腹腔高压症及腹腔压力监测在危重病人中的应用[1]VIP免费

腹腔高压症及腹腔压力监测彭沪背景•19世纪后期，Eddy•1890年，Heinricius•1951年，Baggot•1984年，KronResultsfromtheInternationalConferenceofExpertsonIntra-AbdominalHypertension(IAH)andAbdominalCompartmentSyndrome(ACS)•DEFINITIONS•IntensiveCareMedicine2006;32:1722-1732•www.wsacs.orgINTRODUCTIONTOTHEDEFINITIONS•Intra-abdominalhypertension(IAH)andabdominalcompartmentsyndrome(ACS)havebeenincreasinglyrecognizedinthecriticallyillascausesofsignificantmorbidityandmortality.•Thevarietyofpreviousdefinitionshasledtoconfusionanddifficultyincomparingonestudytoanother.•AninternationalgroupofcriticalcarespecialistsconvenedtostandardizedefinitionsforbothIAHandACSaswellasestablishstandardsforthemeasurementofintra-abdominalpressure(IAP).•www.wsacs.orgWHATISINTRA-ABDOMINALPRESSURE?•ElevatedIAPisacommonfindingintheICU•IAPincreasesanddecreaseswithrespiration•IAPisdirectlyaffectedby:1.Solidorganorhollowvisceravolume2.Spaceoccupyinglesions•Ascites,blood,fluid,tumors3.Conditionsthatlimitexpansionoftheabdominalwall•Burneschars,third-spaceedemawww.wsacs.orgwww.wsacs.orgWHATISABDOMINALPERFUSIONPRESSURE?•“Abdominalperfusionpressure(APP)=meanarterialpressure(MAP)minusintra-abdominalpressure(IAP)=MAP-IAP.”•ThecriticalIAPthatleadstoorganfailurevariesbypatient•AsinglethresholdIAPcannotbegloballyappliedtoallpatients•Analogoustocerebralperfusionpressure,APPassessesnotonlytheseverityofIAP,butalsotherelativeadequacyofabdominalbloodflow•APPissuperiortoIAP,arterialpH,basedeficit,andarteriallactateinpredictingorganfailureandpatientoutcome•FailuretomaintainAPP>60mmHgbyday3predictssurvivalwww.wsacs.orgwww.wsacs.orgHOWSHOULDIAPBEMEASURED?•“IAPshouldbeexpressedinmmHgandmeasuredatend-expirationinthecompletesupinepositionafterensuringthatabdominalmusclecontractionsareabsentandwiththetransducerzeroedatthelevelofthemidaxillaryline.”•PhysicalexamisinaccurateinpredictingIAP–Sensitivity40-61%–Positivepredictivevalue45-76%•IAPmeasurementsareessentialtothediagnosisofelevatedIAPandthemanagementofIAH•AvarietyoftechniquesmaybeusedtomeasureIAPwww.wsacs.orgwww.wsacs.orgWHATISTHEREFERENCESTANDARDFORIAP?•“ThereferencestandardforintermittentIAPmeasurementisviathebladderwithamaximalinstillationvolumeof25mlsterilesaline.”www.wsacs.orgwww.wsacs.orgWHATISNORMALIAP?•“NormalIAPisapproximately5-7mmHgincriticallyilladults.”Normaladult0-5mmHgTypicalICUpatient5-7mmHgPost-laparotomypatient10-15mmHgPatientwithsepticshock15-25mmHgPatientwithacuteabdomen25-40mmHgwww.wsacs.orgwww.wsacs.orgWHATISINTRA-ABDOMINALHYPERTENSION?•“IAHisdefinedbyasustainedorrepeatedpathologicalelevationinIAP≥12mmHg.”•ThedefinitionofIAHhasvariedovertheyearswiththresholdsashighas40mmHgbeingpreviouslyadvocated.–MostcliniciansarethereforeconcernedonlywhenIAPexceeds20-25mmHg•ThisiswellabovetheIAPthatcancauseorgandysfunctionandfailure–FailuretointervenewhenIAPrisesabove25mmHgisassociatedwithpooreroutcomewww.wsacs.orgwww.wsacs.orgHOWISIAHGRADED?•“IAHisgradedasfollows:–GradeIIAP12-15mmHg–GradeIIIAP16-20mmHg–GradeIIIIAP21-25mmHg–GradeIVIAP>25mmHg.”•TheIAHgradeshavebeenreviseddownwardasthedetrimentalimpactofelevatedIAPonend-organfunctionhasbeenrecognizedwww.wsacs.orgwww.wsacs.orgWHATISABDOMINALCOMPARTMENTSYNDROME?•“ACSisdefinedasasustainedIAP>20mmHg(withorwithoutanAPP<60mmHg)thatisassociatedwithneworgandysfunction/failure.”•A...