急性胰腺炎合并腹腔间隔综合症(英语).ppt
Case Report Abdominal Compartment Abdominal Compartment Symdrom Symdrom in A Patient with Severe Acute in A Patient with Severe Acute Pancreatitis Pancreatitis AdmissionA 56-year-old male was admitted to SICU of Research Institute of General Surgery,Jinling Hospital on 20th Oct 2003He sufferd from epigastric pain for two days,dyspnea and decreased urine output for one day after a fat rich dietPE on AdmissionT 38,HR 140bpm,RR 30/min,BP 82/58mmHg Oxygen saturation 92%Acute face with shortness of breath,in agitated state,far distended abdomen with high tension,signs of diffusive peritonitis,weak bowel soundsBloody ascites was drawn out by diagnostic punctureUrine output decreased further and anuria developed Lab Examination on AdHb 18g/dl WBC 11300/mm3(N0.88 L0.09)Platelet 95000/mm3 Amy(serum)1270U/L Amy(urine)14819 Lipase 10003U/L Ca 1.9mmol/LBUN 49mg/dl SCr 4.0mg/dl Arterial blood gas analysis：pH 7.26,PaO2 55mmHg,PaCO2 28 mmHg,BE 14.5mmol/LCT:Diffusive necrosis of pancreas,massive ascites,left pleural effusionDiagnosisSevere acute pancreatitisARDSARFShockAbdominal compartment syndromeTreatmentIntubation,tracheostomy,mechanical ventilationFluid resuscitation and anti-shock therapy Intraabdominal irrigation by laparoscopy,continous draining by persistent negative pressure Continuous venovenous high volume hemofiltrationAnti-acid therapy and Inhibition of pancreatic secretion prophylactic antibiotic therayAdvancement of the Illness and Outcome of the Patient3rd hospital day,developed“Abdominal Compartment Syndrome”,and received the 2nd emergent operation as abdominal opening and gastrointestinal fistulization to relieve the abdominal high pressureIntraabdominal pressure were indirectly Intraabdominal pressure were indirectly measured by bladder pressure measurement.measured by bladder pressure measurement.nHe experienced massive abdominal He experienced massive abdominal hemorrhage for two times,and even the hemorrhage for two times,and even the 3rd emergent operation was performed 3rd emergent operation was performed for for hemostasishemostasis and necrosis tissue and necrosis tissue cleaningcleaningnVarious Various microbialsmicrobials were recurrently were recurrently found in the culture of the specimen of found in the culture of the specimen of blood,sputum,secretion of wound,the blood,sputum,secretion of wound,the tips of central venous catheter,and tips of central venous catheter,and the fluid drained from the abdomenthe fluid drained from the abdomen Advancement of the Illness and Outcome of the Patient14th day,intestinal function partially recovered and TPN was gradually switched to enteral nutrition 28th day,CVVH discontinued,urine output increased to more than 2000ml/d.36th day,mechanical ventilation ceasedserum creatinine returned to normal range on 48th day39th day,and 57th day,received two times of postage stamp autodermoplasty for skin defect in abdomen 161st day,after a CT scan confirming that pancreatic necrosis and effusion well absorbed,discharged 腹腔内压力的变化（膀胱测压法）腹腔内压力的变化（膀胱测压法）吸入氧浓度和血气的变化吸入氧浓度和血气的变化心率的变化心率的变化 尿量的变化尿量的变化MAP,HR Changes and Dopamine/Noradrenine Dose Adjustment PaO2/FiO2 ChangesUrine Output and BUN,SCr Changes during CBPCHVHF(4L/h)CHVHF(4L/h)CVVH(2L/h)CVVH(2L/h)CVVH CVVH DiscontinuedDiscontinuedSerum electrolytes Changes during CHVHFCHVHF dayCHVHF dayArterial pH Changes during CHVHFArterial Arterial pHpHArterial HCO3-and BE Level Changes during CHVHF讨论讨论此例出现此例出现ACS的原因的原因ACS的临床表现及其对我们处理的影响的临床表现及其对我们处理的影响ACS的诊断的诊断腹腔高压的处理腹腔高压的处理腹腔开放在腹腔开放在ACS处理中的价值处理中的价值Thank you Thank you!
