腹内高压对门静脉压、中心静脉压影响的实验研究

目的研究腹内压升高对大鼠中心静脉压和门静脉压的影响。方法将20只成年雄性SD大鼠分别通过颈静脉插管、穿刺门静脉主干法来测定中心静脉压和门静脉压,运用氮气气腹法制作大鼠腹内高压动物模型。建立气腹后分别在0、5、10、15、20、25、30、35、40、45mmHg压力值下测得中心静脉压和门静脉压。结果中心静脉压和腹内压之间的直线回归方程为Y=2.824+0.045X,相关系数r=0.984(P<0.01);门静脉压和腹内压之间的直线回归方程为Y=8.887+0.939X,相关系数r=0.998(P<0.01)。结论腹内压与中心静脉压和门静脉压有很好的相关性,可以根据腹内压监测中心静脉压和门静脉压的变化。     

腹内高压致肠黏膜屏障损伤的实验研究

目的观察不同程度腹内压（IAP）及其不同持续时间对兔肠黏膜屏障功能的影响。方法（1）取9只新西兰兔，制成腹内高压（IAH）模型（IAH模型组），将其IAP分别升至10、20、30mmHg（1mmHg=0．133kPa），维持1h后记录肠黏膜血流量。另检测正’常对照组兔（3只）的该项指标。（2）同前分组及设定IAP。维持IAP1．5h后，两组兔均以异硫氰酸荧光素-葡聚糖（FITC—D）及Ⅱ型辣根过氧化物酶（HRP-Ⅱ）灌胃。继续维持IAP0．5h后取两组兔门静脉血，检测FITC—D含量及HRP-Ⅱ活性。（3）取27只新西兰兔，分组及IAP设定同前，IAH模型组IAP为10、20mmHg时，均持、2、4h；IAP为30mmHg时，持续1、2h。抽取各组兔下腔静脉血，检测D-乳酸含量及二胺氧化酶（DAO）活性；取空肠肠段，常规制作切片，于光学显微镜及透射电镜下观察。结果（1）IAH模型组兔IAP为10mmHg时，其肠黏膜血流量接近正常对照组（P〉0．05）；IAP为20、30mmHg时，肠黏膜血流量分别比正常对照组减少了44％、80％（P〈0．01）。（2）IAH模型组兔IAP为10mmHg时，其门静脉血中FITC—D含量接近正常对照组（P〉0．05）；当IAP为20、30mmHg时，分别为正常对照组的4．8、7．0倍（P〈0．01）。HRP-Ⅱ的变化趋势与之一致。（3）IAH模型组兔IAP为10mmHg时，各时相点下血浆D-乳酸含量、DAO活性与正常对照组相近（P〉0．05）；IAP为20、30mmHg时，随着压力持续时间的延长，两指标均逐渐升高（P〈0．01）。（4）IAP为10mmHg持续2h，IAH模型组兔空肠黏膜轻度水肿；IAP20mmHg持续2h时，空肠黏膜明显水肿，中央乳糜管扩张，黏膜上皮下间隙扩大；肠上皮微绒毛变短，部分变性、坏死、脱落，线粒体高度肿胀、空泡化。IAP升至30mmHg，肠黏膜损伤进一步加重。结论IAH可导致肠黏膜屏障功能严重受损，这可能是继发全身性炎性反应综合征、脓毒症、腹腔间隙综合征及多器官功能衰竭重要原因。     

烧伤病人股静脉压与中心静脉压的相关性研究

目的探寻一种安全、易操作且能替代颈内或锁骨下静脉置管监测中心静脉压的方法。方法对 30例大面积烧伤病人同时测量中心静脉压和股静脉压 (各 2 0 4次 ) ,所得数据采用 SPSS 8.0统计软件包进行处理 ,检验股静脉压与中心静脉压的相关性 ,求出两者之间的相关系数与回归方程。结果同一病人股静脉压与中心静脉压呈直线正相关关系 (r=0 .72 0 ,P<0 .0 1) ;直线回归方程 :Y(中心静脉压 ) =0 .132 +0 .5 5 7X (股静脉压 ) ,对回归系数进行 t检验 ,P<0 .0 5。结论临床抢救大面积烧伤病人时 ,测出股静脉压的值代入回归方程 ,即可计算出该病人中心静脉压的值。     

复方丹参滴丸对门脉高压血流动力学的影响

目的：观察复方丹参滴丸对门脉高压血流动力学的影响。方法：对31例中层得单用复方丹参滴丸治疗8周,应用彩色多普勒超声,测定治疗前后门静脉内径（Dpv)、门静脉血流速度（Vpv)及门静脉血流量（Qpv)。结果：治疗后Dpv,Qpv均显著下降,与治疗前比较,差异有显著性意义（P＜0．05－0．01）。结论复方丹参滴丸对改善肝硬化门脉血流动力学有一定的作用。     

心脏手术后中心静脉压测定的临床意义

目的 探讨中心静脉压（ＣＶＰ）在心脏术后的临床意义。方法 随机选择心脏术后患者２４例,均在三种状态下进行对比研究：（１）患者术毕进入ＩＣＵ处于机械通气状态;（２）术后８小时处于机械通气及清醒状态;（３）术后２４小时处于自主呼吸和清醒状态。分别测定ＣＶＰ、血容量（ＢＶ）、心脏指数（ＣＩ）和其它血流动力学指标,对ＣＶＰ与血流动力学指标之间进行相关分析。结果 ＣＶＰ与ＢＶ在术后不同状态下均无相关性,而与     

中心静脉压监测方法的研究现状

综述了中心静脉压监测时血管路径的选择、零点定位、溶液的选择、具体操作方法及监测中心静脉压时的影响因素。提出置管时首选锁骨下静脉、颈内静脉,在紧急情况下或不具备置管条件时,可以通过监测周围静脉压力来间接反映中心静脉压的变化,为评估机体容量状态提供参考;导管置入的深浅度及通畅度、体位、机械通气、胸内压、腹内压等因素对中心静脉压均有影响,应尽量避免这些干扰因素,使监测的结果更加准确、可靠。     

控制性低中心静脉压对肝移植术中酸碱平衡的影响

目的观察控制性低中心静脉压(CLCVP)对肝移植术中酸碱平衡的影响。方法 46例行非转流原位肝移植患者分为CLCVP组(L组)和正常CVP组(C组),分别于开腹前10 min(T1)、无肝前期60 min(T2)、无肝期30 min(T3)、新肝期5 min(T4)、30 min(T5)及60 min(T6)行动脉血气分析及电解质检测,并记录无肝期时间、手术总时间、术中出血量、输血量和5%碳酸氢钠(NaHCO3)用量。结果 T4～T6时L组pH、BE明显高于C组(P0.05);T1～T6时L组血Ca2+水平高于C组(P0.05);L组术中出血量和输血量明显低于C组(P0.05)。两组无肝期时间、手术总时间5、%NaHCO3用量差异无统计学意义。结论非转流原位肝移植患者在无肝期和新肝期均有明显的酸中毒,CLCVP技术可以改善肝移植术中酸碱平衡紊乱。     

腔镜甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响

目的:探讨腔镜下胸乳入路甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响。方法:30例患者经胸乳入路行腔镜下甲状腺手术,分别于CO_2充气前,充气后10 min、20 min、40 min,关闭充气后5 min、20 min测量颈内静脉压力、中心静脉压,比较不同时点颈内静脉压力、中心静脉压的变化。结果:与充气前相比,充气后各时点的颈内静脉压力、中心静脉压显著上升(P0.05);解除充气后,逐渐下降,与充气前相比差异无统计学意义(P0.05);充气后三个时间点的颈内静脉压力均大于8 mmHg(P0.05),中心静脉压均小于8 mmHg(P0.05)。结论:经胸乳入路腔镜甲状腺手术中CO_2气腹会导致颈内静脉压力、中心静脉压显著升高,切除甲状腺中上部时无发生气体栓塞的可能,但切除甲状腺下部时有发生气体栓塞的可能。     

低中心静脉压减少肝切除术中出血的临床研究

目的探讨低中心静脉压对减少肝癌(HCC)切除手术出血的影响。方法将2003年12月以前中山大学附属第一医院同一手术组医生施行肝切除术的HCC病人50例,按随机数字采用信封法分为低中心静脉压(LCVP)组和常规手术组(对照组),各为25例。LCVP组切肝时经体位、药物处理使CVP在2~4mmHg(1mmHg=0·133kPa)、收缩压>90mmHg,对照组则按常规处理,比较两组的术前一般情况、术中和切肝时的出血量及输血量、术后恢复情况和肝肾功能变化。结果两组病人术前一般情况差异无显著性。病人的肿瘤最大直径、手术方式、入肝血流阻断时间、手术时间、切除肝组织的重量、术后并发症发生、术后肝肾功能的恢复两组差异均无显著性。LCVP组手术出血量、切肝时出血量分别为(903·9±180·8)mL、(672·4±429·9)mL,均明显低于对照组(W值分别为495·5、543·5,P<0·01),而切肝前和切肝后的出血量两组差异无显著性意义。LCVP组术后留院时间为(16·3±6·8)d,对照组为(21·5±8·6)d,两组差异有显著性意义(W=532·5,P<0·05)。结论LCVP技术在操作上简便易行,将中心静脉压控制在≤4mmHg,能够减少切肝过程的出血量、缩短术后留院时间、对病人肝肾功能无损害。     

腹腔恶性肿瘤伴大量腹水所致慢性腹内高压对相关脏器功能的影响

目的 了解慢性腹内高压对机体多个系统和器官功能的影响.方法 选择2004年1月至2008年1月在北京大学人民医院住院确诊腹腔恶性肿瘤伴大量腹水的慢性腹内高压患者共30例,包括结肠癌12例,胰腺癌7例,胃癌11例.另选取同期住院腹腔恶性肿瘤但不伴腹水患者30例作为对照组,其中结肠癌15例,胰腺癌8例,胃癌7例.统计两组患者的循环系统、呼吸系统、消化系统症状及肝功能、肾功能、一般体力状况KPS评分.结果 慢性腹内高压组有气喘、胸闷等呼吸道症状者为9例(30%),腹部胀满感15例(50%),心悸、低血压10例(33%),肝功能异常16例(53%),肾功能异常14例(47%),KPS评分低于40者22例(73%),以上各指标均显著高于对照组(分别为3%、16%、10%、20%、3%、23%)(P<0.05).结论 慢性腹内高压可导敛机体循环系统、呼吸系统、消化系统功能不全,并对患者一般状况造成显著影响.慢性腹内高压亦可出现腹腔间隔综合征.     

腹腔高压症对中枢神经系统影响的研究进展

腹腔高压症是腹腔内压持续或反复病理性升高并〉12mmHg的病理状态,不仅可以引起腹腔脏器的变化,而且会损害心、肺及中枢神经系统功能,在危重患者中发病率和死亡率高。阐明其对中枢神经系统损害的影像表现、具体病理表现、分子水平变化和引起这些变化的具体机制,可进一步提高合并有颅脑损伤患者的治愈率。     

股静脉测压法和膀胱测压法在危重患者腹内压监测中的比较

目的：比较股静脉测压法和膀胱测压法在危重患者腹内压（IAP）监测中的应用价值.方法：对2013年1-6月住院治疗的20例ICU重症患者,分别使用两种测压方法进行IAP监测,均每8 h 1次,连续测定3 d,每次随机选择两种方法的测量顺序,共测量720次,比较两种测压法在读数精准性、测压数值、操作时间、并发症和医护人员满意度等方面的异同.结果：股静脉测压法所测压力数值与膀胱测压法相近[（14.14±4.33）mmHg比（12.91±4.75）mmHg,P〉0.05];但是股静脉测压法的操作时间[（57.94±19.00）s]较膀胱测压法更短[（112.49±27.07）s,P〈0.05];股静脉测压法读数精准率（84.44%）较膀胱测压法（49.44%）高（P〈0.01）,操作并发症低至1.1%（4例次）,远低于膀胱测压法的5.3%（19例次,P〈0.05）;医护人员满意度达（3.90±0.26）分,优于膀胱测压法[（2.48±0.19）分,P〈0.01].结论：相对于膀胱测压法而言,股静脉测压法具有测压值相似、操作时间短、读数精准度高、操作并发症少、接纳度高等优点,值得在危重患者IAP监测中推广.     

Intra-abdominal pressure and intra-abdominal hypertension in critically ill obstetric patients: a prospective cohort study

BackgroundCritically ill obstetric patients may have risk factors for intra-abdominal hypertension. This study evaluated the intra-abdominal pressure and its effect on organ function and the epidemiology of intra-abdominal hypertension.MethodsObstetric patients admitted to an Intensive Care Unit, with an anticipated stay greater than 24 hours, were included. Intra-abdominal pressure was measured daily via a Foley catheter, based on intravesical pressure.ResultsOne-hundred-and-one patients were enrolled. The intra-abdominal pressure was 5–7 mmHg in 34%; 7–12 mmHg in 60%; and ≥12 mmHg (intra-abdominal hypertension) in 6%. All six patients with intra-abdominal hypertension were pregnant at the time of admission. The intra-abdominal pressure in four patients normalized to <12 mmHg following delivery, but in the remaining two it persisted ≥12 mmHg and both these patients died. Correlation between intra-abdominal pressure and organ dysfunction was weak (r=0.211). Statistical comparison between patients with and without intra-abdominal hypertension for risk factors, daily intra-abdominal pressures, and Sequential Organ Failure Assessment score could not be done due to the disproportionately small number of patients with intra-abdominal hypertension as opposed to those without (6 versus 95). Intra-abdominal pressure did not significantly differ between survivors and non-survivors (8.5 ± 1.1 vs 7.9 ± 1.7 mmHg, P=0.079).ConclusionsThe incidence of intra-abdominal hypertension in critically ill obstetric patients was lower than previously defined for mixed Intensive Care Unit populations, with an association with the pregnant state. Normalization of intra-abdominal pressure after delivery was associated with better survival. There was no correlation between intra-abdominal pressure and organ function or mortality.     

Iliac venous pressure estimates central venous pressure after laparotomy

Background

Central venous pressure (CVP) is traditionally obtained through subclavian or internal jugular central catheters; however, many patients who could benefit from CVP monitoring have only femoral lines. The accuracy of illiac venous pressure (IVP) as a measure of CVP is unknown, particularly following laparotomy.

Methods

This was a prospective, observational study. Patients who had both internal jugular or subclavian lines and femoral lines already in place were eligible for the study. Pressure measurements were taken from both lines in addition to measurement of bladder pressure, mean arterial pressure, and peak airway pressure. Data were evaluated using paired t-test, Bland-Altman analysis, and linear regression.

Results

Measurements were obtained from 40 patients, 26 of which had laparotomy. The mean difference between measurements was 2.2 mm Hg. There were no significant differences between patients who had laparotomy and nonsurgical patients (P = 0.93). Bland-Altman analysis revealed a bias of 1.63 ± 2.44 mm Hg. There was no correlation between IVP accuracy and bladder pressure, mean arterial pressure, or peak airway pressure.

Conclusions

IVP is an adequate measure of CVP, even in surgical patients who have had recent laparotomy. Measurement of IVP to guide resuscitation is encouraged in patients who have only femoral venous catheter access.     

肝移植术后腹内压监测的临床意义

目的探讨肝移植术后腹内压监测的临床意义。方法2003年9月至2005年1月,采用膀胱内压检测法间接测量腹内压,术后每天腹内压>20mmHg(1mmHg=0.133kPa)时定为腹内高压(IAH)。比较腹内高压组与正常组的原发病因、手术方式、术中相关指标及愈后。记录病人术后0～72h的腹内压、肾功能相关指标,血流动力学指标以及动脉血氧分压/吸入氧浓度比,同时记录病人的机械通气时间和术后第4天的肝功能。结果腹内高压组与正常组比较,手术时间、术中补液量、术中输血量及术后急性肾衰、呼吸衰竭的发生率差异有显著性,术后24～72h血肌酐、血尿素氮水平、每小时尿量以及心率、动脉血氧分压/吸入氧浓度比、机械通气时间也存在显著不同。结论肝移植术后并发的腹内高压对器官功能的损害是快速、多部位的,最常见的损害是肾功能与呼吸功能。重视腹内高压、术后早期腹内压的严密监测具有较重要的临床意义。     

Endoscopic ultrasound-guided portal pressure gradient measurement in managing portal hypertension

Portal hypertension (PH) is still a challenging clinical condition due to its silent manifestations in the early stage and needs to be measured accurately for early detection. Hepatic vein pressure gradient measurement has been considered as the gold standard measurement for PH; however, it needs special skill, experience, and high expertise. Recently, there has been an innovative development in using endoscopic ultrasound (EUS) for the diagnosis and management of liver diseases, including portal pressure measurement, which is commonly known as EUS-guided portal pressure gradient (EUS-PPG) measurement. EUS-PPG measurement can be performed concomitantly with EUS evaluation for deep esophageal varices, EUS-guided liver biopsy, and EUS-guided cyanoacrylate injection. However, there are still major issues, such as different etiologies of liver disease, procedural training, expertise, availability, and cost-effectiveness in several situations with regard to the standard management.     

生长抑素对兔大部分肝切除术后门静脉压力的影响

目的探讨生长抑素对肝切除术后门静脉压力的影响。方法32只家兔随机分成正常对照组、生理盐水组、生长抑素组，并建立门静脉置管及肝切除动物模型。术中及术后持续给药，比较各组间门静脉压力的差值。结果与生理盐水组比较，生长抑素组肝切除术前与术后门静脉压力的差值显著减少（P=0．003）。结论生长抑素可明显降低肝切除术后升高的门静脉压力，而且其降压作用是持续而稳定的。     

Peripheral venous pressure is an alternative to central venous pressure in paediatric surgery patients

BACKGROUND: Peripheral venous pressure (PVP) is easily and safely measured. In adults, PVP correlates closely with central venous pressure (CVP) during major non-cardiac surgery. The objective of this study was to evaluate the agreement between CVP and PVP in children during major surgery and during recovery. METHODS: Fifty patients aged 3-9 years, scheduled for major elective surgery, each underwent simultaneous measurements of CVP and PVP at random points during controlled ventilation intraoperatively (six readings) and during spontaneous ventilation in the post-anaesthesia care unit (three readings). In a subset of four patients, measurements were taken during periods of hypotension and subsequent fluid resuscitation (15 readings from each patient). RESULTS: Peripheral venous pressure was closely correlated to CVP intraoperatively, during controlled ventilation (r=0.93), with a bias of 1.92 (0.47) mmHg (95% confidence interval = 2.16-1.68). In the post-anaesthesia care unit, during spontaneous ventilation, PVP correlated strongly with CVP (r = 0.89), with a bias of 2.45 (0.57) mmHg (95% confidence interval = 2.73-2.17). During periods of intraoperative hypotension and fluid resuscitation, within-patient changes in PVP mirrored changes in CVP (r = 0.92). CONCLUSION: In children undergoing major surgery, PVP showed good agreement with CVP in the perioperative period. As changes in PVP parallel, in direction, changes in CVP, PVP monitoring may offer an alternative to direct CVP measurement for perioperative estimation of volume status and guiding fluid therapy.     

Continuous intra-abdominal pressure measurement technique

BACKGROUND: Abdominal compartment syndrome can develop within 12 hours of intensive care unit (ICU) admission in high-risk (shock/trauma, burn, pancreatitis, postabdominal aortic surgery) patients. The current standard of intra-abdominal pressure (IAP) measurement via the urinary catheter is labor intensive, and its intermittent nature could prevent timely recognition of significant changes in IAP. We propose that continuous IAP (CIAP) can be accurately measured via the irrigation port of a three-way catheter and has good agreement with the standard intermittent IAP (IIAP). METHODS: CIAP was prospectively validated by comparing it with IIAP measurement in general surgical and trauma patients admitted to the ICU with a three-way urinary catheter. CIAP was measured via the irrigation port of the three-way catheter transduced to the bedside monitor as a continuous trace without intermittent clamping of the catheter. The standard IIAP measurements were performed via the urine drainage port after clamping the catheter and filling the bladder with 50 mL of 0.9% saline. Each patient had three separate paired measurements performed in standardized manner to compare CIAP with IIAP. Patients' demographics, injury severity, type of surgery, body mass index (BMI), and the paired individual IAP measurements were recorded. The paired measurements were compared using the Bland-Altman (B-A) method for comparing a new clinical measurement with an established one. Data are presented as mean +/- standard error of the mean. RESULTS: During a 6-month period (ending in July 2003), 25 patients were investigated. The mean age was 61.5 +/- 4 years, 66% were men, and BMI was 29.2 +/- 2 kg/m(2). Six patients had vascular surgical, four elective and three urgent general surgical interventions. There were 12 trauma patients with ISS of 23 +/- 2. The CIAP was 14.2 +/- 0.66 (range 2 to 24) mm Hg, and the IIAP was 14.0 +/- 0.68 (range 3 to 24) mm Hg. Seventy-five percent of the measured pairs were exactly the same; in 21%, there was 1 mm Hg difference and in 4% 2 mm Hg. There was no measurement difference greater than 2 mm Hg. The mean difference between the CIAP and IIAP was 0.019 +/- 0.05 mmHg. The B-A statistics revealed that the difference between the means of measurements in each individual patient was between +/-1.96 SD (95% confidence intervals). The B-A scatter plot did not follow any patterns of typical systematic bias. CONCLUSION: CIAP measurement with a three-way urinary catheter is a simple and accurate method for monitoring IAP. It has an excellent agreement with the IIAP over wide pressure ranges and should replace the current labor-intensive intermittent technique.