重症急性胰腺炎腹腔高压的处理 2018(0)
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CVP MAP
• • • • • =2:1--3:1
12h (11000ml ) 10ml/kg )
SAP-IAH/ACS
2. 3.
• • CVVH
SAP-IAH/ACS
----CVVH
1 2 3 4 5
+
-IAH/ACS
6 CVVH IAH
SAP-IAH/ACS
•wk.baidu.com• •
•
u
SAP-IAH IAH/ACS SAP 17 14 4 ACS--IAP IAP 20mmHg 50%. 18% vs 46%[20]. 1D
• IAP
u u
ü
25mmHg 26 ACS
ü
•
ü
•
ü ü ü
46%
ü
71-84%
Abdominal compartment syndrome in patients with severe acute pancreatitis in early stage
44 ACS 60% 7.4% P 0.001 P 0.001 MODS 90% vs 31.5% 59.46% 1 IAH MODS 70% vs 11.1% 75% vs 3.7% P 0.001 P 0.001 ACS 27.03%
• ACS 8 • 5
World J Gastroenterol 2008 June 14; 14(22): 3541-3548
Abdominal Compartment Syndrome and Intra-abdominal Ischemia in Patients with Severe Acute Pancreatitis
59
• •
SAP IAH 10 ACS 29/29 ACS 8
Non-ACS
13/29
44.8% 6
ACS
60%
World J Surg (2016) 40:1454–1461
Relationship between intra-abdominal hypertension, outcome and the revised Atlanta and determinant-based classifications in acute pancreatitis
PCD N=60 5.55±2.20 31(51.67%) 11.32±5.75 11.12±6.26 8.43±4.27 19 (31.67%) 11 (18.33%) 25 (41.67%) 23 (38.33%) 11(18.33%) 37 (61.67%) 2.45±1.48 2.35±1.42 36.10±59.53 52.17±37.08 16 (26.67%)
IAP
>25 mm Hg
•
mm Hg
ACS
IAP>20 mm Hg
APP<60
•
APP
abdominal perfusion pressure
60 mm Hg
APP
=MAP-IAP
ACS
SAP
12-36%
IAH
• • • • • MODS AKI -
IAH
OF---
• • IAP
CRRT SOFA
ü ü
SAP-IAH/ACS
1. 2. Equipoise
, 2007 . ( ) 72h , 2012.
World J Gastrointest Pathophysiol 2016 February 15; 7(1): 186-198
SAP-IAH/ACS
1.
•
SAP
≈
HR HCT
SEPSIS
ICU
1.
• • • • • • •
2 MCTSI100ml WON ICU EN PCD / PCD
PCD N=31 4.48±2.87 18 (58.06%) 7.76±6.74 11.21±7.27 6.72±3.95 7 (22.58%) 1 (3.23%) 7 (22.58%) 6 (19.35%) 2 (6.45%) 25 (80.65%) 2.75±1.44 1.68±0.80 22.58±21.21 47.16±32.86 4 (12.90%)
P
*
0.026 0.562 0.028 0.476 0.033 0.363 0.090 0.070 0.066 0.223 0.066 0.179 0.018 0.112 0.264 0.133
SAP-IAH/ACS
1.
PCD
ü ü ü ü ü ü ü
CVC
5 PCD
SAP-IAH/ACS
1. 2.
2
SAP
I
AKI-1
ACS
IAP 29 cmH2O 24h 21 cmH2O
5
• IAP
ü ü ü ü ü
25mmHg
ACS-MODSCVVH PCD ACS
• ACS-IAH •
25
MODS
1 2 3
ACS ACS ACS MODS
4
IAH/ACS
• MSAP-SAP • •
• IAP 12-15mmHg
ü ü ü
IAP 4-6h IAP IAP 15mmHg
• IAP 16-20mmHg
ü ü ü ü ü
4-6h
IAP
PCD
• IAP21-25mmHg
ü ü ü ü
ACS-MODS CVVH PCD
Ø Ø Ø Ø
SAP-IAH/ACS
Ø Ø
• • • •
Ø
30
•
Ø
• •
°
pH
7.2 33℃ 55000 m3 1.5 PT 15s
• APTT • • • 2
INR
• • •
5 L/d
SAP-IAH/ACS
•
• • •
SAP-IAH/ACS
• • 48h IAH IAH/ACS IAH[19,40]
World J Surg 2009 Jun;33(6):1128e33. Pancreas 2011 Nov;40(8):1220e5.
SAP-IAH/ACS
Ø
p p p
Ø Ø Ø
SAP-IAH/ACS
1. 2. 3. 4. 5. IAH /
SAP-IAH/ACS
1. —
AFC
SAP-IAH/ACS
IAH
ACS
2006—2013 IAH/ACS
•
-
• • mmHg IAP
) 25 ml
( IAP
• IAH(intra-abdominal hypertension,IAH) ≥12mm Hg • IAH I Ⅱ III IV 12 16 21 15 mm Hg 20 mm Hg 25 mm Hg
Shanghai Ruijin Emergency and Critical Care Medicine International Forum
0
• •
% 6 4 4 1
Pancreas 2008 Jan;36(1):39e43. World J Gastroenterol 2008 Jun14;14(22):3541e8.
IAP
Development of organ dysfunction in SAP could be associated with increased IAP.
•
ACS
IAP>20 mm Hg
APP<60 mm Hg
ü
IAH/ACS IAH IAH MODS
SAP
(
ICU
ü ü
APP
IAH/ACS
• 301 • 9
AP-IAH
• ACS developed in 103 patients (34.2%) (8.7%) underwent decompressive laparotomy
BJS Open 2018; 1: 175–181
• •
Elevation of IAP over 25 cmH2O should not be considered the single indication for emergency decompressive laparotomy. Aggressive conservative treatment and CVVH rather than surgical intervention is recommended, particularly in the most severe cases. HPB, 2006; 8: 227232 SAP-ACS 24h IAP 25mmHg
• • • • • =2:1--3:1
12h (11000ml ) 10ml/kg )
SAP-IAH/ACS
2. 3.
• • CVVH
SAP-IAH/ACS
----CVVH
1 2 3 4 5
+
-IAH/ACS
6 CVVH IAH
SAP-IAH/ACS
•wk.baidu.com• •
•
u
SAP-IAH IAH/ACS SAP 17 14 4 ACS--IAP IAP 20mmHg 50%. 18% vs 46%[20]. 1D
• IAP
u u
ü
25mmHg 26 ACS
ü
•
ü
•
ü ü ü
46%
ü
71-84%
Abdominal compartment syndrome in patients with severe acute pancreatitis in early stage
44 ACS 60% 7.4% P 0.001 P 0.001 MODS 90% vs 31.5% 59.46% 1 IAH MODS 70% vs 11.1% 75% vs 3.7% P 0.001 P 0.001 ACS 27.03%
• ACS 8 • 5
World J Gastroenterol 2008 June 14; 14(22): 3541-3548
Abdominal Compartment Syndrome and Intra-abdominal Ischemia in Patients with Severe Acute Pancreatitis
59
• •
SAP IAH 10 ACS 29/29 ACS 8
Non-ACS
13/29
44.8% 6
ACS
60%
World J Surg (2016) 40:1454–1461
Relationship between intra-abdominal hypertension, outcome and the revised Atlanta and determinant-based classifications in acute pancreatitis
PCD N=60 5.55±2.20 31(51.67%) 11.32±5.75 11.12±6.26 8.43±4.27 19 (31.67%) 11 (18.33%) 25 (41.67%) 23 (38.33%) 11(18.33%) 37 (61.67%) 2.45±1.48 2.35±1.42 36.10±59.53 52.17±37.08 16 (26.67%)
IAP
>25 mm Hg
•
mm Hg
ACS
IAP>20 mm Hg
APP<60
•
APP
abdominal perfusion pressure
60 mm Hg
APP
=MAP-IAP
ACS
SAP
12-36%
IAH
• • • • • MODS AKI -
IAH
OF---
• • IAP
CRRT SOFA
ü ü
SAP-IAH/ACS
1. 2. Equipoise
, 2007 . ( ) 72h , 2012.
World J Gastrointest Pathophysiol 2016 February 15; 7(1): 186-198
SAP-IAH/ACS
1.
•
SAP
≈
HR HCT
SEPSIS
ICU
1.
• • • • • • •
2 MCTSI100ml WON ICU EN PCD / PCD
PCD N=31 4.48±2.87 18 (58.06%) 7.76±6.74 11.21±7.27 6.72±3.95 7 (22.58%) 1 (3.23%) 7 (22.58%) 6 (19.35%) 2 (6.45%) 25 (80.65%) 2.75±1.44 1.68±0.80 22.58±21.21 47.16±32.86 4 (12.90%)
P
*
0.026 0.562 0.028 0.476 0.033 0.363 0.090 0.070 0.066 0.223 0.066 0.179 0.018 0.112 0.264 0.133
SAP-IAH/ACS
1.
PCD
ü ü ü ü ü ü ü
CVC
5 PCD
SAP-IAH/ACS
1. 2.
2
SAP
I
AKI-1
ACS
IAP 29 cmH2O 24h 21 cmH2O
5
• IAP
ü ü ü ü ü
25mmHg
ACS-MODSCVVH PCD ACS
• ACS-IAH •
25
MODS
1 2 3
ACS ACS ACS MODS
4
IAH/ACS
• MSAP-SAP • •
• IAP 12-15mmHg
ü ü ü
IAP 4-6h IAP IAP 15mmHg
• IAP 16-20mmHg
ü ü ü ü ü
4-6h
IAP
PCD
• IAP21-25mmHg
ü ü ü ü
ACS-MODS CVVH PCD
Ø Ø Ø Ø
SAP-IAH/ACS
Ø Ø
• • • •
Ø
30
•
Ø
• •
°
pH
7.2 33℃ 55000 m3 1.5 PT 15s
• APTT • • • 2
INR
• • •
5 L/d
SAP-IAH/ACS
•
• • •
SAP-IAH/ACS
• • 48h IAH IAH/ACS IAH[19,40]
World J Surg 2009 Jun;33(6):1128e33. Pancreas 2011 Nov;40(8):1220e5.
SAP-IAH/ACS
Ø
p p p
Ø Ø Ø
SAP-IAH/ACS
1. 2. 3. 4. 5. IAH /
SAP-IAH/ACS
1. —
AFC
SAP-IAH/ACS
IAH
ACS
2006—2013 IAH/ACS
•
-
• • mmHg IAP
) 25 ml
( IAP
• IAH(intra-abdominal hypertension,IAH) ≥12mm Hg • IAH I Ⅱ III IV 12 16 21 15 mm Hg 20 mm Hg 25 mm Hg
Shanghai Ruijin Emergency and Critical Care Medicine International Forum
0
• •
% 6 4 4 1
Pancreas 2008 Jan;36(1):39e43. World J Gastroenterol 2008 Jun14;14(22):3541e8.
IAP
Development of organ dysfunction in SAP could be associated with increased IAP.
•
ACS
IAP>20 mm Hg
APP<60 mm Hg
ü
IAH/ACS IAH IAH MODS
SAP
(
ICU
ü ü
APP
IAH/ACS
• 301 • 9
AP-IAH
• ACS developed in 103 patients (34.2%) (8.7%) underwent decompressive laparotomy
BJS Open 2018; 1: 175–181
• •
Elevation of IAP over 25 cmH2O should not be considered the single indication for emergency decompressive laparotomy. Aggressive conservative treatment and CVVH rather than surgical intervention is recommended, particularly in the most severe cases. HPB, 2006; 8: 227232 SAP-ACS 24h IAP 25mmHg