Chen R J, Fang J F, Chen M F
Department of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
J Trauma. 2001 Jul;51(1):44-50. doi: 10.1097/00005373-200107000-00007.
Nonoperative management has been validated as a standard of care for patients with blunt hepatic trauma. We herein study the correlation of intra-abdominal pressure (IAP) and other clinical parameters to predict the failure of nonoperative management, and attempt to use IAP to determine further therapeutic options.
During a 9-month period, 25 hemodynamically stable patients sustaining grades III to V blunt hepatic injuries were prospectively studied. They were admitted to the intensive care unit for clinical reevaluation, and hemodynamic and IAP monitoring. If the patient developed an IAP greater than 25 cm H(2)O, then an emergent laparotomy or laparoscopy was performed to achieve hemostasis and decompression of intra-abdominal hypertension (IAH). On the basis of an IAP of 25 cm H(2)O, the correlation between the IAP and an estimated amount of liver-related transfusion, the Pao(2)/Fio(2) ratio and peritoneal signs were analyzed.
Of the 25 patients being studied, 20 (80%) had an IAP below 25 cm H(2)O, 1 of whom was found to have a pelvic abscess from an amputated segment of liver. On the other hand, five other patients with an IAP greater than 25 cm H(2)O received decompression and laparoscopic examinations, and one needed an open hepatorrhaphy. In general, though, 19 patients (76%) were successfully treated without operation. All recovered well after different therapeutic regimens; however, two developed liver abscesses, for a morbidity rate of 8% (2 of 25). This analysis revealed a strong association between the IAP value and the presence of peritoneal signs (Phi coefficient = 0.890, p < 0.001), but not in the estimated amount of liver-related transfusion and Pao(2)/Fio(2) ratio.
This preliminary investigation suggests that IAH or abdominal compartment syndrome can develop while patients receive nonoperative management for grade III to V blunt hepatic injuries. There were no parameters that precisely reflected ongoing hepatic hemorrhage or predicted hemodynamic instability. Although the amount of hepatic hemorrhage was not accurately measured by the IAP, it could be reflected by an increased IAP. During nonoperative management, IAP monitoring may be a simple and objective guideline to suggest further intervention for patients with blunt hepatic trauma. Laparoscopic hepatic evaluation and abdominal decompression may be helpful in this situation.
非手术治疗已被确认为钝性肝外伤患者的标准治疗方法。我们在此研究腹内压（IAP）与其他临床参数之间的相关性，以预测非手术治疗的失败，并尝试使用IAP来确定进一步的治疗方案。
在9个月的时间里，对25例血流动力学稳定的Ⅲ至Ⅴ级钝性肝损伤患者进行了前瞻性研究。他们被收入重症监护病房进行临床重新评估、血流动力学和IAP监测。如果患者的IAP大于25 cm H₂O，则进行急诊剖腹手术或腹腔镜检查以实现止血和腹内高压（IAH）减压。以25 cm H₂O的IAP为基础，分析IAP与估计的肝脏相关输血量、Pao₂/Fio₂比值和腹膜征之间的相关性。
在研究的25例患者中，20例（80%）的IAP低于25 cm H₂O，其中1例被发现因肝切除段出现盆腔脓肿。另一方面，另外5例IAP大于25 cm H₂O的患者接受了减压和腹腔镜检查，1例需要进行开放性肝缝合术。总体而言，19例（76%）患者未经手术成功治疗。所有患者在接受不同治疗方案后恢复良好；然而，2例发生肝脓肿，发病率为8%（25例中的2例）。该分析显示IAP值与腹膜征的存在之间存在密切关联（Phi系数 = 0.890，p < 0.001），但与估计的肝脏相关输血量和Pao₂/Fio₂比值无关。
这项初步研究表明，在对Ⅲ至Ⅴ级钝性肝损伤患者进行非手术治疗时，可能会发生IAH或腹腔间隔室综合征。没有参数能精确反映持续的肝出血或预测血流动力学不稳定。虽然IAP不能准确测量肝出血量，但肝出血量的增加可通过IAP升高反映出来。在非手术治疗期间，IAP监测可能是一个简单而客观的指标，提示对钝性肝外伤患者进行进一步干预。在这种情况下，腹腔镜肝脏评估和腹部减压可能会有所帮助。
