ipertensione addominale - siti-isic cavaliere.pdf · pressione intra-addominale: la palpazione non...
TRANSCRIPT
Ipertensione addominale:intervento diagnostico-terapeutico
F. Cavaliere
U.C.S.C., Rome
Pressione intra-addominale:la palpazione non è uno strumento adeguato
Prospective, blinded trial - Staff physician judgment
Results: < 50% of the time was the clinician able to determine when IAP was elevated.
Kirkpatrick AW, Is clinical examination an accurate indicator of raised intra-abdominal pressure in critically injured patients? Can J Surg, 43, 207, 2000
Come misurare la pressione addominale
Diametro sagittale addominaleKahn and Pavkov, 2011
Pressione nella vena femorale De Keulenaer BL et al, 2011
Pressione intragastrica Chiumello D, 2011
Gold standard:Pressione vescicale
Studies should adopt the trans-bladder technique as the standard IAP measurement
We recommend use of protocolized monitoring and management of IAP versus not
La pressione vescicale va misurata:
• col trasduttore vicino alla cresta iliaca a livello della linea medio-ascellare
• 30 – 60 secondi dopo aver iniettato in vescica meno di 25 mL di SF
• esprimendola in mmHg
(1 mmHg = 1.36 cmH2O)
La pressione vescicale va misurata…
IAP
a fine espirazione
In posizione supina
iniettando in vescica meno di 25 mL di SF
Inclinazione del letto
Abdominal compartment syndrome (ACS)
Una sindrome definita come:
• una pressione endoaddominale stabilmente sopra 20 mmHg
• associata ad una o più disfunzioni d’organo
MalbrainML, CheathamML, Kirkpatrick A, et al. Results fromthe international conference of experts on intra-abdominalhypertension and abdominal compartment syndrome. I.Definitions. Intensive Care Med 2006;32:1722e1732.
Ipertensione addominale & sindrome compartimentale addominale
Abdominal compartment syndrome
• Primaria (causa primaria addominale)
– Rottura di aneurismi dell’aorta addominale, traumi addominali, emorragie retroperitoneali
– Ascite massiva, rumori ovarici giganti, ematomi rettali
• Secondaria (causa extra-abdominale)
– Politrauma
– Ustioni gravi
– Infusioni massive
• Terziaria (ricorrente)
Carr JA, J Am Coll Surg 2013
Due pazienti che hanno sviluppato l’ACS durante ECMO A-V
• Grave ipotensione arteriosa dopo 72 ore di ECMO• Migliomento dopo laparotomia per sospetta ischemia intestinale• Pressione addominale dopo la laparotomia 19 mmHg
• Grave ipotensione arteriosa dopo 36 ore di ECMO• Pressione addominale 35 mmHg• Exitus prima della laparotomia decompressiva
Aspetto comune è stata l’infusione massiva di fluidi per mantenere flussi ematici adeguati
IAP > 12 mmHg per oltre 4 ore
69 pazienti sottoposti a cardiochirugia elettiva
23 (31.8%) hanno developed the IAH group
We recommend measuring IAP when any known risk factor for IAH/ACS is present in a critically ill or injured patient
updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome
Risk factors for intra-abdominal hypertension and abdominal compartment syndrome
• high BMI
• abdominal surgery
• liver dysfunction/ascites
• hypotension/vasoactive therapy
• respiratory failure
• excessive fluid balance
Carr JA, J Am Coll Surg 2013
Holodinsky JK, et Al. Crit Care 17, R249, 2013
Risk factors for intra-abdominal hypertension and abdominal compartment syndrome
IAH9 studies1519 pts
ACS6 studies974 pts
Imaging in IAH: CT or sonographic findingsin 21 patients with proved ACS
Patel A et al: Abdominal compartment syndrome. AJR Am J Roentgenol 2007; 189:1037-1043
Anteroposterior and lateral IVC diameters in bowel obstruction
Cavaliere F, Biomed Res Int, 2013
Renal resistance
RI = Resistive Index
peak systolic velocity – end diastolic velocity
peak systolic velocity
Normal value < 0.70
Abnormal values may suggest:
•Increased vascular resistance
•Increased intrarenal pressure
CVP and PCWP increase due to pressure transmission across diaphragm
–Transmural PAOP = PAOP -0.5*IAP
–Transmural CVP = CVP -0.5*IAP
IAH and the cardiovascular system
IAH: Management 2013
Trattamentomedico
Monitoraggio IAP (ogni 4 ore)
Trattamentochirurgico
A. Evacuate intraluminal contents
Patofisiologia dell’ileo dinamico
Madl C, Druml W, Best Pract & Res Clin Gastroenterol 17, 445, 2003
Pseudo-obstruction in the critically ill
• reflex motor inhibition in response to noxious stimuli
• excess sympathetic (inhibitory) motor input (intestine does not contract);
• excess parasympathetic (excitatory) motor input (intestine does not relax)
• decreased parasympathetic (excitatory) motor input (intestine does not contract)
• excess stimulation by endogenous or exogenous opioids;
• inhibition of nitric oxide (NO) release from inhibitory motoneurons (intestine does not relax)
Delgado-Aros S, Camilleri M, Best Pract & Res Clin Gastroenterol 17, 427, 2003
Impiego di procinetici
Prostigmine 0.4-0.8 mg/h for 24 hours(van der Spoel JI, 2001)
Prostigmine 2 mg in 3-5 min (Ponec RJ, 1999)
The WSACS SUGGESTS that neostigmine may be used for the treatment of establised colonic ileus not responding to other simple measures and inducing IAH (GRADE 2D).
Contraindications:• heart rate <60 bpm• systolic blood pressure < 90 mmHg• active bronchospasm• serum creatinine concentration > 3 mg/dl• signs of bowel perforation.
Evacuazione del contenuto intestinale
• Altri procinetici:
metoclopramide, cisapride, eritromicina, antagonisti degli oppioidi, clisteri evacuativi, lassativi
• Farmaci da evitare perché riducono la perfusione intestinale:
adrenalina, noradrenalina, dopamina, vasopressina
• Riduzione o sospensione della nutrizione enterale
Madl C, Druml W, Best Pract & Res Clin Gastroenterol 17, 445, 2003
B. Evacuate intra abdominal space - occupying lesions
C. Improve abdominal wall compliance
C. Improve abdominal wall compliance
Sturini, Int Care Med 2008
L’ampiezza delle variazioni della pressione endoaddominale durante ventilazione
meccanica sono indicative della compliance
C. Improve abdominal wall compliance
Possibile impiego di miorilassanti
De Waele, Crit Care Med 2003
Kimball, WCACS 2007No recommendations by WSACS guidelines
D. Optimize fluid administration
1. Impiego del rapporto 1:1 trasangue e plasma
2. Impiego di colloidi Vs cristalloidi
3. Bilancio in parità dalla 3^ giornata
4. Diuretici / CVVHDF
No recommendations by WSACS guidelines
E. Optimize systemic and regional perfusion
Abdominal perfusion pressure:
APP = MAP - IAP
It seems prudent to maintain APP above 60 mmHg, although hard prospective evidence for this statement is still lacking
Malbrain MLNG, Best Practice & Research Clinical Anaesthesiology 2013
No recommendations by WSACS guidelines
Does patienthave primary
ACS?
Patient hassecundary or recurrent ACS
Is IAP > 20mmHg with progressive organ failure ?
Perform/reviseabdominal
decompression withtemporary abdominal
closure
No
Yes
Yes
Yes
Se la risposta alla terapia medica è insufficiente non va perso tempo!
Grazie per l’attenzione