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1、腹腔内高压与腹腔间隙综合症Intra-Abdominal Hypertension(IAH)&Abdominal CompartmentSyndrome(ACS),Sillent killer!,你关注过他们的腹内压是多少呢?,你曾经见过危重患者液体复苏后越来越肿胀吗？你见过ICU患者发生 肾衰 需要透析吗？你曾经见过患者发生多器官衰竭 最后死亡吗?,病例1:脓毒症儿童,5 岁女孩因脓毒症入院治疗:补液、血管活性药物、抗生素24小时后症状加重：低血压、无尿、低氧、高碳酸血症。IAP=26 腹腔减压术迅速缓解了肾、肺和血流动力学不稳定状态7 天后关腹、存活出院,DeCou,J Ped Surg
2、2000,病例2:肺栓塞,46 岁肺栓塞男性使用肝素抗凝后：迅速进展,需要血管活性药物、大量补液、输血（后腹膜血肿）无尿、血压下降、通气困难IAP 50 mm Hg腹腔减压后无尿、低血压及呼吸机支持程度均好转最后存活出院,Dabney,Intensive Care Med 2001,病例3:胸部和盆腔创伤,54 岁男性15英尺高坠落 肋骨、盆腔、腰椎骨折盆腔外固定、腰部制动2 天后出现呼吸困难、插管机械通气肺部症状进展，出现低血压，需要大量补液及多巴胺和去甲肾上腺素肺动脉导管显示前负荷正常，但是出现无尿膀胱压力 46 cm 减压初期心肺功能迅速改善，但是后期恶化，9天后死于MSOF.,Kope
3、lman,J Trauma 2000,77 岁男性卧床后误吸.转入 ICU 后插管，低血压一晚上给与10 升的静脉补液,去甲肾 1.0 mg/kg/min.无尿(8小时35 ml 尿).血乳酸=4.6IAP=31 mm Hg.腹部平片 大小肠明显肿胀，超声未显示腹腔积液.外科会诊后予以剖腹减压1 小时后:IAP 12 mm Hg,尿量210 ml,去甲肾撤用,Cheatham,WSACS 2006,病例4:误吸患者,由此可见,创伤并不是ACS 唯一病因:IAH 和ACS 出现于多数ICU中(PICU,MICU,SICU,CVICU,NCC,OR,ER).临床监测IAP 是必要的:能有助于判定I
4、AH是否会导致器官功能衰竭 仅关注 IAP升高到一定的值将会导致诊断的延误:临床出现明显的ACS症状后才去测定 IAP势必会使 亚急性的临床事件变为急症.IAP 监测 能早期发现和早期干预 IAH，以免发生 ACS.,定义 what is it?病因病理生理流行病学对患者预后的影响监测:经膀胱测压治疗t犹他（Utah）大学的诊疗规范,What is compartment syndrome?,定义WCACS,Antwerp Belgium 2007,腹腔内压Intra-abdominal Pressure(IAP):腹膜腔内的压力 腹腔内高压Intra-abdominal Hypertensi
5、on(IAH):IAP持续 12 mm Hg(通常伴随隐性缺血)，不伴明显的器官功能障碍腹腔间隙综合征Abdominal Compartment Syndrome(ACS):IAH 20 mm Hg，并且至少1个器官功能衰竭,腹腔内压力水平是如何定义的?,压力(mm Hg)定义 0-5 正常 5-10 大多 ICU患者常见 12(Grade I)腹腔内高压 16-20(Grade II)危险的 IAH-建议开始非创伤性的 干预 21-25(Grade III)强烈提示ACS-剖腹减压伴随对腹腔内压力增高对器官功能的影响，对腹腔内高压的定义基准已经下调WSACS.org,生理改变/危重急症,组织
6、缺血,全身炎症反应(SIRS),毛细血管渗漏,组织水肿(包括肠壁和肠系膜),腹腔内高压（IAH）,液体复苏,IAP升高的原因,严重的腹腔内、腹膜后病变缺血改变/SIRS 需要液体复苏：24小时内大量补液后正出的量超过5000ml 这么多液体到哪里去了呢？,水在这儿呢!,IAH&ACS,病理生理改变,心血管系统:腹腔内压力增高导致:静脉回心血流量减少导致大静脉塌陷受压胸腔内压力（ITP）增高后产生多种负性心肌效应 结果:心脏输出量减少 全身血管阻力增加心脏负荷增加组织灌注降低,混合血血氧饱和度ScvO2降低CVP 和 PAWP升高，但并不能反应真正的右心室前负荷水平心脏供血不足 心脏骤停,PEE
7、P,PIP吸气压峰值,腹内压,胸廓顺应性,胸膜腔压力,肺顺应性,气道阻力,心脏内压力,肺动脉导管,心室顺应性改变、瓣膜病变,导管尖端的压力 血管内容量,CVP,PAOP&CI in the presence of Intra-abdominal Hypertension,r=-0.33,r=-0.33,CVP,PAOP 和心脏指数之间是无相关关系的,Cheatham,Malbrain 2005,Ridings,et al 1995,肺:IAP增加导致:膈肌抬高导致肺容量减少,胸廓顺应性变差，变得“僵硬”,肺泡充气不良,组织间液增加(淋巴回流受阻)结果:胸内压增高气道峰压增加,潮气量减少间质水肿
8、、肺充气不良、低氧血症、高碳酸血症机械通气相关性肺损伤/气压伤细胞因子释放 前炎症反应ARDS,病理生理改变:肺,IAH,正常,ITP,胃肠道:腹内压增高导致:肠系膜静脉和毛细血管受压/充血心输出到胃肠道血流量减少 结果:肠道灌注减少,水肿和渗出增加缺血、坏死、细胞因子释放、中性粒细胞趋化聚集细菌易位SIRS发生发展腹腔内液体进一步增加,肾脏:腹腔内压力增加导致:肾静脉和实质受压心脏输出到肾脏血流量减少结果:肾血流量减少肾充血水肿肾小球滤过率降低(GFR)肾衰、少尿/无尿,正常腹部 CT,下腔静脉,注意腹腔是椭圆的，而不是球形,正常肾脏,后腹膜血肿,注意：腹腔是圆的，而不是椭圆形了！,肾脏受压
9、，病人无尿,Pickhardt,AJR 1999,ACS 时异常的腹部 肾脏受压,变得扁平的下腔静脉,中枢神经系统:腹腔内压力增高导致:胸内压增高上腔静脉压力增高导致回胸腔血流降低结果:中心静脉压增高颅内压增高 大脑灌注压降低脑水肿,脑缺氧,脑损伤 Maryland 休克创伤中心对颅内压顽固升高的患者均常规实施开腹减压手术,病理生理改变,腹腔内压力改变对其它压力指标的影响:IAP 增高会导致 ICP（颅内压）,IJP（颈内静脉压）and CVP(PAOP，肺动脉阻塞压)增高,15 升袋置于腹壁(Citerio 2001),IAH in neuro patients,Joseph 2004:腹腔
10、减压治疗顽固性颅内高压17 位经其它治疗(其中14位实施开颅减压手术)后仍顽固性 ICP增高患者-平均 ICP 30 mm Hg,平均 IAP 27 mm Hg 17位均行剖腹减压术 100%ICP立即或数小时后下降-平均 17 mm Hg11 位 ICP一直正常这 11位均存活，并且无神经系统后遗症“good neurologic outcome”,缺血时间与细胞存活的关系,不可逆的细胞凋亡或坏死,Rivers Early goal directed therapy for sepsis lecture,细胞氧需量的基线,无氧代谢,有氧代谢,时间紧迫的(黄金小时-分钟为单位)心脏骤停(5 m
11、in)严重创伤(“The golden hour”)急性心肌梗死(“time is muscle”“90 min DTB”)休克(“Brain attack”3 hour time window)严重的ICP 升高(cranial compartment syndrome)张力性气胸、心包填塞(thoracic compart syndrome)时间紧急的(6 小时-小时为单位)脓毒性休克(“Surviving sepsis”total body ischemia)IAH-ACS(“Surviving fluid resuscitation”total body ischemia)肢体缺血(栓
12、塞,肢端间隔综合征)肠系膜缺血(主动脉栓塞,IAH-ACS),Circling the Drain,Intra-abdominal PressureMucosalBreakdown(Multi-System Organ Failure)Bacterial translocation,Cellular Apoptosis,NecrosisAcidosis,Decreased O2 deliveryAnaerobic metabolism,Capillary leakFree radical formation,MSOF,ICU患者ACS的发病率*?,Malbrain,Intensive Care
13、 Medicine(2004):,*These data are for ALL ICU patients.MUCH higher if you use a protocol to select high risk patients.,脓毒症患者的发病率*,Efstathiou et al,Intensive Care Med 2005;31 supp1 1:S183 Abs 703,*These data are for ALL sepsis patients.MUCH higher if you look only at major fluid resuscitation.,休克 和 液体
14、复苏患者的发病率？,Requeira,2007:脓毒性休克患者ACS的发病率.51%incidence of IAP 20 mm Hg in septic shock Daugherty,2007:ACS常见于ICU中需要大量液体复苏的患者.85%of patients with 5 liters positive fluid balance had IAH30%had IAP 20 with organ failure(abdominal compartment syndrome),临床判断IAP升高的措施究竟有多少用处呢?,随机-双盲的研究结果:50%时间临床医生能在IAP升高的时候第一时
15、间发现.“研究发现需要一些更常规通用的方法如经膀胱测压”,Kirkpatrick,Can J Surg 2000,IAH 能预测死亡IAH 12 死亡率 38.8%无 IAH-死亡率:22.2%,Malbrain,Crit Care Med,2005,内外危重ICU患者,IAH/ACS 会影响患者结局吗?,Al-Bahrani,2008:重症胰腺炎患者腹内高压的临床相关性.18例重症胰腺炎7(39%)例 IAP 15(均超过 20)mm Hg:45%死亡率 平均ICU住院时间 21 days,IAH/ACS 会影响患者结局吗?,IAH 干预 会影响患者结局吗?,Ivatury,J Trauma
16、,1998:损伤控制后的ACS.70 例检测 IAP 18 mm Hg(25 cm H2O)25 例手术后立即关腹:52%IAP 18 mm Hg39%死亡-45 例 腹腔“开放”:22%IAP 18 mm Hg10.6%死亡,Sun,2006:爆发性胰腺炎持续腹腔引流与传统治疗.110 例爆发性胰腺炎-RCT对照组:常规 ICU 治疗 实验组:常规治疗再加上IAP监测(第一天平均 21 mm Hg)持续腹腔内引流(drain 1800 cc on day 1)结局:对照组-20.7%死亡,28天住院时间 实验组-10.0%死亡(p0.01),15 天住院时间,IAH 干预 会影响患者结局吗?
17、,Cheatham 2007,积极管理IAH/ACS 提高存活率吗?Acta Clinica Belgica引入management protocol in 2005前后的比较:开腹率 from 28%to 15%(medical management)如果开腹减压,早期进行(不是发生ACS后)关腹天数从平均21天降至6天初次成功关腹率从 1/3 to 2/3机械通气天数降低住院日从 28 天到 18 天存活率从 51%到72%,IAH 干预 会影响患者结局吗?,Does IAH/ACS affect patient outcome?,Points:IAH/ACS is common in t
18、he ICU 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 cou
19、rse.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
20、5 ml sterile saline.”,WSACS.org,“Home Made”Pressure Transducer Technique,Home-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”Pressure T
21、ransducer Technique,PROBLEMS: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 costs/morbidity
22、 of inaccurate or delayed information?Other:Needle stick,Recurrent penetration of sterile system,Leaks,re-zeroing problems,failure to trend,Fluid-Column Manometry,Sedrak 2002,Problems:Failure to pay extreme attention to detail may lead to errorsSiphon effect leads to false elevationsInadequate volum
23、e of infusion will lead to falsely low measurementsCAUTI Risk-Need to infuse urine back into patient,Bladder Pressure Monitoring:How to do it,Commercially available devices:Foley Manometer(Bladder manometer)CiMon(Gastric)Spiegelberg(Gastric)AbViser(Bladder transduction)IAP monitor(Bladder transducti
24、on)Advantages Simple,Standardized,Reproducible,Time efficient,Sterile,AbViser:Reproducibility Study,Inter-observer Scatterplot(r=0.95,p 0.001),Kimball,Int Care Med 2007,Nursing driven study with 89 different nurses participating.Excellent intra-and inter-observer reproducibility,Common Questions:How
25、 much fluid should be infused into bladder?,Volume of infusion(ml),IAP Measured(mm Hg),Non-compliant bladder:Measured pressure increases as volumes exceed 50 ml of infusion,Compliant bladder:Measured pressure changes very little with higher volumes of fluid infusion,WSACS:Max volume 25 ml,1 ml/kg in
26、 children.,Common Question:How do I recognize appropriate IAP transduction onto my monitor?,Proper transduction clues:Respiratory variation noted(subtle at low pressures)Oscillation test positiveReproducible over several measurements,Concern UTI can cause sepsis.CAUTI is not reimbursableInfection co
27、ntrol statements“Closed system is required to reduce UTI risk,bladder pressure monitoring violates closed system concept”Contrary concern Everything is medicine is based on risk benefit analysisWhat is the risk of UTI versus the risk of missing IAH/ACS?How do we resolve this-What is the actual data?
28、,Common Questions:What is the risk of UTI from transvesicular IAP monitoring?,Common Questions:What is the risk of UTI from transvesicular IAP monitoring?,Myth:Breaking the“closed system”increases risk of UTIWong,Guidelines to prevent CAUTI,Am J Inf Control 1983Research Data:“Closed sealed systems”v
29、ersus“open systems”demonstrate no difference in CAUTI risk.Three prospective randomized controlled trials(level 1 evidence),one non-randomizedAll studies compared open(not connected)vs closed(pre-connected,tamper seal)drain systemDeGroot,Inf Cont Hosp Epid 1988 203 patients,RCT,CAUTI rates equalWill
30、e,J Hosp Inf,1993 183 patients RCT,CAUTI rates equalLeone,Int Care Med 2003 311 ICU patients,RCT,CAUTI rates equalLeone,Int Care Med 2003 224 ICU patients,CAUTI rates equal,So what does cause CAUTI?,Common Questions:What is the risk of UTI from transvesicular IAP monitoring?,Maki,Engineering out the
31、 risk of infection with urinary catheters,Emerg Inf Control 2001,“Infections in which biofilm does not play a role are probably caused by mass transport of intraluminal contents into the bladder by retrograde reflux of microbe laden urine when a collection system is manipulated.”,(Loop),Cheatham,Int
32、ravesicular pressure monitoring does not cause urinary tract infection.Int Care Med 2006Compared ICU patients getting IAP monitoring to those who did not get IAP monitoringCAUTI rate 7.9 versus 6.5 per 1000 cath days(P=N.S.)despite higher acuity and mortality in the IAP group.,Common Questions:What
33、is the risk of UTI from transvesicular IAP monitoring?,Conclusions:Transvesicular monitoring of IAP probably carries little risk of CAUTI.Failure to monitor and detect IAH/ACS does carry a high risk to patient so risk benefit analysis suggests monitoring needs to be done regardless.Closed system myt
34、h may have some merit(aseptic technique),but is not defended by evidence based medicine and is over-blown.Obviously we need to be careful,but not paranoid.Manipulation of the urinary drain tube with repeated dumping of old urine back into the patients bladder is probably a modifiable risk we can imp
35、act.,Common Questions:What is the risk of UTI from transvesicular IAP monitoring?,Management of IAH and ACS,IAH/ACS Management,Relatively easy,bedside nursing control interventionsBed Position(Binders NO!)Consider fully recumbent with reverse trendelenbergBalance VAP issues against IAH issues(risk b
36、enefit analysis)Sedation,Pain controlOften all that is neededFluids enough but not too muchBe aware of problems with hemodynamic data in the face of IAHThink about infusion volumes,concentrating some of the drips Abdominal perfusion pressure(50-60 mm Hg)Similar to Cerebral perfusion pressureAPP=MAP-
37、IAPNGT/Cathartics/Rectal tube/enemasParalysis-Balance risk vs.benefit,IAH/ACS Management:Positioning,Vasquez,2007,IAH/ACS Management:Paralysis,De Waele,Crit Care Med 2003,UOP,IAP,IAH/ACS Management:Colloids,OMara,2005:Prospective randomized evaluation of IAP with crystalloid and colloid resuscitatio
38、n in burns31 cases with 25%burn plus inhalation or 40%burn without inhalationRandomized to saline vs plasmaResults post resuscitation:Crystalloid IAP mean 26.5 mm HgPlasma IAP mean 10.6 mm Hg,IAH/ACS Management:Hemofiltration,Oda,2005:Management of IAH in patients with severe acute pancreatitis usin
39、g continuous hemofiltration.17 cases of severe pancreatitis 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 intersti
40、tial edemaMean IAP value dropped from 15 mm to less than 10 mm16 of 17 patients discharged alive without complication,IAH/ACS Management:Paracentesis,Multiple case series reporting successful treatment of IAH and ACS:Latenser 2002:Burn patient managementReckard 2005:Peripancreatic fluid filled massS
41、harp 2002:Pediatric blunt traumaEtzion 2004:Malignant ascites therapySun 2006:Pancreatitis(prospective RCT)Cut deaths in half,cut hospital LOS by 13 days,IAH/ACS Management,Decompressive Laparotomy:Err on the side of early vs late interventionLess bowel edema or cell damage,better chance of early cl
42、osure and early recovery.Be aware that delaying 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 b
43、y time ventral hernia finally repaired).,IAH/ACS Management:Decompressive Laparotomy,Rigid Abdomen in ACS,Post decompressive laparotomy,Decompressive Laparotomy,Delay in abdominal decompression may lead to intestinal ischemiaDecompress Early!,Decompressive Laparotomy,Post-operative dressing,Several
44、days post-op,No such thing as an“Open Abdomen”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 H2O,No such thing as an“Open Abdomen”in the ICU,24 hours into ICU stay:Worsened bowel edemaHowever:MAP=79IAP=12Lactate=1.9,Note expan
45、sion of viscera,Surgical Management of Compartment Syndromes,Compartment Cranium ChestPericardiumLimb,PathophysiologyICP elevationTension pneumothoraxCardiac tamponadeExtremity compartment syndrome,Surgical Management Craniotomy,etc.Chest tube PericardiocentesisFasciotomy,Compartment Syndromes versu
46、s Hypertension,Abdominal compartment syndrome=Emergent Surgical Disease.Intra-abdominal hypertension=Urgent Medical Disease.,Cost analysis,Is IAP monitoring and intervention cost effective?,Cost analysis,Compartment syndrome risk comparisonThe Cranium:Fall,hit head,LOC,vomiting but alertIs it worth
47、the cost of a head CT?(Standard 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 ACS,Cost analysis:Time depe
48、ndent critical care interventions vs.lives saved,Number 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:111,Cost analysis:IAP monit
49、oring impact on resource 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 protoco
50、l driven care.Open up ICU bed soonerIncrease survival,Cost 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 dur
