Acute Severe Pancreatitis Treatment in the second millenium Up to date Martin Albert M.D. Critical...
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Transcript of Acute Severe Pancreatitis Treatment in the second millenium Up to date Martin Albert M.D. Critical...
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