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1、 Acute Gastrointestinal Injuryin the ICU 安徽省立医院ICU 陶晓根概 念 Intensive Care Med (1997) 23: 476479 Traditional teachings in critical illness More recent information: 肠道具有重要功能，这些功能反过来又影响危重病人 的临床预后The epithelial barrier，The molecular barrier， The immune barrier防止吸收腔内微生物和/或微生物的产品, 人体中最大的淋 巴器官，在危重患者的免疫反应中起着
2、重要的作用急性胃肠损伤急性胃肠损伤3肠功能衰竭定义困难 “肠衰竭” 在50 年代即在文献中出现并沿用至今,但是没有完整的含义 Irving M定义(1956)： “功能性肠道减少,不能满足食物的 消化吸收” Fleming 与Remington定义(1981) “肠道功能下降至难以维 持消化、吸收营养的最低需要量”很长时间以来对胃肠道功能障碍及衰竭的诊断标准尚无共识，一些作者把GIF描述为“ 胃和肠梗阻”，而另一些人把它定义为消化道出血 Deitch 定义,“肠功能障碍”定为腹胀,不耐受食物5 天以上; 而“肠衰竭”则为应激性溃疡出血与急性胆囊炎名称和含义不一样 Gut Failure Gas
3、 trointestinal Disfunction Gut Disfunction Gastrointestinal Failure Acute intestinal failure Acute intestinal Disfunction 概 念 Intensive Care Med (1997) 23: 476479A Round Table Conference on Gut Dysfunction in Critical Illness was conducted at the 16th International Symposium on Intensive Care and Em
4、ergency Medicine held in Brussels, Belgium.急性胃肠损伤急性胃肠损伤概 念 Intensive Care Med (1997) 23: 476479 the normal structure and function of the intestinal barrier; the pathogenesis of intestinal dysfunction; monitoring intestinal function; potential treatments of gut dysfunction急性胃肠损伤急性胃肠损伤本文定义为：能耐受适当的肠内营养
5、治疗方案。尽管存在明显的局限性，临床意义巨大。肠功能障碍需要 更为客观的定义。理想情况下，肠功能障碍的定义也应该 反应功能障碍的严重程度。 Methods: 回顾性研究 ，n = 2588 3 ICUs 2002年 GIF 定义： (food intolerance, gastrointestinal haemorrhage, and/or ileus) in the patient data at any period of their ICU stay.BMC Gastroenterology 2006, 6:19Incidence, characteristics and outcome
6、 of gastrointestinal failure (GIF) in intensive care patients.BMC Gastroenterology 2006, 6:19回顾性研究 ，n = 2588 3 ICUs 2002年GIF 定义： (food intolerance, gastrointestinal haemorrhage, and/orileus) 病人来源于紧急手术或内科病人，APACHE和SOFA评 分、入院时儿茶酚胺类物质的使用被确定为GIF的独立危 险因素。 住ICU期间的发生GIF是死亡的独立预测因素BMC Gastroenterology 2006,
7、6:19Acta Anaesthesiol Scand 2009; 53: 318324Acta Anaesthesiol Scand 2009; 53: 318324Acta Anaesthesiol Scand 2009; 53: 318324Acta Anaesthesiol Scand 2009; 53: 318324Markers of gut dysfunction in critical illnessCritical Care 2008, 12:R90PointsClinical symptomatology0Normal gastrointestinal function1E
8、nteral feeding 50% of calculated needs or no feeding 3 days after abdominal surgery 2Food intolerance (enteral feeding not applicable due to high gastric aspirate volume, vomiting, bowel distension, or severe diarrhoea) or IAH 3Food intolerance and IAH4Abdominal compartment syndromeGIF scoreCritical
9、 Care 2008, 12:R90GIF score264 ICU pts,MV, longer than 24 hours in ICUResults FI developed in 58.3%, IAH in 27.3%, and both together in 22.7% of patients. The mean GIF score for the first 3 days in the ICU was identified as an independent risk factorfor mortality (odds ratio = 3.02, 95% confidence i
10、nterval = 1.63 to 5.59; P 0.001). The GIF score integrated into the SOFA score allowed better prediction of ICU mortality than did the SOFA score alone, and was an independent predictor of mortality (odds ratio = 1.49, 95% confidence interval = 1.28 to 1.74; P 0.001). The development of gastrointest
11、inal failure (FI plus IAH) was associated with significantly higher ICU and 90-day mortality. Conclusion The GIF score is useful for classifying information on the gastrointestinal system. The mean GIF score during the first 3 days in the ICU had high prognostic value for ICU mortality. Development
12、of gastrointestinal failure is associated with significantly impaired outcome.Critical Care 2008, 12:R90GIF score264 ICU pts,MV, longer than 24 hours in ICUCritical Care 2008, 12:R90GIF scoreCritical Care 2008, 12:R90GIF scoreCritical Care 2008, 12:R90GIF score Feeding intolerance was a subjective m
13、easurement intraabdominal hypertension was not specific to gut failure GIF评分不足n 将IAP仅分作IAH和ACS两档看来过于简单，需要细分的必要n 细菌毒素移位和由此引发的炎症反应是GIF重要的病理变化 和组分，如何在评分中得到反映值得探讨Acta Anaesthesiol Scand 2009; 53: 318324概 念 Intensive Care Med (2012) 38:384394 胃肠道功能障碍及衰竭的定义不明确 重症患者胃肠道功能障碍发生率高 胃肠道功能障碍的评估方法不足 胃肠道功能障碍与患者预后显著
14、相关急性胃肠损伤急性胃肠损伤ESICM(2012)推荐意见制定背景概 念 Intensive Care Med (2012) 38:384394正常胃肠道功能包括促进营养物质和液体的消化吸 收、调控肠道菌群及其产物的吸收、内分泌和免疫功能。 灌注、分泌、运动和协调的肠道微生物相互作用是足够功 能的先决条件急性胃肠损伤急性胃肠损伤胃肠道功能概 念 Intensive Care Med (2012) 38:384394 器官功能障碍是一个持续的病理变化过程 胃肠道功能障碍所描述的多发生在ICU之外，如胃 肠道症状（腹泻、呕吐等）和诊断（胃肠炎等） 因此对于重症患者，“急性胃肠损伤”概念应运而 生急
15、性胃肠损伤急性胃肠损伤acute gastrointestinal injury, AGI概 念 Intensive Care Med (2012) 38:384394原发性AGI：由胃肠道系统的原发疾病或直接损伤导致的AGI（第一 打击）;常见于胃肠道系统损伤初期。如腹膜炎、胰腺或肝脏病理改变 、腹部手术、腹部创伤等 继发性AGI：机体对重症疾病反应的结果，无胃肠系统原发疾病（第 二打击）;无胃肠道系统直接损伤;如发生于肺炎、心脏疾病、非腹部 手术或创伤、心肺复苏后等急性胃肠损伤急性胃肠损伤acute gastrointestinal injury, AGI：由于重症患者的急性疾病导致的胃肠
16、道功能障碍概 念 Intensive Care Med (2012) 38:384394 AGI级（存在胃肠道功能障碍和衰竭的风险） AGI级（胃肠功能障碍） AGI 级（胃肠功能衰竭） AGI 级（胃肠功能衰竭伴有远隔器官功能障碍）急性胃肠损伤急性胃肠损伤AGI 严重程度分级 ： 133 patients 83 cases (62.4%) with AGI and 50 cases (37.6%) without AGI. AGI grade I ：38 cases (45.8%), AGI grade II ：33 cases (39.8%) , AGI grade III ：8 cases (9.6%) , AGI grade IV 4 cases (4.8%) . The major causes of AGI shock (15 cases), severe sepsis (15 cases
