腹腔压力-2009,济南.ppt

腹腔压力监测 首都医科大学附属北京同仁医院 ICU 李彤 IAP（intro-abdominal pressure）↑ IAP ↑→MODS, death IAH (Intro- abdominal hypertention) ACS (abdominal compartment syndrome) IAP is determined by –Abdominal organ volume –Space occupying lesions ? Blood, fluid, tumor –Abdominal wall compliance 3 factors affect IAP Gravity Uniform compression Shear deformation As a liquid-filled container –hydraulic system 正常值 正常值 Malbrain, Intensive Care Medicine (2004): The higher the IAP, the poorer the survival rate 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-IAP ACS and MODS ACS and MODS ACS治疗 Many clinicians still believe this to be true “I don’t need to measure IAP because I don’t take care of trauma patients” – IAP will not be measured unless patients are perceived to be at risk 可逆性：依赖 监测早 发现早 处理早 IAP监测方法 腹腔压力测定 直接测压法 腹部或腹膜后手术中 14-F PVC圆形引流管 下腔静脉压力测定方法 经股静脉插管测定下腔静脉压力 放置股静脉导管，导管尖端位置应达到肾血管水平，测量方法同中心静脉压测定 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 导管相关性感染 经胃测压法 胃内压力测定方法 带气囊导管 避免了UTI，但鼻窦炎风险增加，影响EN 胃腔内自身液体影响，胃壁较厚，影响测量结果 与膀胱压力测定相关性较好 膀胱内压力测定方法 （transvesical catheter） Simple, quick, and inexpensive Kron first described modern IAP monitoring in 1984 原理：膀胱内有50—100ml液体时膀胱壁会象膈肌一样反映IAP的变化。 经膀胱压力测定法 禁忌 神经性膀胱 膀胱损伤 膀胱挛缩 经膀胱压力测定法 注射器向膀胱内注入NS,?每次测量前膀胱内液体相等 关闭注射器连接阀，读取平均压力 q 2 - 4 hours监测一次. 无菌 操作 经膀胱压力测定法 With the transducer zeroed at the mid-axillary line 30-60 seconds after instillation of priming fluid (to allow bladder detrusor muscle relaxation) In the absence of abdominal muscle contractions 经膀胱测压法 间断测量 工作量、增加污染机会 刺伤危险 REVISED INTRAVESICULAR TECHQIQUE Revised KRON technique Safer Closed, needle-free More efficient Remains connected Faster IAP measurements Cost-effective Non sterile field Fewer supplies CONTINUOUS INTRAVESICULAR PRESSURE Three-way urinary catheter Continuous saline irrigation Pressure transduced through the irrigation port Provides continuous IAP measurement and does not interrupt urine flow Requires replacement of standard urina