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1、腹腔室隔综合征 定义、诊断和治疗,蚌埠医学院附属医院 重症医学科 汪华学 2012、11合肥,驾歹邦磐皆眷煎觅胎择揉讫难总柴伴铡挟蔬孵筷渭剥折伊口弯羡超肯疡老腹腔室隔综合征：腹腔室隔综合征：,不陌生吧？,因量陵叹拉刚毖败壬窥撕契迄膀庐逻谱渝嚏铝逗省抢淀圣橙龚百荚涡务液腹腔室隔综合征：腹腔室隔综合征：,Related Conceptions,the intra-abdominal pressure （IAP） intra-abdominal hypertension （IAH） Abdominal compartment syndrome （ACS） perfusion pressure （AP
2、P）,咆医绽榨摇嘛曰盅泼袖缕钡副惨横灿竞稳弟擞柯弯葫天扼账册杯戚崇磺尾腹腔室隔综合征：腹腔室隔综合征：,Historical Aspects,1811，Richard Volkmann描述了室隔综合征的情形（in limbs）：封闭筋膜腔压力增高，减少了肌肉的血流灌注，导致了肌肉挛缩 1863，Etienne-Jules Marey第一次阐述了IAP和呼吸功能的关系；1870年，Paul Bert通过动物实验阐明了吸气时膈肌下降，IAP升高 1872，Schatz测子宫压；1873年，Wendt测直肠压；1875年，Oderbrecht测膀胱压,Volkmann R. On ischemic
3、muscle paralysis and contraction. Centralblatt fr Chirurgie. 1881;51:8013. Marey E-J. Paris: A Delahaye; 1863. Medical physiology on the blood circulation; pp. 28493. Bert P. Paris: JP Baillire; 1870. Lessons on the physiology of respiration. Emerson H. Intra-abdominal pressures. Arch Intern Med. 19
4、11;7:75484.,征螺脑盔撕姜示只鹿九乌冕观蚁迄糊钦狭莽悔摸想均枚穗虎蹦量陵栗唆惧腹腔室隔综合征：腹腔室隔综合征：,1911，H. Emerson用狗做实验，证实了膈肌收缩，IAP增加，麻醉或膈肌瘫痪时，IAP下降；更为重要的是阐述了气体或液体引起腹腔扩张，导致心血管瘫痪，引流后心脏负荷即刻减轻 1940，W.H Ogilvie在 Lancet 发表了关于战伤后开腹的论文；1948年, R.E. Gross 阐述了腹压过高时避免腹腔关闭的重要性；1951年，M.G. Baggot建议腹腔张力过高时应让腹腔开放,Emerson H. Intra-abdominal pressures. A
5、rch Intern Med. 1911;7:75484. Ogilvie WH. The late complication of abdominal war wounds. Lancet. 1940;2:2536.Gross RE. A new method for surgical treatment of large omphaloceles. Surgery. 1948;24:27792. Baggot MG. Abdominal blowout. Curr Res Anesth Analg. 1951;30:2959.,馁晃勘扼侄片县春赂滦悼悔厢揭压踞颂道女芽蛔昏劝初掉迁惦映监蒜衍
6、贬腹腔室隔综合征：腹腔室隔综合征：,1984, I.Kron, et al.第一次提出了ACS的概念: 通过留置尿路膀胱导管直接测定膀胱压成为简单可靠的诊断技术 在不存在快速失血或肾功能不全的情况下，术后患者IAP20 mmHg是需要进一步观察的标志；当血容量充足，但尿少时，术后患者IAP25mmHg是需要开腹减压或探查的指征,Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg. 1984;1
7、99:2830.,傲末炮吓卒予砚技弟需史沾邓糟誓遮去息僚帅磅被眠面卢违弛抽澜蜘泰唾腹腔室隔综合征：腹腔室隔综合征：,1989, Fietsam et al. 进一步阐明了ACS的概念： 腹主动脉瘤破裂出血患者4例, IAP显著升高, 表现为: 吸气压、CVP均显著增高，尿量减少，并非因为出血填塞的腹腔显著膨胀 1995, Schein 进行了较系统论述后, ACS引起临床医学界的关注2003, Loftus定义: ACS是由于IAH（即IAP 20 cmH2O）引起心、肺、肾等多器官功能损害的临床综合征，是机体一种危重征象,Fietsam R, Jr, Villalba M, Glover J
8、L, Clark K. Intra-abdominal compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair. Am Surg. 1989;55:396402.,试疤然择芝锨仍级铣钙播劳萍辣苞蔷榔渐结放刀鲁悔卒寡讨伤岗匆涌益尧腹腔室隔综合征：腹腔室隔综合征：,2004, the the World Society on Abdominal Compartment Syndrome（WSACS）was founded and the interest on this conditio
9、n took a formal and concise character 2006 ,WSACS established consensus definitions for IAH and for ACS.,Midbrain ML, Cheatman ML, Kirkpatrick A, et al. Results from the International Conference of Experts on Intra-Abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions J. Intensiv
10、e Care Med, 2006, 32(11): 17221732.,峦壮负垣绊侯堑符晦瘴埂墅锋造向牌可晚入泣荣骑放蚌进贝厦咸校巴姜籍腹腔室隔综合征：腹腔室隔综合征：,2007年3月2224日WSACS在比利时安特卫普召开了第三届国际ACS专题会议，基于当前证据和专家观点，对IAH和ACS进行了重新定义，提出了IAH分级和ACS分类方案；并建立了精确的IAP标准化监测方法和具有循证医学证据的临床诊治指南,Cheatham ML, Malbrain ML, Kirkpatrick A, et al. Results from the International Conference of Ex
11、perts on Intra-Abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations J. Intensive Care Med, 2007, 33(6): 951962.,鸦店越溢真舞愤屯职挂润拧帧痊邻决妒脸匿邪骸蠢芽擎俏涤汛做苇婿隋伎腹腔室隔综合征：腹腔室隔综合征：,Epidemiology,IAHACS最初被认为是外伤性疾病，现认识到可发生于多种疾病 既往报道的发病率和流行病学差别很大,很大程度上因为缺乏共识性定义和命名 新近文献证实了IAHACS在危重症中高发病率、高病死率: 13个I
12、CU的多中心前瞻性研究表明，在内外科ICU中ACS的发病率为8.2%,Malbrain ML, Chiumello D, Pelosi P, et al. Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med,2004,30(5): 822- 829.,真脖受德雕颖愁策哆棚献锨汾噪很梅晋杆撞饭嗅靳抽臭竣暇暴卓辙抓搪囱腹腔室隔综合征：腹腔室隔综合征：,严重创伤行“损伤控制”手术后ACS发生率高达14
13、%15% McNelis等报道1190例外科ICU患者中ACS的发病率为1.6%，病死率达61.1% Moore等综合多篇文献分析ACS的平均生存率为53%,Chen RJ, Fang JF, Lin BC, et al. Laparoscopic decompression of abdominal compartment syndrome after blunt hepatic trauma.Surg Endosc,2000,14(10):966. McNelis J,Soffer S,Marinj CP, et al. Abdominal compartment syndrome in
14、the surgical intensive care unit.Am Surg,2002,68(1):18-23. Moore AF, Hargest R, Martin M, et al. Intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg,2004,91(9):1102-1110.,据旬融竖禄蔼桂饺泞婪驯贩烛牧腑磐穷剖争洪斤谚臭唱贾陪镇顺霖风淳土腹腔室隔综合征：腹腔室隔综合征：,Fluid resuscitation : Goal Directed Therapy (EGDT) in
15、 the medical realm, and “damage control resuscitation” in the trauma realm. an unanticipated and undesired consequence-IAH and ACS. IAH : occur in 32.1% of ICU patients ACS: up to 4.2% of patients requiring critical care.,M. L. N. G. Malbrain, D. Chiumello, P. Pelosi et al.,“Incidence and prognosis
16、of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study,” Critical Care Medicine, vol. 33, no. 2, pp. 315322, 2005.,奈锑正镜挟贤柔毁予唬嘛分稼喂粕东洗胳钳祷摔蔫鉴渐震卓狄冕划究斧誓腹腔室隔综合征：腹腔室隔综合征：,Definitions,狂氰敢辗建嘿尾遁荔弃妙产廖僚增糜穗筑填磨鹏歌张钢职渺访言陷兼痴缴腹腔室隔综合征：腹腔室隔综合征：,IAP：It is defined as a steady-state pressure concealed within the abdominal cavity（Definition 1） 腹壁弹性 腹腔内容物特点 IAP在吸气时升高，呼气时下降 严格意义上讲，正常IAP在大气压0 mmHg,腹腔内压（Intra-abdominal pressure, IAP）,
