Predicting Value of Abdominal Perfusion Pressure and Plasma Renin Activity in Mechanically Ventilated Patients

腹內灌流壓及血清腎激素對於病人使用呼吸器臨床預後的評估價值

劉文德(Wen-Te Liu) ； 楊美貞(Mei-Chen Yang) ； 黃崇仁(Chung-Jen Huang) ； 林鴻銓(Horng-Chyuan Lin) ； 王圳華(Chun-Hua Wang) ； 郭漢彬(Han-Pin Kuo)

《胸腔醫學》 19卷2期 (2004/04) Pp. 99-108

https://doi.org/10.29806/TM.200404.0003

摘要

背景：臨床經驗與動物實驗都可以發現：腹腔內的高壓以及維持呼氣末端正壓的呼吸方式(Positive end-expiratory pressure, PEEP)，會對於腹腔內器官的血行動力狀態造成顯著的改變。我們研究增加呼氣末端正壓值對於腹內壓與renin-angiotensin-aldosterone system的影響。
方法：總計26位氣管插管使用呼吸器且血行動力學穩定的病患被納入這次研究，我們測量這些病患的腹內壓、平均動脈壓、血清腎激素(plasma renin activity)與醛固酮(aldosterone level)的濃度，在其他因素不變的情形下增加PEEP（6或10cmH2O，避免最大呼吸道阻力超過35cmH2O），一小時後再次測量上述的變因；另外並定義腹內灌流壓(abdominal perfusion pressure)為平均動脈壓與腹內壓的差值。這些病患被持續追蹤至離開加護病房並紀錄其死亡率。
結果：在腹內壓較高(higher intra-abdominal pressure)及腹內灌流壓較低(lower abdominal perfusion pressure)的病人身上可以觀察到顯著偏高的血清腎激素。加護病房住院期間死亡的7位病患身上可以觀察到顯著較高的血清腎激素(plasma renin activity)與醛固酮(plasma aldosterone level)，他們的腹內灌流壓則明顯低於存活的另外19位病患。增加PEEP會顯著提高腹內壓與減低腹內灌流壓(abdominal perfusion pressure)。然而，比較PEEP提高前後血清腎激素(plasma renin activity)與醛固酮(aldosterone level)的濃度則沒有顯著的差異。
結論：本篇研究發現，腹內壓(Intra-abdominal pressure)及腹內灌流壓(Abdominal perfusion pressure)皆和血清腎激素的多寡呈顯著相關；較高的腹內灌流壓與較低的血清腎激素顯示病人有較好的預後。而腹內壓及腹內灌流壓亦會受到PEEP調整的影響，因此測量腹內灌流壓及血清腎激素有助於臨床醫師對重症病人的評估與呼吸器的調整。

關鍵字

呼氣末端正壓(PEEP) ； 腹內壓 ； 腹內灌流壓 ； 血清腎激素

並列摘要

Rationale: Clinical experience and experimental studies suggest that intra-abdominal hypertension and positive end-expiratory pressure (PEEP) ventilation might alter splanchnic hemodynamics to a significantly greater degree. Our study assessed the influences of raising positive end-expiratory pressure (PEEP) on intra-abdominal pressure (IAP) and the reninangiotensin-aldosterone system in patients admitted to intensive care unit.
Motheds: Twenty-six mechanically ventilated patients with normal hemodynamic status were recruited. Their IAP, mean arterial pressure (MAP), plasma renin activity, and aldosterone level were measured at 0 and 1 hour after the raising current PEEP level. In addition, we assessed intra-abdominal perfusion by simply calculating abdominal perfusion pressure (APP) as MAP minus IAP. The values of the elevated PEEP were 6 or 10 cmH2Oselectively with the intention of avoiding peak airway pressure beyond 35 cmH2O. All the patients were followed up until the termination of ICU hospitalization and their mortality rates were recorded.
Results: The patients with a higher IAP and lower APP had significantly elevated renin activity (n=26, r=0.64, p＜0.001 and n=26, r=-0.70, p＜0.0001, respectively). The seven patients who expired in the ICU had significantly elevated renin activity and aldosterone levels and lower APP, compared with the 19 patients who survived ICU hospitalization. Elevated PEEP could significantly affect IAP from 7.9±0.7 to 9.6±0.7mm Hg (n=26, p＜0.0001) and APP from 66.7±1.3 to 65.2±1.4 mm Hg (n=26, p＜0.05) respectively. However, there was no significant difference in plasma renin activity and aldosterone levels in the two levels of PEEP. Conclusions Plasma renin activity was significantly correlated with IAP and in an inverse manner, with APP. Higher APP and lower plasma renin revealed better patient outcome. Both IAP and APP were significantly affected by raising the PEEP level. Assessment of APP and plasma renin activity in patients receiving mechanical ventilation can help clinicians in adjusting the ventilator and predict patients’ outcome.

並列關鍵字

positive end-expiratory pressure (PEEP) ； intra-abdominal pressure ； abdominal perfusion pressure ； plasma renin activity