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Acute Severe Pancreatitis Treatment Up to date

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Acute Severe Pancreatitis Treatment in the second millenium Up to date Martin Albert M.D. Critical Care Fellow October 2000 PLAN Definition Antibioprophylaxis ERCP ... – PowerPoint PPT presentation

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Title: Acute Severe Pancreatitis Treatment Up to date


1
(No Transcript)
2
Acute Severe Pancreatitis Treatment in the second
millenium Up to date Martin Albert M.D. Critical
Care Fellow October 2000

3
PLAN
  • Definition
  • Antibioprophylaxis
  • ERCP
  • Surgery
  • Nutrition

4
PLAN
  • Other modalities
  • lexipafant
  • octreotide...
  • Conclusion

5
DEFINITION
  • Ranson ? 3 ( Gallstone )
  • Age gt 70
  • WBC gt 18000
  • Glucose gt220 mg/dl
  • LDH gt 400
  • AST gt250
  • Decrease gt 10 Ht
  • Increase in BUN gt 2mg/dl
  • Calcium lt 8 mg/dl
  • Base deficit gt 5
  • Fluid deficit gt 4L

6
DEFINITION
  • Ranson ? 3 ( other causes )
  • Age gt 55
  • WBC gt 16000
  • Glucose gt200 mg/dl
  • LDH gt 350
  • AST gt250
  • Decrease gt 10 Ht
  • Increase in BUN gt 5mg/dl
  • Calcium lt 8 mg/dl
  • PaO2 lt 60 mmHg
  • Base deficit gt 4
  • Fluid deficit gt 6L

7
DEFINITION
  • 10 AP patients have severe disease
  • IF Ranson s criteria lt 3
  • mortality less than 1
  • IF Ranson s criteria gt 3
  • 34 of septic complications
  • IF Ranson s criteria gt 8
  • 90 mortality

8
DEFINITION
  • IMRIE gt 3 Imrie and al
    Br Jour Sur 65,337, 1978
  • Age over 55
  • WBC gt 15000
  • Glucose gt 10
  • BUN gt16
  • PaO2 lt 60
  • Calcium lt 2
  • LDH gt 600
  • AST gt 32
  • ALBUMIN lt32 g/l

9
Definition
  • APACHE 2 ? 8

10
Definition
  • Balthazars 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 1990174331-336

11
CT-SCAN
12
CT-SCAN
13
CT-SCAN
  • Relationship between mortality/morbidity and
    imaging

14
CT-SCAN
  • Relationship between mortality/morbidity and
    degree of necrosis

15
TREATMENT
  • General approach
  • Antibioprophylaxis
  • Nutrition
  • Surgery
  • ERCP
  • Octreotide and lexipafant...

16
TREATMENT ( General approach )
  • ABC s
  • Stratification
  • Control of pain ( Demerol..)
  • Fluid ressuscitation

17
TREATMENT ( General approach )
  • Metabolic correction
  • hyperglycemia
  • hypocalcemia
  • hypomagnesemia
  • acidosis...

18
ANTIBIOPROPHYLAXIS
  • 20 of all acute pancreatitis necrotizing
  • Up to 70 of infection in N.Pancreatitis
  • Bradley III EL and al Arch Surg 128586,1993
  • 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 9972-979,1985

19
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

20
  • Ratschko and al Gastro Clinics N A,283,641 1999

21
ANTIBIOPROPHYLAXIS
  • Ratschko and al Gastro Clinics N A,283,641 1999

22
ANTIBIOPROPHYLAXIS
23
ANTIBIOPROPHYLAXIS
  • Multicenter,randomized study
  • 6 centers in Italy
  • 74 patients with necrotizing pancreatitis
  • 37 biliary
  • 24 roh

24
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

25
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

26
ANTIBIOPROPHYLAXIS
27
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

28
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

29
ANTIBIOPROPHYLAXIS
  • Ratschko and al Gastro Clinics N A,283,641 1999

30
ANTIBIOPROPHYLAXIS
  • Selective gut decontamination
  • Ratschko and al Gastro Clinics N A,283,641 1999
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