腹腔压力监测---腹腔高压及腹间隔室综和征的诊治VIP专享VIP免费

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IAPIAPIAHIAHACSACS腹腔内压力Intra-abdominalPressure正常IAP:0-5mmHg腹腔高压症Intra-abdominalHypertensionIAP≥12mmHg*腹间隔室综合征AbdominalCompartmentSyndromeIAP≥20mmHg出现一个或多个脏器功能衰竭*MalbrainML;DeerenD;DePotter,etal..CurrentopinioninCriticalCare.2005,11(2):156-171.IAH/ACSIAH/ACSIAH/ACSIAH/ACSIAP决定于脏器容积占位性损伤出血积液肿瘤腹壁顺应性DefinitionofWSACSWSACSCurrentopinioninCriticalCare.2005,11(2):156-171.正常值PatientpopulationNumberIAP(mean±SD)SugermanUC55.1±1.2SanchezS-NS275.0±2.9ChionhS-NS587.0(0.7–3.2)LambertELS40.0±1.5ArfvidssonGS46.2±1.2WSACS：5-7mmHgIntensiveCareMed(2009)35:969–976正常值ComparisonofIAPamongdifferentweightgroupsIntensiveCareMed(2009)35:969–9767-14mmHgIAH发病率IAH发生率约50%ACS病死率：40-100％IAP正常67.9％IAH32.1%ACS4.2%IAH中发生ACS12.9％MalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322IAPTotalPrevalenceMICUPrevalenceSICUPrevalenceIAP>1258.8%54.5%65%IAP>1528.9%29.8%27.5%IAP>20Plusorganfailure8.2%10.5%5.0%Malbrain,IntensiveCareMedicine(2004):ThehighertheIAPthepoorerthesurvivalrateMalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322预测病人死亡率的独立危险因素年龄APACHEⅡ收入ICU类型有无肝功能不全ICU期间发生IAH•入院第一日IAP≥12mmHgAPP(腹腔灌注压)=MAP-IAPMalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322*CheathamML,WhiteMW,SagravesSG,etal.JTrauma2000;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ACSandMODSMalbrainML,Deeren,D,DePotter,etal.CurrentopinioninCriticalCare.2005,11(2):156-171.ACS：IAH+器官功能障碍ACSandMODSACSIAP↑---→MODS---→DEATH呼吸循环肾脏t颅脑胃肠其它ACSandMODSMalbrainML,ChiumelloD,PelosiP,etal.CCM,2005,33(2):315-322IAP越高器官衰竭的数目越多ACSandMODS腹胀CO↓Ppeak↑肺顺应性↓少尿无尿ACSIAP↑↑循环系统ACSandMODS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AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.003;55:734–740.ACSandMODS–循环系统CVP升高心输出量(CO)下降ACSandMODS–循环系统ACSandMODS循环系统IAH增加对前负荷评估的难度•CVP?•PAWP?•CO?ACSandMODS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。膈肌抬高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。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。肺不张肺泡水肿AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS–呼吸系统血管外肺水增加气道峰压升高ACSandMODS–呼吸系统MalbrainML.CurruntOpinionofCriticalCare.2004,10(2):132-145呼吸系统静态顺应性降低有认为：IAP25mmHg是肾衰最敏感、特异性最高的指标之一。FG(肾脏滤过压)=MAP-2IAPACSandMODS–肾功能少尿，Cr,BUN↑,CCr↓肾素、醛固酮、ADH↑ACSandMODS–肾功能AlexanderSchachtrupp,JuergenGraf,ChristianTons,etal.JTrauma.2003;55:734–740.ACSandMODS–肾功能尿量减少CirclingtheDrainIntra-abdominalPressureMucosalBreakdown(Multi-SystemOrganFailure)BacterialtranslocationAcidosisDecreasedO2deliveryAnaerobicmetabolismCapillaryleakFreeradicalformation腹腔压力（IAP）监测与EN05101520253035404513579111315171921232527TPNEN+PNIAP（cmH2O）天腹壁腹腔...