Acute Severe PancreatitisTreatment in the second

milleniumUp to date

Martin Albert M.D.Critical Care Fellow

October 2000

PLAN

• Definition

• Antibioprophylaxis

• ERCP

• Surgery

• Nutrition

PLAN

• Other modalities• lexipafant

• octreotide...

• Conclusion

DEFINITION

• Ranson 3 ( Gallstone )

• Age > 70

• WBC > 18000

• Glucose >220 mg/dl

• LDH > 400

• AST >250

• Decrease > 10% Ht

• Increase in BUN >

2mg/dl

• Calcium < 8 mg/dl

• Base deficit > 5

• Fluid deficit > 4L

DEFINITION

• Ranson 3 ( other causes )

• Age > 55

• WBC > 16000

• Glucose >200 mg/dl

• LDH > 350

• AST >250

• Decrease > 10% Ht

• Increase in BUN >

5mg/dl

• Calcium < 8 mg/dl

• PaO2 < 60 mmHg

• Base deficit > 4

• Fluid deficit > 6L

DEFINITION

• 10 % AP patients have severe disease

• IF Ranson ’s criteria < 3» mortality less than 1%

• IF Ranson ’s criteria > 3» 34% of septic complications

• IF Ranson ’s criteria > 8» 90% mortality

DEFINITION

• IMRIE > 3 Imrie and al Br Jour Sur 65,337, 1978

• Age over 55

• WBC > 15000

• Glucose > 10

• BUN >16

• PaO2 < 60

• Calcium < 2

• LDH > 600

• AST > 32

• ALBUMIN <32 g/l

Definition• APACHE 2 8

Definition

• Balthazar’s scale• A) Normal CT-SCAN

• B) Focal or diffuse enlargment

• C) Pancreatic gland abdnormalities» haziness

» streaky densities

• D) Acute fluid collection

• E) 2 or more collections and/or gaz» Balthazar and al Radiology 1990:174:331-336

CT-SCAN

CT-SCAN

CT-SCAN

• Relationship between mortality/morbidity and imaging

CT-SCAN

• Relationship between mortality/morbidity and degree of necrosis

TREATMENT

• General approach

• Antibioprophylaxis

• Nutrition

• Surgery

• ERCP

• Octreotide and lexipafant...

TREATMENT ( General approach )

• ABC ’s

• Stratification

• Control of pain ( Demerol..)

• Fluid ressuscitation

TREATMENT ( General approach )

• Metabolic correction• hyperglycemia

• hypocalcemia

• hypomagnesemia

• acidosis...

ANTIBIOPROPHYLAXIS

• 20% of all acute pancreatitis = necrotizing• Up to 70% of infection in N.Pancreatitis

» Bradley III EL and al Arch Surg 128:586,1993

• 50% of all infections in the first 2 weeks• 80% mortality of AP = infections• Mortality:

• Infected NP = 25%

• Sterile NP = 13%» Beger and al World J Surg 9:972-979,1985

ANTIBIOPROPHYLAXIS

• ATB could be a good choice to• Reduce necrosis infection?

• Decrease the need in surgery?

• Decrease mortality?...

• ATB should:• Have a broad spectrum

• Good pancreas penetration

» Ratschko and al Gastro Clinics N A,28;3,641 1999

ANTIBIOPROPHYLAXIS

» Ratschko and al Gastro Clinics N A,28;3,641 1999

ANTIBIOPROPHYLAXIS

ANTIBIOPROPHYLAXIS

• Multicenter,randomized study

• 6 centers in Italy

• 74 patients with necrotizing pancreatitis» 37 biliary

» 24 roh

ANTIBIOPROPHYLAXIS

• Inclusion criteria• admission within 48 hrs

• no previous pancreatic disease

• no clinical evidence of sepsis

• no previous antibiotic treatment

• Ct-Scan within 72 hrs

• presence of necrosis

ANTIBIOPROPHYLAXIS

• Group 1 control

• Group 2 imipenem 500mg QID for 2 weeks

• Fine needle aspiration PRN for pancreas sepsis suspicion

• Group 1 treated with ampicilin or an aminoglycosid for urinary or pulm. infections

ANTIBIOPROPHYLAXIS

ANTIBIOPROPHYLAXIS

• Discussion• ATB decrease the number of pancreatic and extra-

pancreatic infection

• The power of that study was not enough to demonstrate any difference in mortality

ANTIBIOPROPHYLAXIS

• But many problems• Unblind study

• Criteria for infection???

• Use of TPN and antiprotease ( reproducibility )

• Standardisation of treatment?

• Indication of surgery???

• Use of ampi + genta

ANTIBIOPROPHYLAXIS

• Ratschko and al Gastro Clinics N A,28;3,641 1999

ANTIBIOPROPHYLAXIS

• Selective gut decontamination

» Ratschko and al Gastro Clinics N A,28;3,641 1999