acute severe pancreatitis treatment in the second millenium up to date martin albert m.d. critical...
TRANSCRIPT
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Acute Severe PancreatitisTreatment in the second
milleniumUp to date
Martin Albert M.D.Critical Care Fellow
October 2000
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PLAN
• Definition
• Antibioprophylaxis
• ERCP
• Surgery
• Nutrition
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PLAN
• Other modalities• lexipafant
• octreotide...
• Conclusion
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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
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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
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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
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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
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Definition• APACHE 2 8
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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
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CT-SCAN
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CT-SCAN
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CT-SCAN
• Relationship between mortality/morbidity and imaging
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CT-SCAN
• Relationship between mortality/morbidity and degree of necrosis
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TREATMENT
• General approach
• Antibioprophylaxis
• Nutrition
• Surgery
• ERCP
• Octreotide and lexipafant...
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TREATMENT ( General approach )
• ABC ’s
• Stratification
• Control of pain ( Demerol..)
• Fluid ressuscitation
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TREATMENT ( General approach )
• Metabolic correction• hyperglycemia
• hypocalcemia
• hypomagnesemia
• acidosis...
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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
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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
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» Ratschko and al Gastro Clinics N A,28;3,641 1999
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ANTIBIOPROPHYLAXIS
» Ratschko and al Gastro Clinics N A,28;3,641 1999
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ANTIBIOPROPHYLAXIS
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ANTIBIOPROPHYLAXIS
• Multicenter,randomized study
• 6 centers in Italy
• 74 patients with necrotizing pancreatitis» 37 biliary
» 24 roh
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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
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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
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ANTIBIOPROPHYLAXIS
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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
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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
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ANTIBIOPROPHYLAXIS
• Ratschko and al Gastro Clinics N A,28;3,641 1999
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ANTIBIOPROPHYLAXIS
• Selective gut decontamination
» Ratschko and al Gastro Clinics N A,28;3,641 1999