How to deal with acute pancreatitis complicated with intra-abdominal hypertension

Acute pancreatitis is a common critical illness in the digestive syste.

Acute pancreatitis is a common critical illness in the digestive syste.

- How to monitor intra-abdominal pressure - How to monitor intra-abdominal pressure - How to monitor intra-abdominal pressure

The abdominal cavity is a closed space, and both increased abdominal volume and decreased abdominal wall compliance can lead to increased intra-abdominal pressu.

The abdominal cavity is a closed space, and both increased abdominal volume and decreased abdominal wall compliance can lead to increased intra-abdominal pressu.

Intra-abdominal pressure (IAP) measurement methods include cystometry, transgastric manometry, transrectal manometry, and inferior vena cava manomet.

To ensure accurate measurement, the following points should be noted:

1) Inject ≤25ml of normal saline during measurement;

1) Inject ≤25ml of normal saline during measurement;

2) During the measurement, the patient should be in a completely supine position, the sensor should be zeroed at the level of the mid-axillary line, and there is no need to flex both lower limbs to ensure that the abdominal muscles are not contract.

2) During the measurement, the patient should be in a completely supine position, the sensor should be zeroed at the level of the mid-axillary line, and there is no need to flex both lower limbs to ensure that the abdominal muscles are not contract.

2 How to grade intra-abdominal hypertension 2 How to grade intra-abdominal hypertension 2 How to grade intra-abdominal hypertension

The normal intra-abdominal pressure in the supine position is 5-7 mm.

The normal intra-abdominal pressure in the supine position is 5-7 mm.

According to the level of intra-abdominal pressure, its severity is divided into 4 grades:

Grade I intra-abdominal pressure is 12-15mmHg;

Grade I intra-abdominal pressure is 12-15mmHg;

Grade II intra-abdominal pressure is 16-20mmHg;

Grade II intra-abdominal pressure is 16-20mmHg;

Grade III is intra-abdominal pressure of 21-25mmHg;

Grade III is intra-abdominal pressure of 21-25mmHg;

Grade IV intra-abdominal pressure is >25mm.

Grade IV intra-abdominal pressure is >25mm.

Abdominal compartment syndrome (ACS) was diagnosed when the intra-abdominal pressure was >20 mmHg with new onset organ insufficiency or failu.

3 The effect of intra-abdominal hypertension on the body 3 The effect of intra-abdominal hypertension on the body

Intra-abdominal hypertension can cause organ dysfunction in two ways: increased intra-abdominal pressure can be directly transmitted to other compartments of the body; increased intra-abdominal pressure can affect systemic hemodynami.

Intra-abdominal hypertension can cause organ dysfunction in two ways: increased intra-abdominal pressure can be directly transmitted to other compartments of the body; increased intra-abdominal pressure can affect systemic hemodynami.

1) Intra-abdominal hypertension increases the intrathoracic pressure due to the elevation of the diaphragm, increases dead space ventilation, shunts in the lungs, decreases the compliance of the respiratory system, and increases pulmonary artery afterlo.

2) Intra-abdominal hypertension increases thoracic pressure, resulting in increased central venous pressure and jugular venous pressure, impaired cerebral venous return pressure gradient, and reduced cranial venous retu.

3) Intra-abdominal hypertension reduces cardiac preload, inhibits myocardial contractility, and increases cardiac afterload, thereby reducing cardiac outp.

4) Intra-abdominal hypertension leads to increased renal venous pressure, decreased perfusion pressure, and decreased glomerular filtration rate, resulting in oliguria and renal tubular dysfuncti.

4) Intra-abdominal hypertension leads to increased renal venous pressure, decreased perfusion pressure, and decreased glomerular filtration rate, resulting in oliguria and renal tubular dysfuncti.

5) Intra-abdominal hypertension obstructs the return of intestinal veins and lymph fluid and has a direct effect on the intestinal canal, which can lead to intestinal congestion and swelling, and then occurs ischemia and hypoxia, intestinal mucosal necrosis, increased permeability, and affects intestinal motili.

Digestion and absorption functions also increase the risk of bacterial translocati.

5) Intra-abdominal hypertension obstructs the return of intestinal veins and lymph fluid and has a direct effect on the intestinal canal, which can lead to intestinal congestion and swelling, and then occurs ischemia and hypoxia, intestinal mucosal necrosis, increased permeability, and affects intestinal motili.

Digestion and absorption functions also increase the risk of bacterial translocati.

Digestion

6) Intra-abdominal hypertension reduces blood perfusion in hepatic artery and portal vein, affects the function of hepatocytes and hepatic sinusoidal endothelial cells, and leads to abnormal liver functi.

6) Intra-abdominal hypertension reduces blood perfusion in hepatic artery and portal vein, affects the function of hepatocytes and hepatic sinusoidal endothelial cells, and leads to abnormal liver functi.

7) Intra-abdominal hypertension can affect the tolerance of gastrointestinal nutriti.

Feeding intolerance was significantly increased when intra-abdominal pressure was ≥15 mm.

7) Intra-abdominal hypertension can affect the tolerance of gastrointestinal nutriti.

Feeding intolerance was significantly increased when intra-abdominal pressure was ≥15 mm.

Treatment of quadrilateral intra-abdominal hypertension

treatment of intra-abdominal hypertension treatment of intra-abdominal hypertension treatment of intra-abdominal hypertension treatment of intra-abdominal hypertension

(1) Non-surgical treatment:

(1) Non-surgical treatment: (1) Non-surgical treatment:

Principles: Empty organ contents, increase abdominal wall compliance, clear ascites, correct positive fluid balance, and support organ functi.

Principles: Empty organ contents, increase abdominal wall compliance, remove ascites, correct fluid balance, and support organ functi.

1) Gastrointestinal decompression: including various decompression of stomach, duodenum, colon and rect.

The most commonly used clinical decompression is gastric cavity decompression, which can reduce gastric juice to stimulate intestinal mucosa to produce intestinal hormones, reduce the secretion of pancreatic juice, thereby delaying the progression of pancreatit.

1) Gastrointestinal decompression: including various decompression of stomach, duodenum, colon and rect.

The most commonly used clinical decompression is gastric cavity decompression, which can reduce gastric juice to stimulate intestinal mucosa to produce intestinal hormones, reduce the secretion of pancreatic juice, thereby delaying the progression of pancreatit.

2) Improve the compliance of the abdominal wall: The use of sedatives and analgesics can reduce the tension of the chest and abdominal muscles , improve the compliance of the abdominal wall, and help reduce I.

In patients on ventilators, brief use of muscle relaxants can be used as a temporary measure for IAH and A.

2) Improve the compliance of the abdominal wall: The use of sedatives and analgesics can reduce the tension of the chest and abdominal muscles , improve the compliance of the abdominal wall, and help reduce I.

In patients on ventilators, brief use of muscle relaxants can be used as a temporary measure for IAH and A.

tension

3) Percutaneous paracentesis catheter drainage: There is a large amount of intra-abdominal exudation in patients with pancreatitis, and even a large amount of pancreatic ascites can be formed, which is an important cause of intra-abdominal hypertensi.

Draining ascites can quickly relieve intra-abdominal high pressure, restore blood supply to intra-abdominal organs, promote the recovery of intestinal function, reduce the damage of inflammatory mediators and cytokines to the body, effectively reduce the body's systemic inflammatory response, and improve the conditi.

In addition, peritoneal lavage on the basis of catheter drainage can further accelerate the removal of toxic substances and inflammatory mediators, but it may increase intra-abdominal pressure in the short term, which needs to be weigh.

3) Percutaneous paracentesis catheter drainage: There is a large amount of intra-abdominal exudation in patients with pancreatitis, and even a large amount of pancreatic ascites can be formed, which is an important cause of intra-abdominal hypertensi.

Draining ascites can quickly relieve intra-abdominal high pressure, restore blood supply to intra-abdominal organs, promote the recovery of intestinal function, reduce the damage of inflammatory mediators and cytokines to the body, effectively reduce the body's systemic inflammatory response, and improve the conditi.

In addition, peritoneal lavage on the basis of catheter drainage can further accelerate the removal of toxic substances and inflammatory mediators, but it may increase intra-abdominal pressure in the short term, which needs to be weigh.

4) Restrictive fluid resuscitation: Rapid excess fluid infusion is an independent risk factor for intra-abdominal hypertension and ACS, and positive fluid balance should be avoided as much as possible after successful emergency resuscitati.

Under strict hemodynamic monitoring, to correct the hypovolemic state, the ratio of crystalloids to colloids is 2:1, which can be increased to 1:1 if necessary to increase the osmotic pressure of plasma colloids, and diuretics are given as appropriate to drain the fluid from the third spa.

The goals of successful restrictive fluid resuscitation are heart rate 80-110bpm, MAP ≥65mmHg, urine output ≥5ml/kg/h, CVP8-12cmH ₂ 0, HCT(30±5)%, central venous oxygen saturation ≥7

4) Restrictive fluid resuscitation: Rapid excess fluid infusion is an independent risk factor for intra-abdominal hypertension and ACS, and positive fluid balance should be avoided as much as possible after successful emergency resuscitati.

Under strict hemodynamic monitoring, to correct the hypovolemic state, the ratio of crystalloids to colloids is 2:1, which can be increased to 1:1 if necessary to increase the osmotic pressure of plasma colloids, and diuretics are given as appropriate to drain the fluid from the third spa.

The goals of successful restrictive fluid resuscitation are heart rate 80-110bpm, MAP ≥65mmHg, urine output ≥5ml/kg/h, CVP8-12cmH ₂ 0, HCT(30±5)%, central venous oxygen saturation ≥7
₂

5) Continuous hemofiltration treatment: It can remove excessive inflammatory mediators, endotoxins and fluids in the blood, and significantly delay the further deterioration of intra-abdominal hypertension or A.

5) Continuous hemofiltration treatment: It can remove excessive inflammatory mediators, endotoxins and fluids in the blood, and significantly delay the further deterioration of intra-abdominal hypertension or A.

6) Peritoneal dialysis: Early peritoneal dialysis can promptly remove pancreatic necrotic substances, pancreatic enzymes and inflammatory factors in the abdominal cavity and reduce their entry into the blo.

At the same time, antibiotics can be added to effectively inhibit the inflammatory response, prevent and treat abdominal infection , and delay gastrointestinal failure and inhibiti.

Translocation of gut bacteria, thereby preventing the occurrence of A.

However, peritoneal dialysis is also a high-risk factor for intra-abdominal hypertension and should be used with cauti.

6) Peritoneal dialysis: Early peritoneal dialysis can promptly remove pancreatic necrotic substances, pancreatic enzymes and inflammatory factors in the abdominal cavity and reduce their entry into the blo.

At the same time, antibiotics can be added to effectively inhibit the inflammatory response, prevent and treat abdominal infection , and delay gastrointestinal failure and inhibiti.

Translocation of gut bacteria, thereby preventing the occurrence of A.

However, peritoneal dialysis is also a high-risk factor for intra-abdominal hypertension and should be used with cauti.

antibiotic infection

7) Improve gastrointestinal function: The exudation caused by inflammation can cause extensive edema in the retroperitoneum, compress the celiac plexus, and stimulate the hemorrhage and necrosis of the pancreas to weaken the function of the gastrointestinal tract, resulting in paralytic ile.

7) Improve gastrointestinal function: The exudation caused by inflammation can cause extensive edema in the retroperitoneum, compress the celiac plexus, and stimulate the hemorrhage and necrosis of the pancreas to weaken the function of the gastrointestinal tract, resulting in paralytic ile.

Neostigmine is an anticholinesterase drug that exerts a muscarinic effect and can promote intestinal peristals.

It is recommended for patients with intra-abdominal hypertension with definite paralytic colon obstructi.

It can enhance intestinal peristalsis and promote anal exhau.

, defecation, reduce intra-abdominal pressu.

However, it is contraindicated in patients with previous surgical history and mechanical intestinal obstruction caused by pancreatic necrotic tissue adhesion in the late stage of pancreatit.

Neostigmine is an anticholinesterase drug that exerts a muscarinic effect and can promote intestinal peristals.

It is recommended for patients with intra-abdominal hypertension with definite paralytic colon obstructi.

It can enhance intestinal peristalsis and promote anal exhau.

, defecation, reduce intra-abdominal pressu.

However, it is contraindicated in patients with previous surgical history and mechanical intestinal obstruction caused by pancreatic necrotic tissue adhesion in the late stage of pancreatit.

Mannitol can form a high osmotic pressure in the intestine, reduce intestinal edema, stimulate intestinal peristalsis, and then cause osmotic diarrhea, excrete a large amount of toxins from the body, and dehydrate the bile duct and duodenal papilla, Oddi The sphincter opens, improves blood supply, produces obvious choleretic effect and relieves biliary sympto.

Mannitol can form a high osmotic pressure in the intestine, reduce intestinal edema, stimulate intestinal peristalsis, and then cause osmotic diarrhea, excrete a large amount of toxins from the body, and dehydrate the bile duct and duodenal papilla, Oddi The sphincter opens, improves blood supply, produces obvious choleretic effect and relieves biliary sympto.

Traditional Chinese medicines such as rhubarb and mirabilite can maintain the stability of the intestinal micro-ecological environment, and at the same time can promote the proliferation of goblet cells in the intestinal mucosa, increase the secretion of mucus in the intestinal lumen, protect the intestinal mucosa, prevent the migration of intestinal flora, and reduce pancreatit.

infection ra.

Traditional Chinese medicines such as rhubarb and mirabilite can maintain the stability of the intestinal micro-ecological environment, and at the same time can promote the proliferation of goblet cells in the intestinal mucosa, increase the secretion of mucus in the intestinal lumen, protect the intestinal mucosa, prevent the migration of intestinal flora, and reduce pancreatit.

infection ra.

8) Enteral nutrition support: Individualized according to the patient's intra-abdominal pressure and intestinal function: ① IAP <15 mmHg, early enteral nutrition is started through naso-jejunal or nasogastric tu.

Continuously monitor intra-abdominal pressu.

② In patients with IAP >15 mmHg, through the naso-jejunal tube, the rate starts at 20 mL/h and increases according to toleran.

When the IAP value increases further, nutrition should be slowed down or discontinu.

③ For patients with IAP >20 mmHg or ACS or intestinal failure, gastrointestinal nutrition should be delayed or stopped, and parenteral nutrition should be giv.

For patients with open abdominal cavity, early enteral nutrition is recommend.

8) Enteral nutrition support: Individualized according to the patient's intra-abdominal pressure and intestinal function: ① IAP <15 mmHg, early enteral nutrition is started through naso-jejunal or nasogastric tu.

Continuously monitor intra-abdominal pressu.

② In patients with IAP >15 mmHg, through the naso-jejunal tube, the rate starts at 20 mL/h and increases according to toleran.

When the IAP value increases further, nutrition should be slowed down or discontinu.

③ For patients with IAP >20 mmHg or ACS or intestinal failure, gastrointestinal nutrition should be delayed or stopped, and parenteral nutrition should be giv.

For patients with open abdominal cavity, early enteral nutrition is recommend.

(2) Surgical treatment:

(2) Surgical treatment: (2) Surgical treatment:

After active non-surgical intervention, if IAP is still >20 mmHg, and there is a risk of other organ dysfunction and failure at the same time, more active surgical intervention should be adopted, and the operation should focus on decompression and draina.

After active non-surgical intervention, if IAP is still >20 mmHg, and there is a risk of other organ dysfunction and failure at the same time, more active surgical intervention should be adopted, and the operation should focus on decompression and draina.

The advantages of surgical treatment are:

The advantages of surgical treatment are:

(1) Relieve intra-abdominal hypertension, improve the function of kidneys, lungs and other organs and blood circulation of other internal organs, and severe patients may need to delay abdominal closure;

(1) Relieve intra-abdominal hypertension, improve the function of kidneys, lungs and other organs and blood circulation of other internal organs, and severe patients may need to delay abdominal closure;

(2) Clear the intra-abdominal enzymatic toxic exudate and reduce the absorption of necrotic substances;

(2) Clear the intra-abdominal enzymatic toxic exudate and reduce the absorption of necrotic substances;

(3) Relieve the state of retroperitoneal high pressure, decompress the swollen pancreas, and improve the pancreatic microcirculation; for those with obvious mesenteric edema and high pressure, cut the mesenteric root to decompress the retroperitoneum;

(3) Relieve the state of retroperitoneal high pressure, decompress the swollen pancreas, and improve the pancreatic microcirculation; for those with obvious mesenteric edema and high pressure, cut the mesenteric root to decompress the retroperitoneum;

(4) Multi-tube drainage is placed, which is beneficial to abdominal cavity drainage and lavage;

(4) Multi-tube drainage is placed, which is beneficial to abdominal cavity drainage and lavage;

(5) A feeding tube can be placed at the proximal end of the jejunum during the operation to facilitate postoperative enteral nutrition support and reduce complications such as dysbacterios.

(5) A feeding tube can be placed at the proximal end of the jejunum during the operation to facilitate postoperative enteral nutrition support and reduce complications such as dysbacterios.

Summary--the treatment process of acute pancreatitis complicated with intra-abdominal hypertension

Summary--Summary of the treatment process of acute pancreatitis complicated with intra-abdominal hypertension --Summary of the treatment process of acute pancreatitis complicated with intra-abdominal hypertension