹腔內壓力增高對器官功能的影響，

6、對腹腔內高壓的定義基準已經(jīng)下調WSACS.org生理改變/危重急癥組織缺血全身炎癥反應 (SIRS) 毛細血管滲漏組織水腫 (包括腸壁和腸系膜) 腹腔內高壓（IAH）液體復蘇IAP升高的原因嚴重的腹腔內、腹膜后病變缺血改變 / SIRS 需要液體復蘇：24小時內大量補液后正出的量超過5000ml 這么多液體到哪里去了呢？水在這兒呢!IAH&ACS病理生理改變心血管系統(tǒng): 腹腔內壓力增高導致:靜脈回心血流量減少導致大靜脈塌陷受壓胸腔內壓力 （ITP）增高后產生多種負性心肌效應 結果:心臟輸出量減少 全身血管阻力增加心臟負荷增加組織灌注降低, 混合血血氧飽和度ScvO2降低CVP 和 PAWP升高

7、，但并不能反應真正的右心室前負荷水平心臟供血不足 心臟驟停 PEEPPIP吸氣壓峰值腹內壓胸廓順應性胸膜腔壓力肺順應性氣道阻力心臟內壓力肺動脈導管心室順應性改變、瓣膜病變導管尖端的壓力 血管內容量CVP, PAOP & CI in the presence of Intra-abdominal Hypertensionr = -0.33r = -0.33CVP, PAOP 和心臟指數(shù)之間是無相關關系的Cheatham, Malbrain 2005Ridings, et al 1995肺: IAP增加導致:膈肌抬高導致肺容量減少, 胸廓順應性變差，變得“僵硬”, 肺泡充氣不良, 組織間液增加 (

8、淋巴回流受阻)結果:胸內壓增高氣道峰壓增加, 潮氣量減少間質水腫、 肺充氣不良、低氧血癥、高碳酸血癥機械通氣相關性肺損傷/氣壓傷細胞因子釋放 前炎癥反應ARDS病理生理改變:肺IAH正常ITP胃腸道: 腹內壓增高導致:腸系膜靜脈和毛細血管受壓/充血心輸出到胃腸道血流量減少 結果:腸道灌注減少, 水腫和滲出增加缺血、壞死 、細胞因子釋放、 中性粒細胞趨化聚集細菌易位SIRS發(fā)生發(fā)展腹腔內液體進一步增加腎臟: 腹腔內壓力增加導致:腎靜脈和實質受壓心臟輸出到腎臟血流量減少結果:腎血流量減少腎充血水腫腎小球濾過率降低 (GFR)腎衰、 少尿/無尿 正常腹部 CT 下腔靜脈注意腹腔是橢圓的，而不是球形正

9、常腎臟后腹膜血腫注意：腹腔是圓的，而不是橢圓形了！腎臟受壓，病人無尿Pickhardt, AJR 1999ACS 時異常的腹部 腎臟受壓變得扁平的下腔靜脈中樞神經(jīng)系統(tǒng): 腹腔內壓力增高導致:胸內壓增高上腔靜脈壓力增高導致回胸腔血流降低結果:中心靜脈壓增高顱內壓增高 大腦灌注壓降低腦水腫, 腦缺氧, 腦損傷 Maryland 休克創(chuàng)傷中心對顱內壓頑固升高的患者均常規(guī)實施開腹減壓手術病理生理改變腹腔內壓力改變對其它壓力指標的影響:IAP 增高會導致 ICP（顱內壓）, IJP（頸內靜脈壓） and CVP ( PAOP，肺動脈阻塞壓)增高15 升袋置于腹壁(Citerio 2001)IAH in

10、neuro patientsJoseph 2004: 腹腔減壓治療頑固性顱內高壓17 位經(jīng)其它治療(其中14位實施開顱減壓手術)后仍頑固性 ICP增高患者-平均 ICP 30 mm Hg, 平均 IAP 27 mm Hg 17位均行剖腹減壓術 100% ICP立即或數(shù)小時后下降-平均 17 mm Hg11 位 ICP一直正常這 11位均存活，并且無神經(jīng)系統(tǒng)后遺癥 “good neurologic outcome”缺血時間與細胞存活的關系不可逆的細胞凋亡或壞死Rivers Early goal directed therapy for sepsis lecture細胞氧需量的基線無氧代謝有氧代謝

11、時間緊迫的 (黃金小時- 分鐘為單位)心臟驟停 (5 min) 嚴重創(chuàng)傷(“The golden hour”)急性心肌梗死 (“time is muscle ” “90 min DTB”)休克 (“Brain attack” 3 hour time window)嚴重的ICP 升高 (cranial compartment syndrome)張力性氣胸、心包填塞 (thoracic compart syndrome)時間緊急的 (6 小時 - 小時為單位)膿毒性休克 (“Surviving sepsis” total body ischemia)IAH-ACS (“Surviving flui

12、d resuscitation” total body ischemia)肢體缺血 (栓塞, 肢端間隔綜合征)腸系膜缺血 (主動脈栓塞, IAH-ACS)Circling the DrainIntra-abdominal PressureMucosalBreakdown(Multi-System Organ Failure)Bacterial translocation,Cellular Apoptosis,NecrosisAcidosisDecreased O2 deliveryAnaerobic metabolismCapillary leakFree radical formationM

13、SOFICU患者ACS的發(fā)病率*?Malbrain, Intensive Care Medicine (2004):Abdominal pressure:Total PrevalenceMICU prevalenceSICU prevalenceIAP 1258.8%54.4%65%IAP 1528.9%29.8%27.5%IAP 20 plus organ failure8.2%10.5%5.0%*These data are for ALL ICU patients. MUCH higher if you use a protocol to select high risk patient

14、s.膿毒癥患者的發(fā)病率*Efstathiou et al, Intensive Care Med 2005;31 supp1 1: S183 Abs 703Abdominal pressure:Total PrevalenceMedical prevalenceSurgical prevalenceIAP 1258%52.1%67%IAP 1529%27.6%25.2%IAP 20 plus organ failure6%9.3%4.1%* These data are for ALL sepsis patients. MUCH higher if you look only at major

15、 fluid resuscitation.休克 和 液體復蘇患者的發(fā)病率？Requeira, 2007: 膿毒性休克患者ACS的發(fā)病率. 51% incidence of IAP 20 mm Hg in septic shock Daugherty, 2007: ACS常見于ICU中需要大量液體復蘇的患者.85% of patients with 5 liters positive fluid balance had IAH30% had IAP 20 with organ failure (abdominal compartment syndrome) 臨床判斷IAP升高的措施究竟有多少用處

16、呢? 隨機-雙盲的研究結果: 12 死亡率 38.8%無 IAH - 死亡率: 22.2%Malbrain, Crit Care Med, 2005內外危重ICU患者 IAH / ACS 會影響患者結局嗎?Al-Bahrani, 2008: 重癥胰腺炎患者腹內高壓的臨床相關性.18例重癥胰腺炎7 (39%) 例 IAP 15 (均超過 20) mm Hg: 45 % 死亡率 平均ICU住院時間 21 days IAH / ACS 會影響患者結局嗎? IAH 干預 會影響患者結局嗎?Ivatury, J Trauma, 1998: 損傷控制后的ACS.70 例檢測 IAP 18 mm Hg (2

17、5 cm H2O)25 例手術后立即關腹: 52% IAP 18 mm Hg39% 死亡-45 例 腹腔“開放”: 22% IAP 18 mm Hg10.6% 死亡Sun, 2006: 爆發(fā)性胰腺炎持續(xù)腹腔引流與傳統(tǒng)治療.110 例爆發(fā)性胰腺炎 - RCT對照組: 常規(guī) ICU 治療 實驗組: 常規(guī)治療再加上IAP監(jiān)測 (第一天平均 21 mm Hg )持續(xù)腹腔內引流 (drain 1800 cc on day 1)結局: 對照組 - 20.7%死亡, 28天住院時間 實驗組- 10.0% 死亡 (p0.01), 15 天住院時間 IAH 干預 會影響患者結局嗎?Cheatham 2007,

18、積極管理IAH/ ACS 提高存活率嗎? Acta Clinica Belgica引入management protocol in 2005前后的比較:開腹率 from 28% to 15% (medical management)如果開腹減壓, 早期進行 (不是發(fā)生ACS后) 關腹天數(shù)從平均21天降至6天初次成功關腹率從 1/3 to 2/3機械通氣天數(shù)降低住院日從 28 天到 18 天存活率從 51%到72% IAH 干預 會影響患者結局嗎?Does IAH / ACS affect patient outcome?Points:IAH / ACS is common in the ICU

19、 environment (including yours).IAH and ACS increase morbidity, mortality and ICU length of stay.Early, protocol driven interventions improve outcomes without increasing cost of care (shorter ICU and hospital LOS)However:Clinical signs of IAH are unreliable and only show up late in the clinical cours

20、e .SO Early monitoring (TRENDING) & detection of IAH with early intervention is needed to obtain optimal outcomes.Intra-Abdominal Pressure Monitoring Intra-Abdominal Pressure Monitoring“The reference standard for intermittent IAP measurement is via the bladder with a maximal instillation volume of 2

21、5 ml sterile saline.”WSACS.org“Home Made” Pressure Transducer TechniqueHome-made assembly:Transducer2 stopcocks1 60 ml syringe, 1 tubing with saline bag spike / luer connector1 tubing with luer both ends1 needle / angiocathClamp for FoleyAssembled sterilely, used in proper fashion!“Home Made” Pressu

22、re Transducer TechniquePROBLEMS:Home-made: No standardization - confidence problem with dataSterility issues - CAUTI no longer reimbursedTime consuming* therefor its use is late and infrequent due to the hassle factor (i.e. not monitoring - waiting for ACS)Data reproducibility errors - what are the

23、costs / morbidity of inaccurate or delayed information?Other: Needle stick, Recurrent penetration of sterile system, Leaks, re-zeroing problems, failure to trendFluid-Column ManometrySedrak 2002Problems:Failure to pay extreme attention to detail may lead to errorsSiphon effect leads to false elevati

24、onsInadequate volume of infusion will lead to falsely low measurementsCAUTI Risk - Need to infuse urine back into patientBladder Pressure Monitoring: How to do itCommercially available devices :Foley Manometer (Bladder manometer) CiMon (Gastric)Spiegelberg (Gastric)AbViser (Bladder transduction)IAP

25、monitor (Bladder transduction)Advantages Simple, Standardized, Reproducible, Time efficient, SterileAbViser: Reproducibility StudyInter-observer Scatterplot (r = 0.95, p 50- 60 mm Hg) Similar to Cerebral perfusion pressureAPP = MAP-IAPNGT / Cathartics / Rectal tube / enemasParalysis - Balance risk v

26、s. benefit IAH/ACS Management : PositioningVasquez, 2007IAH/ACS Management: ParalysisDe Waele, Crit Care Med 2003UOPIAPIAH/ACS Management: ColloidsOMara, 2005: Prospective randomized evaluation of IAP with crystalloid and colloid resuscitation in burns31 cases with 25% burn plus inhalation or 40% bu

27、rn without inhalationRandomized to saline vs plasmaResults post resuscitation:Crystalloid IAP mean 26.5 mm HgPlasma IAP mean 10.6 mm HgIAH/ACS Management: HemofiltrationOda, 2005: Management of IAH in patients with severe acute pancreatitis using continuous hemofiltration.17 cases of severe pancreat

28、itis and IAHTreated with hemofiltration when IAP + 15 mm, PRIOR to developing renal insufficiency (maintained adequate serum oncotic pressure with albumin)Results:Interleukin (IL-6) cytokine levels cut in halfReduced vascular permeability and interstitial edemaMean IAP value dropped from 15 mm to le

29、ss than 10 mm16 of 17 patients discharged alive without complicationIAH/ACS Management: ParacentesisMultiple case series reporting successful treatment of IAH and ACS:Latenser 2002: Burn patient managementReckard 2005: Peripancreatic fluid filled massSharp 2002: Pediatric blunt traumaEtzion 2004: Ma

30、lignant ascites therapySun 2006: Pancreatitis (prospective RCT) Cut deaths in half, cut hospital LOS by 13 daysIAH/ACS ManagementDecompressive Laparotomy:Err on the side of early vs late interventionLess bowel edema or cell damage, better chance of early closure and early recovery.Be aware that dela

31、ying care until this complication occurs is VERY expensive more expensive the longer you wait:Vanderbilt costs for open abdomen (Vogel 2007): Same admission closure - $150,000Failure to close on initial admission $250,000 (estimate nearly as much over next year by time ventral hernia finally repaire

32、d).IAH/ACS Management: Decompressive LaparotomyRigid Abdomen in ACS Post decompressive laparotomy Decompressive LaparotomyDelay in abdominal decompression may lead to intestinal ischemiaDecompress Early!Decompressive LaparotomyPost-operative dressingSeveral days post-opNo such thing as an “Open Abdo

33、men” in the ICU“Open Abdomen” Vac-pac dressing placed in OR. Now 6 hours post-op:MAP=70 HR=114 IAP=24UOP 100 cc/ hour PIP = 30 cm H2ONo such thing as an “Open Abdomen” in the ICU24 hours into ICU stay:Worsened bowel edemaHowever:MAP = 79IAP = 12Lactate = 1.9Note expansion of visceraSurgical Manageme

34、nt of Compartment SyndromesCompartment Cranium ChestPericardiumLimbPathophysiologyICP elevationTension pneumothoraxCardiac tamponadeExtremity compartment syndromeSurgical Management Craniotomy, etc.Chest tube PericardiocentesisFasciotomyCompartment Syndromes versus HypertensionAbdominal compartment

35、syndrome = Emergent Surgical Disease.Intra-abdominal hypertension = Urgent Medical Disease.Cost analysisIs IAP monitoring and intervention cost effective?Cost analysisCompartment syndrome risk comparisonThe Cranium: Fall, hit head, LOC, vomiting but alertIs it worth the cost of a head CT? (Standard

36、of Care)Incidence is less than 5% positiveLess than 0.5% need any interventionThe Abdomen: ICU patient with major fluid resuscitation (5 liters positive at 24 hours)Is it worth the cost of measuring their IAP?Incidence of IAH is 85% 30% will have ACSCost analysis: Time dependent critical care interv

37、entions vs. lives savedNumber needed to treat to save one life:IAH/ACS aggressive protocol: 3-10EGDT for sepsis: 6-8Low volume ventilation: 10Xigris activated protein C: 16Thrombolytics or cardiac cath: 37tPA for stroke: 100tPA instead of streptokinase: 111Cost analysis: IAP monitoring impact on res

38、ource utilization.Summary of Cheatham and Sun data:Simplest and most conservative calculation is 10 to 13 days reduced hospital LOS with far higher survival rate.Assume low end of $1000-$2000/day savings:Save $10,000-$20,000 per patient with IAH who has early monitoring and protocol driven care.Open

39、 up ICU bed soonerIncrease survivalCost analysis: IAP monitoring impact on resource utilization.Other more difficult to quantify costsOpportunity costs (think waitress with a table)Longer ICU LOS leads to inability to admit another patient to that bed.ICU charges are far higher during first few days

40、 of admission so in terms of business, long ICU LOS leads to losses in terms of new patient billing.Mortality costsHigher death rate without treatment leads to loss of that person from productive life in society. What is the economic value of a human life?What is a reasonable cost to save one life?S

41、ummary: Is IAP monitoring and intervention cost effective?IAH is very common in fluid resuscitated patientsIAH cannot be clinically detected IAH/ACS outcome is time dependent.Delayed detection/intervention consumes more resourcesDelayed detection/intervention results in higher mortality.Aggressive i

42、ntervention leads to reduced costs with better outcomes.So.Conclusion - Is IAP monitoring and intervention cost effective?The cost of monitoring intra-abdominal pressure - early and often - is far outweighed by the savings in clinician time, organ function, hospital days and lives saved.IAH monitoring and intervention protocolWSACS IAH/ACS Guidelines 2007Assessment algorithmManagement algorithmIAP monitoring algorithmEntry criteria defined in tableNurse is empowered to enter any patient f