Tissue perfusion and metabolism during intra-abdominal hypertension
Date
2014-05-05
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Abstract
Eestis vajab kõrgeima astme intensiivravi peaaegu 10 000 patsienti aastas. Ligi kolmandikul neist esineb kõhuõõnesisese rõhu tõus, mis võib põhjustada kõhuõõne organite funktsioonihäireid ja on seeläbi seotud suurenenud suremusega. Tõusnud kõhuõõnesisene rõhk jaotatakse nelja-astmelisel skaalal: I 12-15 mmHg, II 16-20 mmHg, III 21-25 mmHg; IV üle 25 mmHg. Halvimal juhul, s.o kõhukoopasisese rõhu tõusul üle 20 mmHg võib kujuneda eluohtlik kõhuõõnesisene kompaartmentsündroom. Sel juhul on ravivõtted tavapraktikas üheselt mõistetavad – kiired ja agressiivsed. I ja II astme kõhuõõnesisese rõhu tõusu ravi on aga vastuoluline. Olemasolevad ravisoovitused ei anna täpseid juhiseid selle kohta, kas mõõdukas kõhukoopasisese rõhu tõus vajab kohest ravi.
Antud töö eesmärk oli selgitada, kas I ja II astme kõhuõõnesisese rõhu tõus põhjustab tavapäraste jälgimismeetoditega mittetuvastatavaid muutusi kudede verevarustuses ja ainevahetuses. Verevarustus- ja ainevahetushäirete ilmnemine oleks oluline argument sündroomi raviks juba selle varajases staadiumis. Verevoolu muutuste hindamiseks kasutasime videomikroskoopi, millega uurisime patsientide keelealust veresoonestikku. Varasemad uuringud on näidanud, et selle piirkonna veresooned käituvad sarnaselt seedetrakti (mao ja soolestiku) veresoonestikuga ning seega peegeldavad keelealuse piirkonna muutused seedetrakti muutusi. Lisaks hindasime mikrodialüüsi metoodika abil ainevahetust kõhusirglihases.
37 haigel tehtud uuringute tulemusena leidsime, et kõhuõõnesisese rõhu tõus ei mõjuta oluliselt keelealuse piikonna verevarustust intensiivravi haigetel, kes on saanud eelnevalt vedelikravi. Küll aga oli keelealune verevarustus halvenenud kirurgilistel haigetel, kes olid plaanilise operatsiooni eelselt söömata-joomata. Kõhu sirglihase ainevahetuse hindamisel selgus, et I ja II astme kõhuõõnesisese rõhu tõus põhjustab hapnikuvaeguses tekkivate lõpp-produktide kuhjumist. See peegeldab verevarustuse olulist häiret. Kokkuvõttes rõhutavad töö tulemused, et vaatamata selgelt identifitseeritavate kliiniliste sümptomite puudumisele põhjustab kõhukoopa sisese rõhu mõõdukas tõus juba koekahjustust ja seetõttu ei tohi I ja II astme kõhuõõnesisese rõhu tõusu jätta ravita.
Approximately 10000 patients are hospitalised to intensive care unit every year in Estonia. One third of them develop elevated intra-abdominal pressure (IAP) i.e. intra-abdominal hypertension (IAH). IAH can lead to severe abdominal organ’s dysfunction and is therefore a reason for elevated mortality. According to the severity, IAH is graded into four levels. Grade I refers to IAP levels from 12 to 15 mmHg, Grade II 16 to 20, Grade III 21 to 25, and Grade IV above 25 mmHg, respectively. The most severe form of IAH (IAP over 20 mmHg) is life-threatening abdominal compartment syndrome (ACS). Treatment of ACS is self-evident – fast and aggressive. Consequences of grade I and II IAH are not uniformly understood and the treatment recommendations are either absent or un-precisely defined. The main aim of present study was to investigate whether grade I and II IAH causes alterations in tissue perfusion and metabolism which are not detectable with conventional methods. Early treatment of mild to moderate IAH would be necessary if tissue perfusion and metabolism are deteriorated. Tissue perfusion was evaluated in sublingual area with videomicroscope. Several researches have previously shown that gastrointestinal and sublingual region microcirculation reacts similarly and that sublingual changes describe the situation in gastrointestinal region. For tissue metabolism evaluation we used microdialysis in the abdominal rectus muscle. Altogether 37 patients we included. Main finding of our work was that grade I or II IAH does not influence sublingual microcirculation in previously fluid-resuscitated critically ill patients. But the microcirculation was significantly altered in surgical patients, who were not allowed to eat-drink prior the elective surgery. The main finding of microdialysis study was the prevalence of anaerobic metabolism in RAM tissue during grade I and II IAH. This indicates to possible tissue hypoperfusion. In conclusion, the results of present work accentuate, that the tissue metabolism is severely altered during grade I and II IAH, despite the lack of clearly identified clinical symptoms and therefore IAH cannot be ignored in critically ill patients.
Approximately 10000 patients are hospitalised to intensive care unit every year in Estonia. One third of them develop elevated intra-abdominal pressure (IAP) i.e. intra-abdominal hypertension (IAH). IAH can lead to severe abdominal organ’s dysfunction and is therefore a reason for elevated mortality. According to the severity, IAH is graded into four levels. Grade I refers to IAP levels from 12 to 15 mmHg, Grade II 16 to 20, Grade III 21 to 25, and Grade IV above 25 mmHg, respectively. The most severe form of IAH (IAP over 20 mmHg) is life-threatening abdominal compartment syndrome (ACS). Treatment of ACS is self-evident – fast and aggressive. Consequences of grade I and II IAH are not uniformly understood and the treatment recommendations are either absent or un-precisely defined. The main aim of present study was to investigate whether grade I and II IAH causes alterations in tissue perfusion and metabolism which are not detectable with conventional methods. Early treatment of mild to moderate IAH would be necessary if tissue perfusion and metabolism are deteriorated. Tissue perfusion was evaluated in sublingual area with videomicroscope. Several researches have previously shown that gastrointestinal and sublingual region microcirculation reacts similarly and that sublingual changes describe the situation in gastrointestinal region. For tissue metabolism evaluation we used microdialysis in the abdominal rectus muscle. Altogether 37 patients we included. Main finding of our work was that grade I or II IAH does not influence sublingual microcirculation in previously fluid-resuscitated critically ill patients. But the microcirculation was significantly altered in surgical patients, who were not allowed to eat-drink prior the elective surgery. The main finding of microdialysis study was the prevalence of anaerobic metabolism in RAM tissue during grade I and II IAH. This indicates to possible tissue hypoperfusion. In conclusion, the results of present work accentuate, that the tissue metabolism is severely altered during grade I and II IAH, despite the lack of clearly identified clinical symptoms and therefore IAH cannot be ignored in critically ill patients.
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Keywords
kõhuõõs, rõhk (füüs.), koekahjustused, hüpertensioon, ravi, abdominal cavity, pressure, tissue damages, hypertension, treatment